Triage Vital Signs Research Articles

Predictive Value of Triage Vital Signs and Conscious Level for Outcome Evaluation in Acutely Organophosphate Poisoned Patients

Triage in Emergency departments requires emergency doctors to make rapid decisions based on their knowledge and experiences. Triage of patients is critical to patient safety, yet no clear information exists by the utility of initial vital signs and conscious levelin identifying critically ill acutely organophosphate (OP) poisoned patients. The objective of this study is to determine the relationship between triage vital signs and conscious level in predicting outcome of acutely organophosphate poisoned patients.A retrospective and prospective study was carried out on 200 patients of acute OP poisoning admitted to the Poison Control Center (PCC), Ain Shams University Hospitals. Information including vital signs and Glasgow coma scale (GCS) on admission after obtaining the permission of the director of PCC and the regional ethics committee was collected from the sheets and computerized data base of the patients, an informed written consent has been obtained from each patient or from his/her caregiver for inclusion in the prospective part of the study. The results were revised, coded and organized for statistical analysis. The study results revealed 180 (90%) patients discharged and 20 (10%) patients died. The study also showed that 8% of patients had fever, 9.5% had tachycardia, 1.5% had bradycardia, 5% had hypotension, 2% had hypertension, 2.5% had tachypnea and 3.5% showed bradypnea. Also 89% of patients had GCS > 8, while 11% of patients had GCS ≤ 8. The study showed statistically significant difference between discharged and died patients as regards heart rate, blood pressure, respiratory rate, body temperature and GCS. It could be concluded that heart rate, respiratory rate and coma scale can serve as easily measurable tools for outcome prediction in acutely OP poisoned patients. From the previous results, our study recommends to use these parameters to help emergency physicians to quickly detect poisoned patients with poor outcomes.

Impact of altitude-adjusted hypoxia on the Pulmonary Embolism Rule-out Criteria

BackgroundThe Pulmonary Embolism Rule-out Criteria (PERC) defines hypoxia as an oxygen saturation (O2 sat) < 95%. Utilizing this threshold for hypoxia at a significant elevation above sea level may lead to an inflated number of PERC-positive patients and unnecessary testing. The aim of this study was to determine the effect of an altitude-adjusted O2 sat on PERC's sensitivity and the potential impact on testing rates. MethodsAt the University of Utah Emergency Department (ED) (elevation: 4980 ft/1518 m), we prospectively enrolled a convenience sample of patients presenting with chest pain and/or shortness of breath. We calculated PERC utilizing triage vital signs and baseline clinical variables and noted the diagnosis of acute PE during the ED visit. We adjusted the PERC O2 sat threshold to <90% to account for altitude to determine the potential impact on outcomes and decision tool performance. ResultsOf 3024 study patients, 1.9% received the diagnosis of an acute PE in the ED, resulting in a sensitivity of 96.6% for the traditional PERC (95% CI: 88.1%–99.6%). Utilizing a definition of hypoxia of <90%, the sensitivity of the altitude-adjusted PERC rule was 94.8% (95% CI: 85.6%–98.9%). Assuming that imaging would not have been pursued for PERC-negative patients, the altitude-adjusted PERC rule would have reduced the overall rate of advanced imaging by 2.7% (95% CI: 1.8%–4.1%). ConclusionAdjusting the PERC O2 sat threshold for altitude may result in decreased rates of advanced imaging for PE without a substantial change in the sensitivity of the PERC rule.

A retrospective analysis of the respiratory adjusted shock index to determine the presence of occult shock in trauma patients.

