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Allen, Casey J., Daniel J. Baldor, Carl I. Schulman, Louis R. Pizano, Alan S. Livingstone, and Nicholas Namias. "Assessing Field Triage Decisions and the International Classification Injury Severity Score (ICISS) at Predicting Outcomes of Trauma Patients." American Surgeon 83, no. 6 (June 2017): 648–52. http://dx.doi.org/10.1177/000313481708300632.
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Florida considers the International Classification Injury Severity Score (ICISS) from hospital discharges within a geographic region in the apportionment of trauma centers (TCs). Patients with an ICISS <0.85 are considered to require triage to a TC, yet many are triaged to an emergency department (ED). We assess outcomes of those with an ICISS <0.85 by the actual triage decision of emergency medical services (EMS). From October 2011 to October 2013, 39,021 consecutive admissions with injury ICD-9 codes were analyzed. ICISS was calculated from the product of the survival risk ratios for a patient's three worst injuries. Outcomes were compared between patients with ICISS <0.85 either triaged to the ED or its separate, neighboring, free-standing TC at a large urban hospital. A total of 32,191 (83%) patients were triaged to the ED by EMS and 6,827 (17%) were triaged to the TC. Of these, 2544 had an ICISS <0.85, with 2145 (84%) being triaged to the TC and 399 (16%) to the ED. In these patients, those taken to the TC more often required admission, and those taken to the ED had better outcomes. When the confounders influencing triage to an ED or a TC are eliminated, those triaged by EMS to the ED rather than the TC had better overall outcomes. EMS providers better identified patients at risk for mortality than did the retrospective application of ICISS. ICISS <0.85 does not identify the absolute need for TC as EMS providers were able to appropriately triage a large portion of this population to the ED.
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Kumar, R., S. Bhoi, S. Chauhan, T. P. Sinha, G. Adhikari, G. Sharma, and K. Shyamla. "(A264) Does the Implementation of Start Triage Criteria in the Emergency Department Reduce Over- and under-Triage of Patients?" Prehospital and Disaster Medicine 26, S1 (May 2011): s72—s73. http://dx.doi.org/10.1017/s1049023x11002482.
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BackgroundAppropriate triage shortens the delay in definitive care. this study examined whether the implementation of START triage criteria in emergency departments (ED) reduces over- and under-triage of patients. The purpose of this study was to examine the impact of START triage criteria on over and under-triage subjects.MethodsThe study was performed between 01 January to 15 September 2008. All patients presenting to the ED were recruited. A triage nurse tagged the patients with a red, yellow, and or green wristband, as per START triage protocol. Over-triage was defined as patients who were re-triaged from red (R) to yellow (Y) or Y to green (G) within 30 minutes of arrival. Under-triage was defined as patients re-triaged from Y to R or G to Y within 30 minutes of arrival.ResultsOf 25,928 patients, triage was performed for 25,468 (98.2%) subjects. A total of 8,303 were triaged during the morning shift, 6,994 during the evening shift, and 9,978 during the night shift. A total of 1,431 (5.6%) subjects were tagged as R, 10,634 (41.7%) with Y, and 13,424 (52.7%) were tagged as G. Four hundred seventy-four (1.9%) patients were over-triaged. Two hundred twenty (0.9%) were under-triaged.ConclusionsThe START triage criteria reduce over- and under-triage of patients.
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McMahon, Margaret M. "ED Triage." AJN, American Journal of Nursing 103, no. 3 (March 2003): 61–63. http://dx.doi.org/10.1097/00000446-200303000-00022.
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McLeod, S., J. McCarron, T. Ahmed, S. Scott, H. Ovens, N. Mittmann, and B. Borgundvaag. "LO70: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score pre and post implementation of eCTAS." CJEM 20, S1 (May 2018): S31—S32. http://dx.doi.org/10.1017/cem.2018.132.
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Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, ED funding and workload models. The Electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes the application of national triage guidelines (CTAS) across Ontario. The objective of this study was to evaluate the implementation of eCTAS in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1200 (738 pre-eCTAS, 462 post-implementation) individual patient CTAS assessments were audited over 33 (21 pre-eCTAS, 11 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients pre-eCTAS, compared to 429 (93.0%) patients triaged with eCTAS. Using the auditors CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.1% vs. 3.2%; 8.9, 95% CI: 5.7, 11.7) and under-triaged (12.9% vs. 3.9%; 9.0, 95% CI: 5.9, 12.0). Interrater agreement was higher with eCTAS (unweighted kappa 0.90 vs 0.63; quadratic-weighted kappa 0.79 vs. 0.94). Research assistants captured triage time for 4403 patients pre-eCTAS and 1849 post implementation of eCTAS. Median triage time was 304 seconds pre-eCTAS and 329 seconds with eCTAS ( 25 seconds, 95% CI: 18, 32 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.