The shock index (SI), calculated as hear rate/systolic blood pressure, is a simple hemodynamic marker that may be used to assess for the presence of occult shock in trauma patients. The normal range for a healthy adult patient is 0.5 to 0.7. Recently, studies have demonstrated that tachypnea is the most important predictor of cardiac arrest in hospital wards and is an important indicator of derangements across multiple organ systems. As such, we have sought to determine whether the inclusion of the patient's respiratory rate (RR) to the already existing SI (called the Respiratory Adjusted Shock Index [RASI]), calculated as hear rate/systolic blood pressure*(RR/10), will improve the overall diagnostic accuracy of detecting patients in early occult shock. A retrospective chart review over a 4-year period (2012-2016) at an urban, Level I trauma center was performed. All patients admitted to hospital for trauma were included in the study. Exclusion criteria were patients in traumatic arrest or in overt shock. Charts were reviewed for triage vital signs and point of care lactate drawn within 30 minutes of presentation. A lactate greater than 2 mmol/L was used to determine presence of hypoperfusion. The upper limit of normal for the RASI was calculated by multiplying the upper limit of the SI by 1.9 (RR of 19 divided by 10) and validated internally. A total of 3,093 patients were included in this study. There was no difference in SI for patients discharged versus patients admitted, 0.6 (95% CI, 0.5-0.7) versus 0.7 (95% CI, 0.5-0.8) and a significant difference between the same groups of patients (discharged vs. admitted) for the RASI, 1.1 (95% CI, 1.04-1.18) versus 1.46 (95% CI, 1.35-1.55), respectively. Area under the curve for SI was 0.58 and for the RASI score was 0.94. The RASI score improves diagnostic accuracy for detecting early occult shock in trauma patients when compared to the SI. Diagnostic, level II.

Safety of a Brief Emergency Department Observation Protocol for Patients With Presumed Fentanyl Overdose

Fentanyl overdoses are increasing and few data guide emergency department (ED) management. We evaluate the safety of an ED protocol for patients with presumed fentanyl overdose. At an urban ED, we used administrative data and explicit chart review to identify and describe consecutive patients with uncomplicated presumed fentanyl overdose (no concurrent acute medical issues) from September to December 2016. We linked regional ED and provincial vital statistics databases to ascertain admissions, revisits, and mortality. Primary outcome was a composite of admission and death within 24 hours. Other outcomes included treatment with additional ED naloxone, development of a new medical issue while in the ED, and length of stay. A prespecified subgroup analysis assessed low-risk patients with normal triage vital signs. There were 1,009 uncomplicated presumed fentanyl overdose, mainly by injection. Median age was 34 years, 85%were men, and 82% received out-of-hospital naloxone. One patient was hospitalized and one discharged patient diedwithin 24 hours (combined outcome 0.2%; 95% confidence interval [CI] 0.04% to 0.8%). Sixteen patients received additional ED naloxone (1.6%; 95% CI 1.0% to 2.6%), none developed a new medical issue (0%; 95% CI 0% to 0.5%), and median length of stay was 173 minutes (interquartile range 101 to 267). For 752 low-risk patients, no patients were admitted or developed a new issue, and one died postdischarge; 3 (0.4%; 95% CI 0.01% to 1.3%) received ED naloxone. In our cohort of ED patients with uncomplicated presumed fentanyl overdose-typically after injection-deterioration, admission, mortality, and postdischarge complications appear low; the majority can be discharged afterbrief observation. Patients with normal triage vital signs are unlikely to require ED naloxone.

Predictors of emergency department discharge following pediatric drowning

ObjectiveDrowning is among the top ten causes of death in children in all regions of the world. Literature is scarce on hospital resource utilization in pediatric drowning. We aimed to identify predictors of discharge home in children presenting to the emergency department (ED) after accidental drowning. MethodsIn this retrospective cohort study, we studied children 0-18 years old presenting to the ED of an urban, free-standing tertiary care children's hospital with submersion injury from 1/1/10 to 12/31/14. Subjects were identified via International Classification of Diseases, Ninth Revision, codes, excluding those indicating intentional injury. Primary outcome was ED disposition. Covariates included standard demographics, witnessed event, field intervention (e.g. cardiopulmonary resuscitation), triage vital signs, radiography, and blood gas analysis. Routine statistical analysis and multivariable logistic regression with adjusted odds ratios (aOR) were performed with SAS 9.4. ResultsNinety-one ED visits were screened with one excluded due to miscoding. The majority were male (59%), non-Hispanic white (72%), and urban (90%). Patients tended to be of younger age (48% age 1-5 years). Fifty-seven children (63%) were admitted, 23 required ICU level care (26%), and one died. In multivariable analysis, ED discharge was significantly more likely with normal oxygen saturations in triage (aOR 6.80, p=0.04) and no field intervention (aOR 5.10; p=0.02). ConclusionsChildren with accidental submersion injury were significantly more likely to be discharged from the ED if they had normal oxygen saturation and no immediate field intervention reported. Future research includes linking these factors to patient outcomes and standardizing clinical approach.

Exploring Vital Sign Data Quality in Electronic Health Records with Focus on Emergency Care Warning Scores.