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Gravel, Jocelyn, Sergio Manzano, and Michael Arsenault. "Validity of the Canadian Paediatric Triage and Acuity Scale in a tertiary care hospital." CJEM 11, no. 01 (January 2009): 23–28. http://dx.doi.org/10.1017/s1481803500010885.
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ABSTRACTObjective:We evaluated the validity of the Canadian Paediatric Triage and Acuity Scale (Paed-CTAS) for children visiting a pediatric emergency department (ED).Methods:This was a retrospective study evaluating all children who presented to a pediatric university-affiliated ED during a 1-year period. Data were retrieved from the ED database. Information regarding triage and disposition was registered in an ED database by a clerk following patient management. In the absence of a gold standard for triage, admission to hospital, admission to pediatric intensive care unit (PICU) and length of stay (LOS) in the ED were used as surrogate markers of severity. The primary outcome measure was the correlation between triage level (from 1 to 5) and admission to hospital. The correlation between triage level and dichotomous outcomes was evaluated by aχ2test and an analysis of variance (ANOVA) was used to evaluate the association between triage level and ED LOS.Results:Over the 1-year period, 58 529 patients were triaged in the ED. The proportion admitted to hospital was 63% for resuscitation (level 1), 37% for emergent (level 2), 14% for urgent (level 3), 2% for semiurgent (level 4) and 1% for nonurgent (level 5) (p< 0.001). There was also a good correlation between triage levels and LOS and admission to PICU (bothp< 0.001).Conclusion:This computerized version of PaedCTAS demonstrates a strong association with admission to hospital, admission to PICU and LOS in the ED. These results suggest that PaedCTAS is a valid tool for triage of children in a pediatric ED.
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Khursheed, M., K. Ejaz, and F. Hanif. "(A261) Evolution of Triage Services in the Emergency Department Aga Khan University Hospital- Karachi." Prehospital and Disaster Medicine 26, S1 (May 2011): s72. http://dx.doi.org/10.1017/s1049023x11002457.
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The history of triage started from the French battle field. In- hospital ED triage started in early 1960's from Baltimore. It is now an essential component of modern ED. Triage is not only to sort out patients as per their criticality, but it also serves the purpose of streamlining the patients so that the patient receives right treatment at the right time in the appropriate area. It helps to manage the ED overcrowding by better flow of patients. AKUH-ER experience of triage dates back to the year 2000, when triage was conducted by physicians and there used to be a manual documentation of patient's particulars such as complaints, vitals and BP. With the expansion of AKU-ED in 2008 responsibility of triage shifted to nursing services. Triage policy was drafted and implemented and for guidance and uniformity of care, triage protocols were developed. Another important development is replacement of register with triage data entry software. This help us to monitor some indicators like number of patients triaged, the time between triaging and actual bed assignment, triage categorization, length of stay, dispositions and return visits. The available information now helps us to make decisions based on evidence and also paves the way for future direction.
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Betz, Martin, James Stempien, Sachin Trevidi, and Rhonda Bryce. "A determination of emergency department pre-triage times in patients not arriving by ambulance compared to widely used guideline recommendations." CJEM 19, no. 04 (December 5, 2016): 265–70. http://dx.doi.org/10.1017/cem.2016.398.
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ABSTRACT Objectives Emergency department (ED) lengths of stay are measured from the time of patient registration or triage. The time that patients wait in line prior to registration and triage has not been well described. We sought to characterize pre-triage wait times and compare them to recommended physician response times, as per the Canadian Triage and Acuity Scale (CTAS). Methods This observational study documented the time that consenting patients entered the ED and the time that they were formally registered and triaged. Participants’ CTAS scores were collected from the electronic record. Patients arriving to the ED by ambulance were excluded. Results A total of 536 participants were timed over 13 separate intervals. Of these, 11 left without being triaged. Participants who scored either CTAS 1 or 2 (n=53) waited a median time of 3.1 (interquartile range [IQR]: 0.43, 11.1) minutes. Patients triaged as CTAS 3 (n=187) waited a median of 11.4 (IQR: 1.6, 24.9) minutes, CTAS 4 (n=139) a median of 16.6 (IQR: 6.0, 29.7) minutes, and CTAS 5 (n=146) a median of 17.5 (IQR: 6.8, 37.3) minutes. Of patients subsequently categorized as CTAS 1 or 2, 20.8% waited longer than the recommended time-to-physician of 15 minutes to be triaged. Conclusions All urban EDs closely follow patients’ wait times, often stratified according to triage category, which are assumed to be time-stamped upon a patient’s arrival in the ED. We note that pre-triage times exceed the CTAS recommended time-to-physician in a possibly significant proportion of patients. EDs should consider documenting times to treatment from the moment of patient arrival rather than registration.
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McLeod, S., J. McCarron, T. Ahmed, S. Scott, H. Ovens, N. Mittmann, and B. Borgundvaag. "LO81: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score pre and post implementation of eCTAS." CJEM 21, S1 (May 2019): S37. http://dx.doi.org/10.1017/cem.2019.123.
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Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, emergency department (ED) funding and workload models. The electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes that application of national triage guidelines across Ontario. The objective of this study was to evaluate triage times and score agreement in ED settings where eCTAS has been implemented. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1491 (752 pre-eCTAS, 739 post-implementation) individual patient CTAS assessments were audited over 42 (21 pre-eCTAS, 21 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 567 (75.4%) patients pre-eCTAS, compared to 685 (92.7%) patients triaged with eCTAS. Using the auditor's CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.0% vs. 5.1%; Δ 6.9, 95% CI: 4.0, 9.7) and under-triaged (12.6% vs. 2.2%; Δ 10.4, 95% CI: 7.9, 13.2). Interrater agreement was higher with eCTAS (unweighted kappa 0.89 vs 0.63; quadratic-weighted kappa 0.91 vs. 0.71). Research assistants captured triage time for 3808 patients pre-eCTAS and 3489 post implementation of eCTAS. Median triage time was 312 seconds pre-eCTAS and 347 seconds with eCTAS (Δ 35 seconds, 95% CI: 29, 40 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.
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McLeod, S. L., J. McCarron, K. Stein, S. Scott, H. J. Ovens, N. Mittman, and B. Borgundvaag. "LO75: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score in 7 emergency departments." CJEM 19, S1 (May 2017): S54. http://dx.doi.org/10.1017/cem.2017.137.
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Introduction: The Canadian Triage and Acuity Scale (CTAS) is the standard used in all Canadian (and many international) emergency departments (EDs) for establishing the priority by which patients should be assessed. In addition to its clinical utility, CTAS has become an important administrative metric used by governments to estimate patient care requirements, ED funding and workload models. Despite its importance, the process by which CTAS scores are derived is highly variable. Emphasis on ED wait times has also drawn attention to the length of time the triage process takes. The primary objective of this study was to determine the interrater agreement of CTAS in current clinical practice. The secondary objective was to determine the time it takes to triage in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 738 consecutive patient CTAS assessments were audited over 21 seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients. Using the auditor’s CTAS score as the reference standard, on-duty triage nurses over-triaged 89 (12.1%) and under-triaged 95 (12.9%) patients. Interrater agreement was “good” with an unweighted kappa of 0.63 (95% CI: 0.58, 0.67) and quadratic-weighted kappa of 0.79 (95% CI: 0.67, 0.90). Research assistants captured triage time for 3808 patients over 69 shifts at 7 different EDs. Median (IQR) triage time was 5.2 (3.8, 7.3) minutes and ranged from 3.9 (3.1, 4.8) minutes to 7.5 (5.8, 10.8) minutes. Conclusion: Variability in the accuracy, and length of time taken to perform CTAS assessments suggest that a standardized approach to performing CTAS assessments would improve both clinical decision making, and administrative data accuracy.
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Dallaire, Clémence, Julien Poitras, Karine Aubin, André Lavoie, Lynne Moore, and Geneviève Audet. "Interrater agreement of Canadian Emergency Department Triage and Acuity Scale scores assigned by base hospital and emergency department nurses." CJEM 12, no. 01 (January 2010): 45–49. http://dx.doi.org/10.1017/s148180350001201x.
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ABSTRACTObjective:We sought to assess the applicability of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the prehospital setting by comparing CTAS scores assigned during ambulance transportation by base hospital (BH) nurses with CTAS scores given by emergency department (ED) nurses on patients' arrival.Methods:We recruited a prospective sample of consecutive patients who were transported to the ED by ambulance between December 2006 and March 2007 for whom a contact was made with the BH. Patients were triaged by the BH nurse with online communication and vital signs transmission. On arrival, patients were blindly triaged again by the ED nurse. We used the quadratic weighted κ statistic to measure the agreement between the 2 CTAS scores.Results:Ninety-four patients were triaged twice by 2 nursing teams (9 nurses at the BH and 39 nurses in the ED). The agreement obtained on prehospital and ED CTAS scores was moderate (κ = 0.50; 95% confidence interval 0.37–0.63).Conclusion:The moderate interrater agreement we obtained may be a result of the changing conditions of patients during transport or may indicate that CTAS scoring requires direct contact to produce reliable triage scores. Our study casts a serious doubt on the appropriateness of BH nurses performing triage with CTAS in the prehospital setting.
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Lee, James S., and Jeffrey M. Franc. "Impact of a Two-step Emergency Department Triage Model with START, then CTAS, on Patient Flow During a Simulated Mass-casualty Incident." Prehospital and Disaster Medicine 30, no. 4 (June 24, 2015): 390–96. http://dx.doi.org/10.1017/s1049023x15004835.