Computerized clinical decision support and automation of warnings have been advocated to assist clinicians in detecting patients at risk of physiological instability. To provide reliable support such systems are dependent on high-quality vital sign data. Data quality depends on how, when and why the data is captured and/or documented. This study aims to describe the effects on data quality of vital signs by three different types of documentation practices in five Swedish emergency hospitals, and to assess data fitness for calculating warning and triage scores. The study also provides reference data on triage vital signs in Swedish emergency care. We extracted a dataset including vital signs, demographic and administrative data from emergency care visits (n=335027) at five Swedish emergency hospitals during 2013 using either completely paper-based, completely electronic or mixed documentation practices. Descriptive statistics were used to assess fitness for use in emergency care decision support systems aiming to calculate warning and triage scores, and data quality was described in three categories: currency, completeness and correctness. To estimate correctness, two further categories - plausibility and concordance - were used. The study showed an acceptable correctness of the registered vital signs irrespectively of the type of documentation practice. Completeness was high in sites where registrations were routinely entered into the Electronic Health Record (EHR). The currency was only acceptable in sites with a completely electronic documentation practice. Although vital signs that were recorded in completely electronic documentation practices showed plausible results regarding correctness, completeness and currency, the study concludes that vital signs documented in Swedish emergency care EHRs cannot generally be considered fit for use for calculation of triage and warning scores. Low completeness and currency were found if the documentation was not completely electronic.

Reliability and validity of four-level and three-district triage standards in emergency department: a randomized sampling cross-sectional study of 1 106 adult patients

To evaluate the reliability and validity of three-district and four-level triage standards in adult emergency department. A randomized sampling cross-sectional study was conducted. A total of 1 106 emergency adult patients admitted to the Second Xiangya Hospital of Central South University in Hunan Province from December 2015 to April 2016 were enrolled. The triage was independently performed by 12 nurses according to the emergency triage criteria. Based on the shift style, 2 nurses were assigned to each shift as the triage guider and assistant respectively, who did the triage for every patient independently. The clinical data were recorded as follows: the demographic data, emergency information (triage time, emergency way, complaints, vital signs, and conscious state), triage information (triage level, admitted department), waiting time, treatment time, destination and outcomes. The reliability of three-district and four-level triage standards was analyzed by Spearman correlation, and the receiver operating characteristic curve (ROC) was plotted to evaluate its validity. (1) A total of 254 patients were enrolled for reliability evaluation in the first 2 weeks of the study. The overall internal consistency rate of the triage instructors and the triage assistants was 72%, the total Kappa value was 0.686 [95% confidence interval (95%CI) = 0.608-0.757, P < 0.001]. (2) Validity analysis showed that in the 1 125 emergency patients collected during the study, a total of 1 106 patients were finally enrolled in the analysis excluding the patients who refused to accept the treatment, whose data was incomplete and who was diagnosed as prehospital death. With the increase of three-district and four-level triage level, a significant increase was showed in the waiting time of patients, the treatment time, and the retention rate; on the contrary, the salvage rate, the hospitalization rate, hospitalization time, emergency mortality, in-hospital mortality and total mortality rate were decreased [the waiting time of patients from triage level 1 to 4 (minutes) was 1.00 (1.00, 1.75), 1.00 (1.00, 5.00), 8.00 (2.00, 23.00), 10.00 (4.50, 28.00), the treatment received time (minutes) was 1.00 (1.00, 10.00), 6.00 (1.00, 23.00), 48.00 (25.00, 105.00), 87.00 (41.00, 140.00), the retention rate was 4.76%, 10.94%, 55.91%, 42.86%, the salvage rate was 95.24%, 87.94%, 20.81%, 0%, the hospitalization rate was 57.14%, 70.98%, 53.62%, 20.41%, the hospitalization time (days) was 19.50 (9.75, 28.00), 11.00 (8.00, 17.00), 12.00 (8.25, 17.00), 10.50 (8.75, 15.25), the emergency mortality was 19.05%, 6.92%, 1.41%, 0%, the in-hospital mortality was 16.67%, 15.09%, 6.25%, 0%, and the total mortality rate was 28.57%, 17.63%, 4.76%, 0%, all P < 0.05]. ROC curve analysis showed that the area under ROC curve (AUC) of three-district and four-level triage standards for identifying patients needed an immediate intervention (triage level 1 to 2) was 0.854 (95%CI = 0.831-0.878), and the sensitivity and specificity were 78.62% and 89.89%, respectively, the misdiagnosis rate was 10.11%, and the missed diagnosis rate was 21.38%. The three-district and four-level triage standards were proved to be a reliable and valid instrument, which can distinguish the severity of the disease and help nurses to triage patients correctly.

The Association Between Use of Brain CT for Atraumatic Headache and 30-Day Emergency Department Revisitation.

The purpose of this article is to describe the association between initial CT for atraumatic headache and repeat emergency department (ED) visitation within 30 days of ED discharge. A retrospective observational study was performed at an academic urban ED with more than 85,000 annual visits. All adult patients with a chief complaint of headache from January through December 2010 who were discharged after ED evaluation were included in the analysis. Patients were excluded if they were transferred, died in the ED, or had a diagnosis indicating a traumatic mechanism. A propensity score-matched logistic regression model was used to determine whether the use of brain CT was associated with the primary outcome of ED revisitation within 30 days, controlling for potential confounding variables. Of 80,619 total patient visits to the ED during the study period, 922 ED discharges with a chief complaint of headache were included. A total of 139 (15.1%) patients revisited within 30 days. The return rate was 11.2% among patients who underwent CT at their initial visit and 21.1% among those who did not. In the adjusted analysis, controlling for age, race, sex, insurance status, triage vital signs, laboratory values, and triage pain level, the odds ratio for revisitation given CT performance was 0.49 (95% CI, 0.27-0.86). After adjustment for clinical factors, we found that patients who underwent a brain CT examination for atraumatic headache at an initial ED visit were less likely to return to the ED within 30 days. Future appropriate use quality metrics regarding ED imaging use may need to incorporate downstream health care use.

Human temperatures for syndromic surveillance in the emergency department: data from the autumn wave of the 2009 swine flu (H1N1) pandemic and a seasonal influenza outbreak.

BackgroundThe emergency department (ED) increasingly acts as a gateway to the evaluation and treatment of acute illnesses. Consequently, it has also become a key testing ground for systems that monitor and identify outbreaks of disease. Here, we describe a new technology that automatically collects body temperatures during triage. The technology was tested in an ED as an approach to monitoring diseases that cause fever, such as seasonal flu and some pandemics.MethodsTemporal artery thermometers that log temperature measurements were placed in a Boston ED and used for initial triage vital signs. Time-stamped measurements were collected from the thermometers to investigate the performance a real-time system would offer. The data were summarized in terms of rates of fever (temperatures ≥100.4 °F [≥38.0 °C]) and were qualitatively compared with regional disease surveillance programs in Massachusetts.ResultsFrom September 2009 through August 2011, 71,865 body temperatures were collected and included in our analysis, 2073 (2.6 %) of which were fevers. The period of study included the autumn–winter wave of the 2009–2010 H1N1 (swine flu) pandemic, during which the weekly incidence of fever reached a maximum of 5.6 %, as well as the 2010–2011 seasonal flu outbreak, during which the maximum weekly incidence of fever was 6.6 %. The periods of peak fever rates corresponded with the periods of regionally elevated flu activity.ConclusionsTemperature measurements were monitored at triage in the ED over a period of 2 years. The resulting data showed promise as a potential surveillance tool for febrile disease that could complement current disease surveillance systems. Because temperature can easily be measured by non-experts, it might also be suitable for monitoring febrile disease activity in schools, workplaces, and transportation hubs, where many traditional syndromic indicators are impractical. However, the system’s validity and generalizability should be evaluated in additional years and settings.Electronic supplementary materialThe online version of this article (doi:10.1186/s12873-016-0080-7) contains supplementary material, which is available to authorized users.

Certification in emergency nursing associated with vital signs attitudes and practices

Regimented vital signs (VS) assessment for all emergency patients is a common practice in many US emergency departments despite the paucity of evidence supporting its utility. Nurse attitude may be a factor that maintains this ritualized practice. Understanding the relationship between attitudes, practices, and nurse demographic factors may be the first step to challenging this ritual in order to implement evidence-based practices. A 20-item questionnaire was developed to assess emergency nurse attitudes and practices related to VS. A convenience sample of emergency nurses from the mid-Atlantic region of the United States was used. Eighty-one emergency nurses participated. Results demonstrated wide variations in VS practice and attitudes, though some strongly held attitudes are inconsistent with the literature. Certification in emergency nursing had significant associations with beliefs that nurses' clinical judgment should be the determinant for VS frequency (p < .05) and that triage VS are not an accurate representation of patient condition (p < .05). The practice of assessing the patient first and reviewing VS after was also associated with certification (p < .05). This study begins to address emergency nurse attitudes and practices of VS so that evidence-based changes can be implemented and further research on VS frequency conducted. It also demonstrates the relationship between specialty certification and evidence-supported attitudes and practices.