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AbstractIntroductionA high influx of patients during a mass-casualty incident (MCI) may disrupt patient flow in an already overcrowded emergency department (ED) that is functioning beyond its operating capacity. This pilot study examined the impact of a two-step ED triage model using Simple Triage and Rapid Treatment (START) for pre-triage, followed by triage with the Canadian Triage and Acuity Scale (CTAS), on patient flow during a MCI simulation exercise.Hypothesis/ProblemIt was hypothesized that there would be no difference in time intervals nor patient volumes at each patient-flow milestone.MethodsPhysicians and nurses participated in a computer-based tabletop disaster simulation exercise. Physicians were randomized into the intervention group using START, then CTAS, or the control group using START alone. Patient-flow milestones including time intervals and patient volumes from ED arrival to triage, ED arrival to bed assignment, ED arrival to physician assessment, and ED arrival to disposition decision were compared. Triage accuracy was compared for secondary purposes.ResultsThere were no significant differences in the time interval from ED arrival to triage (mean difference 108 seconds; 95% CI, -353 to 596 seconds; P=1.0), ED arrival to bed assignment (mean difference 362 seconds; 95% CI, -1,269 to 545 seconds; P=1.0), ED arrival to physician assessment (mean difference 31 seconds; 95% CI, -1,104 to 348 seconds; P=0.92), and ED arrival to disposition decision (mean difference 175 seconds; 95% CI, -1,650 to 1,300 seconds; P=1.0) between the two groups. There were no significant differences in the volume of patients to be triaged (32% vs 34%; 95% CI for the difference -16% to 21%; P=1.0), assigned a bed (16% vs 21%; 95% CI for the difference -11% to 20%; P=1.0), assessed by a physician (20% vs 22%; 95% CI for the difference -14% to 19%; P=1.0), and with a disposition decision (20% vs 9%; 95% CI for the difference -25% to 4%; P=.34) between the two groups. The accuracy of triage was similar in both groups (57% vs 70%; 95% CI for the difference -15% to 41%; P=.46).ConclusionExperienced triage nurses were able to apply CTAS effectively during a MCI simulation exercise. A two-step ED triage model using START, then CTAS, had similar patient flow and triage accuracy when compared to START alone.LeeJS, FrancJM. Impact of a two-step emergency department triage model with START, then CTAS, on patient flow during a simulated mass-casualty incident. Prehosp Disaster Med. 2015;30(4):1–7.
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Eastwood, Kathryn, Karen Smith, Amee Morgans, and Johannes Stoelwinder. "Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study." BMJ Open 7, no. 10 (October 2017): e016845. http://dx.doi.org/10.1136/bmjopen-2017-016845.
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ObjectiveTo investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary telephone triage.DesignA pragmatic retrospective cohort analysis of all the planned and unplanned ED presentations within 48 hours of a secondary telephone triage.SettingThe secondary telephone triage service, called the Referral Service, and the hospitals were located in metropolitan Melbourne, Australia and operated 24 hours a day, servicing 4.25 million people. The Referral Service provides an in-depth secondary triage of cases classified as low acuity when calling the Australian emergency telephone number.PopulationCases triaged by the Referral Service between September 2009 and June 2012 were linked to ED and hospital admission records (N=44,523). Planned ED presentations were cases referred to the ED following the secondary triage, unplanned ED presentations were cases that presented despite being referred to alternative care pathways.Main outcome measuresAppropriateness was measured using an ED suitability definition and hospital admission rates. These were compared with mean population data which consisted of all of the ED presentations for the state (termed the ‘average Victorian ED presentation’).ResultsPlanned ED presentations were more likely to be ED suitable than unplanned ED presentations (OR 1.62; 95% CI 1.5 to 1.7; p<0.001) and the average Victorian ED presentation (OR 1.85; 95% CI 1.01 to 3.4; p=0.046). They were also more likely to be admitted to the hospital than the unplanned ED presentation (OR 1.5; 95% CI 1.4 to 1.6; p<0.001) and the average Victorian ED presentation (OR 2.3, 95% CI 2.24 to 2.33; p<0.001). Just under 15% of cases diverted away from the emergency care pathways presented in the ED (unplanned ED attendances), and 9.5% of all the alternative care pathway cases were classified as ED suitable and 6.5% were admitted to hospital.ConclusionsSecondary telephone triage was able to appropriately identify many ED suitable cases, and while most cases referred to alternative care pathways did not present in the ED. Further research is required to establish that these were not inappropriately triaged away from the emergency care pathways.
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Kovacs, M., and S. Campbell. "LO31: Triage drift: Variation in application of the Canadian Triage Acuity Scale between triage nurses compared to triage paramedics in response to overcrowding pressures in an emergency department." CJEM 22, S1 (May 2020): S18. http://dx.doi.org/10.1017/cem.2020.87.