Predicting blood transfusion using automated analysis of pulse oximetry signals and laboratory values.

Identification of hemorrhaging trauma patients and prediction of blood transfusion needs in near real time will expedite care of the critically injured. We hypothesized that automated analysis of pulse oximetry signals in combination with laboratory values and vital signs obtained at the time of triage would predict the need for blood transfusion with accuracy greater than that of triage vital signs or pulse oximetry analysis alone. Continuous pulse oximetry signals were recorded for directly admitted trauma patients with abnormal prehospital shock index (heart rate [HR] / systolic blood pressure) of 0.62 or greater. Predictions of blood transfusion within 24 hours were compared using Delong's method for area under the receiver operating characteristic (AUROC) curves to determine the optimal combination of triage vital signs (prehospital HR + systolic blood pressure), pulse oximetry features (40 waveform features, O2 saturation, HR), and laboratory values (hematocrit, electrolytes, bicarbonate, prothrombin time, international normalization ratio, lactate) in multivariate logistic regression models. We enrolled 1,191 patients; 339 were excluded because of incomplete data; 40 received blood within 3 hours; and 14 received massive transfusion. Triage vital signs predicted need for transfusion within 3 hours (AUROC, 0.59) and massive transfusion (AUROC, 0.70). Pulse oximetry for 15 minutes predicted transfusion more accurately than triage vital signs for both time frames (3-hour AUROC, 0.74; p = 0.004) (massive transfusion AUROC, 0.88; p < 0.001). An algorithm including triage vital signs, pulse oximetry features, and laboratory values improved accuracy of transfusion prediction (3-hour AUROC, 0.84; p < 0.001) (massive transfusion AUROC, 0.91; p < 0.001). Automated analysis of triage vital signs, 15 minutes of pulse oximetry signals, and laboratory values predicted use of blood transfusion during trauma resuscitation more accurately than triage vital signs or pulse oximetry analysis alone. Results suggest automated calculations from a noninvasive vital sign monitor interfaced with a point-of-care laboratory device may support clinical decisions by recognizing patients with hemorrhage sufficient to need transfusion. Epidemiologic/prognostic study, level III.

Identifying Potentially Preventable Emergency Department Visits by Nursing Home Residents in the United States

ObjectivesTo identify and describe potentially preventable emergency department (ED) visits by nursing home (NH) residents in the United States. These visits are important because they are common, frequently lead to hospitalization, and can be associated with significant cost to the patient and the health care system. DesignRetrospective analysis of the 2005–2010 National Hospital Ambulatory Care Survey (NHAMCS), comparing ED visits by nursing home residents that did not lead to hospital admission (potentially preventable) with those that led to admission (less likely preventable). SettingNationally representative sample of US EDs; federal hospitals and hospitals with fewer than 6 beds were excluded. ParticipantsOlder (age ≥65 years) NH residents with an ED visit during this time period. MeasurementsPatient demographics, ED visit information including testing performed, interventions (both procedures and medications) provided, and diagnoses treated. ResultsOlder NH residents accounted for 3857 of 208,956 ED visits during the time period of interest (1.8%). When weighted to be nationally representative, these represent 13.97 million ED visits, equivalent to 1.8 ED visits annually per NH resident in the United States. More than half of visits (53.5%) did not lead to hospital admission; of those discharged from the ED, 62.8% had normal vital signs on presentation and 18.9% did not have any diagnostic testing before ED discharge. Injuries were 1.78 times more likely to be discharged than admitted (44.8% versus 25.3%, respectively, P < .001), whereas infections were 2.06 times as likely to be admitted as discharged (22.9% versus 11.1%, respectively). Computed tomography (CT) scans were performed in 25.4% and 30.1% of older NH residents who were discharged from the ED and admitted to the hospital, respectively, and more than 70% of these were CTs of the head. NH residents received centrally acting, sedating medications before ED discharge in 9.4% of visits. ConclusionThis nationally representative sample of older NH residents suggests ED visits for injury, those that are associated with normal triage vital signs, and those that are not associated with any diagnostic testing are potentially preventable. Those discharged from the ED often undergo important testing and receive medications that may alter their physical examination on return to the nursing facility, highlighting the need for seamless communication of the ED course to NHs.

The effect of emergency department crowding on reassessment of children with critically abnormal vital signs.

The objective was to determine whether several measures of emergency department (ED) crowding are associated with an important indicator of quality and safety: time to reevaluation of children with documented critically abnormal triage vital signs. This was a retrospective cross-sectional study of all patients with critically abnormal vital signs measured in triage over a 2.5-year period (September 1, 2006, to May 1, 2009). Cox proportional hazard analysis was used to determine rate ratios for time to critically abnormal vital sign reassessment, when controlled for potential confounders. In this 2.5-year sample, 9,976 patients with critically abnormal vital signs in triage (representing 3.9% of 253,408 visits) were placed in regular ED rooms with electronic alerts prompting vital sign reassessment after 1 hour. Overall, the mean time to reassessment was 84 minutes. The rate of vital sign reassessment was reduced by 31% for each additional 10 patients waiting for admission (adjusted odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.98 to 0.99), by 10% for every 10 patients in the lobby (adjusted OR = 0.94; 95% CI = 0.93 to 0.96), and by 6% for every additional 10 patients in the overall ED census (adjusted OR = 0.97; 95% CI = 0.97 to 0.98). Emergency department crowding was associated with delay in the reassessment of critically abnormal vital signs in children; further work is needed to develop systems to mitigate these delays.

135 How Accurate is “My Gut Feeling?”: Comparing the Accuracy of System 1 versus System 2 Decisionmaking for the Acuity Prediction of Patients Presenting to an Emergency Department

Two models of decisionmaking have been characterized by cognitive sciences, in which System 1 represents a fast and information-limited model (eg, intuitive), whereas System 2 represents a slow, information-heavy cognitive model (eg, hypothetico-deductive). The aim of the study was to evaluate the accuracy of diagnostic prediction based on brief System 1 diagnostic reasoning compared to a System 2 process. We conducted a prospective observational study of emergency physicians, residents and faculty, to assess the accuracy of their System 1 and System 2 diagnostic reasoning for the diagnosis and acuity prediction of patients presenting to a tertiary care academic ED with 73,000 annual patient visits. Study personnel provided clinicians the following data: demographics, chief complaint, and vital signs. Clinicians were permitted to briefly observe (less than a minute) each patient as they were roomed and they have access to triage vital signs and chief complaint. Physicians were asked to predict if the patient was “sick” based on a standardized operational definition. Two independent clinician investigators, blinded to real-time assessments of “sick” versus “not sick,” ascertained the gold standard definition of “sick” or “not-sick” using previously published criteria. Disagreements were resolved by a third author. Prognostic accuracy estimates for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and likelihood ratios (LR) were calculated, along with their respective 95% confidence intervals (CIs). We included a total of 662 observations of 289 different patients. Interobserver agreement (kappa) between observers was 0.97 (95% CI 0.95-099). Residents performed 416 (62.8%) of the assessments. For the “sick” versus “not sick” classification, providers overall had a sensitivity of 73.9% (CI 67.7 to 79.5%), specificity 83.3% (CI 79.5 to 86.7%), PPV 70.3%, NPV 85.7%, LR(+) 2.36 and LR(-) 0.17.There was no difference in sensitivity or specificity between attendings and residents in predicting “sick,” with attendings’ sensitivity of 77.5% (CI 66.8 to 86.1%) versus 72.0% (64.1 to 79.0%) for residents (P=.4), and specificity of 83.1% (76.6 to 88.5%) for attendings versus 83.5% (78.4 to 87.7%) for residents (P=.9). When emergency physicians use System 1 diagnostic reasoning for acuity prediction (ie, “sick”) the accuracy seems to be high, with a sensitivity of 74% and specificity of 83%, similar to the diagnostic yield of tests like the rapid influenza test. A brief System 1 decisionmaking process appears to be helpful in providing a cognitive framework for subsequent patient management.