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Introduction: CTAS is a validated five-level triage score utilized in EDs across Canada and internationally. Moderate interrater reliability between prehospital paramedic and triage nurse application of CTAS during clinical practice has been found. This study is the first assessment of the variation in distribution of CTAS scores with increasing departmental pressure as measured by the NEDOCs scale comparing triage allocations made by triage nurses with those made by triage paramedics. Methods: We conducted a retrospective, observational cohort study of EDIS data of all patients triaged in the Halifax Infirmary Emergency Department from January 1, 2017-May 30, 2017 and January 1, 2018 - May 30, 2018. CTAS score assignment by nursing and paramedic triage staff were compared with increasing levels of ED overcrowding, as determined by the department NEDOCS score. Results: Nurses were more likely to assign higher acuity scores in all situations of department crowding; there was a 3% increased probability that a nurse, as compared to a paramedic, would triage as emergent when the ED was not overcrowded (Pearson chi-square(1) = 4.21, p < 0.05, Cramer's v = 0.028, n = 5314), and a 10% increased probability that a nurse, as compared to a paramedic, would triage a patient as emergent when EDs were overcrowded (Pearson chi-square(1) = 623.83, p < 0.001, Cramer's v = 0.11, n = 56 018). Conclusion: Increasing levels of ED overcrowding influence triage nurse CTAS score assignment towards higher acuity to a greater degree than scores assigned by triage paramedics.
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Gravel, Jocelyn, Sergio Manzano, and Michael Arsenault. "Safety of a modification of the triage level for febrile children 6 to 36 months old using the Paediatric Canadian Triage and Acuity Scale." CJEM 10, no. 01 (January 2008): 32–37. http://dx.doi.org/10.1017/s1481803500009982.
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ABSTRACT Objective: The Paediatric Canadian Triage and Acuity Scale (PaedCTAS) stipulates that febrile patients who are 3 to 36 months old should be triaged to the PaedCTAS 3 “urgent” category. To optimize resource use, we implemented a protocol enabling these children to be down-triaged to the PaedCTAS 4 “less urgent” category if there was no sign of toxicity. Our objective was to evaluate the safety of this triage protocol modification. Methods: This retrospective cohort study evaluated all patients triaged in an urban tertiary pediatric hospital during a 6-month period between November 22, 2005, and May 22, 2006. Data were retrieved from the emergency department (ED) database and rates of hospitalization and intensive care unit (ICU) admission were compared for 4 groups: all patients triaged as urgent (level 3), all febrile patients from 3 to 36 months old triaged as urgent (level 3), all patients triaged as less urgent (level 4) and all febrile patients aged 3 to 36 months old who were down-triaged to less urgent (level 4). Results: There were 36 285 total ED visits during the study period, including 3477 febrile children who were 3 to 36 months old. Nurses down-triaged 1869 febrile children (54%) to the level-4 (less urgent) category and left 1322 (38%) in the level-3 (urgent) category. Hospitalization rate for down-triaged febrile patients was similar to that seen for all PaedCTAS 4 patients (2.4% v. 2.8%, 95% confidence interval for difference –0.3% to 1.1%). Down-triaged patients had significantly lower admission rates than those remaining in the level-3 (urgent) category (absolute risk reduction 10.7% standard deviation 1.9%, p < 0.001). No down-triaged patient died or required ICU admission. Conclusion: Febrile children aged 6 to 36 months who have no signs of toxicity can safely be down-triaged, based on triage nurse clinical judgement, to the less urgent PaedCTAS 4 category. This modification would affect the triage level of approximately 5% of all pediatric ED visits.
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Ng, Chip-Jin, Cheng-Yu Chien, Julian Chen-June Seak, Shang-Li Tsai, Yi-Ming Weng, Chung-Hsien Chaou, Chan-Wei Kuo, Jih-Chang Chen, and Kuang-Hung Hsu. "Validation of the five-tier Taiwan Triage and Acuity Scale for prehospital use by Emergency Medical Technicians." Emergency Medicine Journal 36, no. 8 (July 29, 2019): 472–78. http://dx.doi.org/10.1136/emermed-2018-207509.
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ObjectivesThis study aimed to determine the inter-rater reliability of the five-level Taiwan Triage and Acuity Scale (TTAS) when used by emergency medical technicians (EMTs) and triage registered nurses (TRNs). Furthermore, it sought to validate the prehospital TTAS scores according to ED hospitalisation rates and medical resource consumption.MethodsThis was a prospective observational study. After training in five-level triage, EMTs triaged patients arriving to the ED and agreement with the nurse triage (TRN) was assessed. Subsequently, these trained research EMTs rode along on ambulance calls and assigned TTAS scores for each patient at the scene, while the on-duty EMTs applied their standard two-tier prehospital triage scale and followed standard practice, blinded to the TTAS scores. The accuracy of the TTAS scores in the field for prediction of hospitalisation and medical resource consumption were analysed using logistic regression and a linear model, respectively, and compared with the accuracy of the current two-tier prehospital triage scale.ResultsAfter EMT’s underwent initial training in five-level TTAS, inter-rater agreement between EMTs and TRNs for triage of ED patients was very good (κw=0.825, CI 0.750 to 0.900). For the outcome of hospitalisation, TTAS five-level system (Akaike’s Information Criteria (AIC)=486, area under the curve (AUC)=0.75) showed better discrimination compared with TPTS two-level system (AIC=508, AUC=0.66). Triage assignments by the EMTs using the the five-level TTAS was linearly associated with hospitalisation and medical resource consumption.ConclusionsA five-level prehospital triage scale shows good inter-rater reliability and superior discrimination compared with the two-level system for prediction of hospitalisation and medical resource requirements.
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Elkholi, Ahmed, Huda Althobiti, Jamal Al Nofeye, Mohamed Hasan, and Ahmed Ibrahim. "NO WAIT: new organised well-adapted immediate triage: a lean improvement project." BMJ Open Quality 10, no. 1 (January 2021): e001179. http://dx.doi.org/10.1136/bmjoq-2020-001179.
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Long waiting times in the emergency department (ED) are associated with decreased patient satisfaction and increased morbidity and mortality. Triage may be a contributing factor to prolonged wait times in the ED. At Alhada Armed Forces Hospital (Taif, Saudi Arabia), patients other than level 1 and 2 on the Canadian Triage and Acuity Scale are requested to wait until triage. During peak hours (08:00−22:00), the waiting time prior to triage is prolonged, and several patients leave the ED before triage. In this project, a multidisciplinary team was assembled to revise patient flow from the time of arrival at the ED to the time of triage. Lean methodology was used to identify the redundancies and design a seamless flow process for ED patients. Through reorganising the triage area using minimal additional resources, the project team devised a novel floor plan for the triage area which provided a unique patient flow in the ED. The median patient wait time from arrival to triage was reduced from 27 min to 4.09 min and the percentage of patients leaving the ER before triage was reduced to 0%. This project is the first of its kind in Saudi Arabia, as well as in the Gulf region, and provides a radical solution to the problem of patient waiting in the ED during peak hours.
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Fernandes, Christopher M. B., Shelley McLeod, Joel Krause, Amit Shah, Justine Jewell, Barbara Smith, and Lorraine Rollins. "Reliability of the Canadian Triage and Acuity Scale: interrater and intrarater agreement from a community and an academic emergency department." CJEM 15, no. 04 (July 2013): 227–32. http://dx.doi.org/10.2310/8000.2013.130943.
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ABSTRACTObjectives:The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED.Methods:Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured.Results:There was a higher level of agreement (κ = 0.73; 95% CI 0.68–0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ = 0.50; 95% CI 0.42–0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ = 0.80; 95% CI 0.76–0.84).Conclusion:The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.
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Kenningham, MD, Katherine, Kathryn Koelemay, MD, MPH, and Mary A. King, MD, MPH. "Pediatric disaster triage education and skills assessment: A coalition approach." Journal of Emergency Management 12, no. 2 (March 1, 2014): 141. http://dx.doi.org/10.5055/jem.2014.0168.
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Objective: This study aims to 1) demonstrate one method of pediatric disaster preparedness education using a regional disaster coalition organized workshop and 2) evaluate factors reflecting the greatest shortfall in pediatric mass casualty incident (MCI) triage skills in a varied population of medical providers in King County,WA.Design: Educational intervention and cross-sectional survey.Setting: Pediatric disaster preparedness conference created de novo and offered by the King County Healthcare Coalition, with didactic sessions and workshops including a scored mock pediatric MCI triage. Participants: Ninety-eight providers from throughout the King County, WA, region selected by their own institutions following invitation to participate, with 88 completing exit surveys.Interventions: Didactic lectures regarding pediatric MCI triage followed by scored exercises.Main outcome measures: Mock triage scores were analyzed and compared according to participant characteristics and workplace environment.Results: A half-day regional pediatric disaster preparedness educational conference convened in September 2011 by the King County Healthcare Coalition in partnership with regional pediatric experts was so effective and well-received that it has been rescheduled yearly (2012 and 2013) and has expanded to three Washington State venues sponsored by the Washington State Department of Health. Emergency department (ED) or intensive care unit (ICU) employment and regular exposure to pediatric patients best predicted higher mock pediatric MCI triage scores (ED/ICU 80 percent vs non-ED/ICU 73 percent, p = 0.026; regular pediatric exposure 80 percent vs less exposure 77 percent, p = 0.038, respectively). Pediatric Advanced Life Support training was not found to be associated with improved triage performance, and mock patients whose injuries were not immediately life threatening tended to be over-triaged (observed trend).Conclusions: A regional coalition can effectively organize member hospitals and provide education for focused populations using specialty experts such as pediatricians. Providers working in higher acuity environments and those with regular pediatric patient exposure perform better mock pediatric MCI triage than their counterparts after just-in-time training. Pediatric MCI patients with less than life-threatening injuries tended to be over-triaged.