Sensitivity of systemic inflammatory response syndrome for critical illness among ED patients

BackgroundLittle is known about the diagnostic accuracy of systemic inflammatory response syndrome (SIRS) criteria for critical illness among emergency department (ED) patients with and without infection. Our objective was to assess the diagnostic accuracy of SIRS criteria for critical illness in ED patients. MethodsThis was a retrospective cohort study of ED patients at an urban academic hospital. Standardized chart abstraction was performed on a random sample of all adult ED medical patients admitted to the hospital during a 1-year period, excluding repeat visits, transfers, ED deaths, and primary surgical or psychiatric admissions. The binary composite outcome of critical illness was defined as 24 hours or longer in intensive care or inhospital death. Presumed infection was defined as receiving antibiotics within 48 hours of admission. Systemic inflammatory response syndrome criteria were calculated using ED triage vital signs and initial white blood cell count. ResultsWe studied 1152 patients; 39% had SIRS, 27% had presumed infection, and 23% had critical illness (2% had inhospital mortality, and 22% had ≥24 hours in intensive care). Of patients with SIRS, 38% had presumed infection. Of patients without SIRS, 21% had presumed infection. The sensitivity of SIRS criteria for critical illness was 52% (95% confidence interval [CI], 46%-58%) in all patients, 66% (95% CI, 56%-75%) in patients with presumed infection, and 43% (95% CI, 36%-51%) in patients without presumed infection. ConclusionsSystemic inflammatory response syndrome at ED triage, as currently defined, has poor sensitivity for critical illness in medical patients admitted from the ED.

Predictive Value of Triage Vital Signs and Conscious Level For Outcome Evaluation in Acutely Intoxicated Patients

Triage in Emergency departments requires emergency doctors to make rapid decisions based on their knowledge and experiences. Triage of patients is critical to patient safety, yet no clear information exists for the utility of initial vital signs in identifying critically ill poisoned patients. The objective of this study is to determine the relationship between triage vital signs and conscious level in predicting the outcome of acutely poisoned patients. The total number of patients was 321 patients admitted to Poison Control Center (PCC) of Ain Shams University Hospitals. Information was collected from the sheets and computerized data base of the patients including vital signs and Glasgow coma scale (GCS) on admission after obtaining the permission of the director of PCC and the regional ethics committee. The results were revised, coded and organized for statistical analysis. The study results revealed 265 (82.6%) survivors with no complications, 30 patients (9.4%) survived but developed complications and 26 (8%) patients died. The study also showed that 32% of patients had hyperthermia, 1.1% had hypothermia, 22.4% had tachycardia, 6.2% had bradycardia, 10.9% had hypotension, 4% had hypertension and 22.8% showed respiratory distress. Additionally, 69.4% of patients had GCS > 8, while 30.6% had GCS ≤ 8. The study showed statistically significant difference between uncomplicated, complicated and dead cases as regards heart rate, systolic blood pressure, respiratory rate, skin discoloration (pallor or cyanosis) and GCS. It could be concluded that vital signs can serve as an easily measurable tool for outcome prediction in poisoning cases.

Implementation of a Standardized Pediatric Emergency Medicine Transfer of Care Sign-out Guide: A Feasibility Study

This is a feasibility study to determine if a standardized transfer of care (TOC) sign-out guide for Pediatric Emergency Department (PED) patients improves resident satisfaction. Residents from various training programs (Emergency Medicine, Pediatrics, and Family Medicine) voluntarily reported their TOC sign-out satisfaction [100mm Visual Analog Scale (VAS)] and duration (minutes) preand post-implementation of a sign-out guide. Pre-intervention data collection occurred from September 2011 to January 2012, and post-intervention data collection occurred from February to May 2012. The guide included the following prompts: chief complaint, past medical history, history of present illness, admission reason, triage and final vital signs, pertinent positive and negative exam findings, and if applicable, medications, fluids, radiographic studies, consultant recommendations, and noted improvements (or lack of). A final section of the guide prompted the PED resident to ask if the receiving team had any questions. Resident satisfaction and TOC sign-out duration pre-and post-implementation of the sign-out guide were analyzed (n=292, 167 preand 125 post-implementation). Use of the sign-out guide improved resident satisfaction [Satisfaction (100mm VAS): Pre-implementation – 80 (95% Confidence Interval (CI) 70 – 83); Postimplementation – 95 (95% CI 87 – 99, p-value 0.02] without a statistically significant difference in sign-out duration [Duration: Pre-implementation – 5 minutes (95% CI 4.2 – 6.8); Post implementation – 5 minutes (95% CI 4.7– 5.8), p-value 0.3]. A standardized sign-out guide successfully allowed residents to convey important patient care information regarding TOC and improved resident satisfaction.