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Green, Janette, James Dawber, Malcolm Masso, and Kathy Eagar. "Emergency department waiting times: do the raw data tell the whole story?" Australian Health Review 38, no. 1 (2014): 65. http://dx.doi.org/10.1071/ah13065.
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Objective To determine whether there are real differences in emergency department (ED) performance between Australian states and territories. Methods Cross-sectional analysis of 2009−10 attendances at an ED contributing to the Australian non-admitted patient ED care database. The main outcome measure was difference in waiting time across triage categories. Results There were more than 5.8 million ED attendances. Raw ED waiting times varied by a range of factors including jurisdiction, triage category, geographic location and hospital peer group. All variables were significant in a model designed to test the effect of jurisdiction on ED waiting times, including triage category, hospital peer group, patient socioeconomic status and patient remoteness. When the interaction between triage category and jurisdiction entered the model, it was found to have a significant effect on ED waiting times (P < 0.001) and triage was also significant (P < 0.001). Jurisdiction was no longer statistically significant (P = 0.248 using all triage categories and 0.063 using only Australian Triage Scale 2 and 3). Conclusions Although the Council of Australian Governments has adopted raw measures for its key ED performance indicators, raw waiting time statistics are misleading. There are no consistent differences in ED waiting times between states and territories after other factors are accounted for. What is known about the topic? The length of time patients wait to be treated after presenting at an ED is routinely used to measure ED performance. In national health agreements with the federal government, each state and territory in Australia is expected to meet waiting time performance targets for the five ED triage categories. The raw data indicate differences in performance between states and territories. What does this paper add? Measuring ED performance using raw data gives misleading results. There are no consistent differences in ED waiting times between the states and territories after other factors are taken into account. What are the implications for practitioners? Judgements regarding differences in performance across states and territories for triage waiting times need to take into account the mix of patients and the mix of hospitals.
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Klepner, Stephen, Adrian Ong, Anthony Martin, Tom Wasser, Alison L. Muller, Adam Sigal, and Forrest B. Fernandez. "Being Narrow Minded is Not Always Bad: Focusing on Emergent Interventions in Undertriage Initiatives Improves Mortality Prediction." American Surgeon 84, no. 8 (August 2018): 1277–83. http://dx.doi.org/10.1177/000313481808400836.
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The American College of Surgeons Committee on Trauma defines undertriage (UT) as any major trauma patient (injury severity score ≥ 16) not undergoing treatment at the highest level of trauma team activation. This methodology does not account for many important factors that may impact outcome. We performed a retrospective review of the Pennsylvania State Trauma Registry to determine the impact of treatment interventions on mortality. Patients were stratified by triage category as follows: UT, appropriate triage, and overtriage. Multiple prehospital (PH) and ED interventions were assessed. Increased mortality was observed in all triage groups in patients requiring intervention. A logistic regression analysis was performed to assess the independent effect of individual interventions on mortality for patients triaged to partial activation or consult. PH CPR (OR 66.13 [47.07–92.93]), ED CPR (OR 16.87 [8.82–32.27]), PH or ED intubation (OR 16.68 [13.90–20.03]), PH or ED packed red blood cell transfusion (OR 1.89 [1.54–2.33]), emergent operative intervention (OR 3.58 [3.07–4.19]), ED central venous access (OR 5.04 [2.31–10.97]) were all associated with worsening mortality. The American College of Surgeons Committee on Trauma methodology overestimates mortality risk when emergent interventions are not required and underestimates risk where such interventions are necessary. Future methodologies for assessing UT should include these interventions.
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Morphet, Julia, Debra Griffiths, Virginia Plummer, Kelli Innes, Robyn Fairhall, and Jill Beattie. "At the crossroads of violence and aggression in the emergency department: perspectives of Australian emergency nurses." Australian Health Review 38, no. 2 (2014): 194. http://dx.doi.org/10.1071/ah13189.