National estimates of emergency department visits for pediatric severe sepsis in the United States

Objective. We sought to determine the characteristics of children presenting to United States (US) Emergency Departments (ED) with severe sepsis.Study design. Cross-sectional analysis using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Using triage vital signs and ED diagnoses (defined by the International Classification of Diseases, Ninth Revision codes), we identified children <18 years old presenting with both infection (triage fever or ICD-9 infection) and organ dysfunction (triage hypotension or ICD-9 organ dysfunction).Results. Of 28.2 million pediatric patients presenting to US EDs each year, severe sepsis was present in 95,055 (0.34%; 95% CI: 0.29–0.39%). Fever and respiratory infection were the most common indicators of an infection. Hypotension and respiratory failure were the most common indicators of organ dysfunction. Most severe sepsis occurred in children ages 31 days–1 year old (32.1%). Most visits for pediatric severe sepsis occurred during winter months (37.4%), and only 11.1% of patients arrived at the ED by ambulance. Over half of severe sepsis cases were self-pay or insured by Medicaid. A large portion (44.1%) of pediatric severe sepsis ED visits occurred in the South census region. ED length of stay was over 3 h, and 16.5% were admitted to the hospital.Conclusion. Nearly 100,000 children annually present to US EDs with severe sepsis. The findings of this study highlight the unique characteristics of children treated in the ED for severe sepsis.

Asthma Vital Signs at Triage

Commonly used acute asthma scoring systems assess severity of symptoms, whereas other clinical models aim to predict hospitalization; all rely on a measure of response to treatment and use the same criteria across age ranges. This may not reflect a child's changing physiology and response to illness as he or she grows older.This study aimed to find age-specific objective predictors of hospitalization readily known at triage. The goal is to identify rapidly those who will likely need admission regardless of treatment administered or response to aggressive treatment in the emergency department (ED). Children between 1 and 18 years of age with a final primary ED International Classification of Diseases, Ninth Revision, diagnosis of asthma or asthma-related spectrum of disease were studied using data from the National Hospital Ambulatory Medical Care Survey. The primary outcome was hospital admission (observation unit, ward, monitored, or pediatric intensive care unit).Triage vital signs, mode of arrival, recent visits, emergency severity index score, as well as demographic and socioeconomic factors were incorporated into age-specific forward-selection multiple logistic regression models. In 2,454,983 ED visits for asthma or reactive airway disease among children 1 to 18 years of age, patterns of vital sign predictors for admission varied by age group. Across all ages, diastolic hypotension at triage was an early, consistent, independent predictor of admission, especially in 1- to 3-year-olds (odds ratio, 6.27; 95% confidence interval, 6.01-6.54) and 3- to 6-year-olds (odds ratio, 17.95; 95% confidence interval, 16.80-19.17). Age-specific assessment is important in the evaluation of acute asthma or reactive airway exacerbation. Diastolic hypotension may serve as an early warning indicator of severity of disease and need for hospitalization. Variability by age group in vital sign predictor for admission calls for further development or refinement of age-specific asthma assessment tools.

Predictive Value of Initial Triage Vital Signs for Critically Ill Older Adults

Introduction:Triage of patients is critical to patient safety, yet no clear information exists as to the utility of initial vital signs in identifying critically ill older emergency department (ED) patients. The objective of this study is to evaluate a set of initial vital sign thresholds as predictors of severe illness and injury among older adults presenting to the ED.Methods:We reviewed all visits by patients aged 75 and older seen during 2007 at an academic ED serving a large community of older adults. Patients’ charts were abstracted for demographic and clinical information including vital signs, via automated electronic methods. We used bivariate analysis to investigate the relationship between vital sign abnormalities and severe illness or injury, defined as intensive care unit (ICU) admission or ED death. In addition, we calculated likelihood ratios for normal and abnormal vital signs in predicting severe illness or injury.Results:4,873 visits by patients aged 75 and above were made to the ED during 2007, and of these 3,848 had a complete set of triage vital signs. For these elderly patients, the sensitivity and specificity of an abnormal vital sign taken at triage for predicting death or admission to an ICU were 73% (66,81) and 50% (48,52) respectively (positive likelihood ratio 1.47 (1.30,1.60); negative likelihood ratio 0.54 (0.30,0.60).Conclusion:Emergency provider assessment and triage scores that rely primarily on initial vital signs are likely to miss a substantial portion of critically ill older adults.