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Objective Violence is widespread in Australian emergency departments (ED) and most prevalent at triage. The aim of the present study was to identify the causes and common acts of violence in the ED perceived by three distinct groups of nurses. Methods The Delphi technique is a method for consensus-building. In the present study a three-phase Delphi technique was used to identify and compare what nurse unit managers, triage and non-triage nurses believe is the prevalence and nature of violence and aggression in the ED. Results Long waiting times, drugs and alcohol all contributed to ED violence. Triage nurses also indicated that ED staff, including security staff and the triage nurses themselves, can contribute to violence. Improved communication at triage and support from management to follow up episodes of violence were suggested as strategies to reduce violence in the ED Conclusion There is no single solution for the management of ED violence. Needs and strategies vary because people in the waiting room have differing needs to those inside the ED. Participants agreed that the introduction and enforcement of a zero tolerance policy, including support from managers to follow up reports of violence, would reduce violence and improve safety for staff. Education of the public regarding ED processes, and the ED staff in relation to patient needs, may contribute to reducing ED violence. What is known about the topic? Violence is prevalent in Australian healthcare, and particularly in emergency departments (ED). Several organisations and government bodies have made recommendations aimed at reducing the prevalence of violence in healthcare but, to date, these have not been implemented consistently, and violence continues. What does this paper add? This study examined ED violence from the perspective of triage nurses, nurse unit managers and non-triage nurses, and revealed that violence is experienced differently by emergency nurses, depending on their area of work. Triage nurses have identified that they themselves contribute to violence in the ED by their style of communication. Nurse unit managers and non-triage nurses perceive that violence is the result of drugs and alcohol, as well as long waiting times. What are the implications for practitioners? Strategies to reduce violence must address the needs of patients and staff both within the ED and in the waiting room. Such strategies should be multifaceted and include education of ED consumers and staff, as well as support from management to respond to reports of violence.
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Hirigoyen, Jorge, Leonard A. Kalman, Jill Szymanski, Carmen Lazo, Christopher Espinosa, and Amy Malespin. "Evaluating the efficacy of an advanced practice provider symptom management telephone triage program in reducing ED visits and “avoidable” admissions of oncology patients." Journal of Clinical Oncology 35, no. 8_suppl (March 10, 2017): 177. http://dx.doi.org/10.1200/jco.2017.35.8_suppl.177.
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177 Background: One of the biggest challenges for oncology patients is timely access to care. The inability to provide the right care for the right patient at the right time many times result in overuse of Emergency Departments (ED) to receive oncology care. Approximately 77% of oncology patients have an ER visit, and 63.2% of visits result in hospital admission (Mayer et al., 2011). Furthermore, the average cancer patient receiving chemotherapy has at least one hospital admission and two ED visits per year (Klodziej, et al., 2011). Establishing a “triage” program that attempts to avoid “avoidable” admissions can reduce unnecessary ED visits and associated inpatient care, therefore improving health outcomes while reducing costs. Methods: A quality improvement value-based care (VBC) initiative to prevent ED visits and avoid “avoidable” admissions, via an “Express Symptom Management Hotline” (ESMH) was created. ESMH provides oncology patients with direct and rapid phone access to an oncology Advanced Practice Provider (APP) who can appropriately triage a patient that is in need of acute symptom management. A patient can be managed over the telephone, with a clinic visit, and/or with other outpatient oncology same day services. A next day follow up call for triaged ensures that there was appropriate management. Telephone triage, associated early intervention by an APP for cancer related symptoms and a next day follow-up call will reduce ED visits and avoid “avoidable” admissions. Results: Among the 294 calls that were received from oncology patients for acute symptoms during a 12 week trial period, only 14 led to patients requiring ED services. All 14 ED visits required an admission. Conclusions: Telephone triage by APP’s via an ESMH can effectively manage oncology patients’ symptoms by providing early outpatient interventions. Such an ESMH helps avoid “avoidable” admissions, leading to improved health outcomes while reducing costs. [Table: see text]
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Irawan, Deni, Woro Hapsari, and Yohan Tedy Kurniawan. "EFEK TRIAGE EMERGENCY SEVERITY INDEX (ESI) TERHADAP LENGTH OF STAY DI INSTALASI GAWAT DARURAT RSU ISLAM HARAPAN ANDA KOTA TEGAL." JURNAL PENELITIAN KEPERAWATAN 6, no. 1 (May 11, 2020): 20–27. http://dx.doi.org/10.32660/jpk.v6i1.447.
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Kepadatan pasien menjadi masalah serius yang terjadi di unit gawat darurat dan menyebabkan efek negatif dari peningkatan kematian pasien, ketidakpuasan dengan layanan gawat darurat, kelelahan perawat, peningkatan risiko tertular penyakit menular, dan peningkatan lama tinggal. Length of Stay (LOS) berkepanjangan terkait erat dengan kinerja layanan keperawatan dan triase kualitas di ruang gawat darurat. Metode triase rumah sakit saat ini telah berevolusi, sistem triase cepat dan efisien telah terbukti mengurangi kepadatan pasien dan lama tinggal. Emergency Severity Index (ESI) adalah sistem triase yang valid dan akurat dengan mengidentifikasi pasien secara cepat yang membutuhkan perhatian segera. Tujuan dari penelitian ini adalah untuk mengukur "Triage Emergency Severity Index (ESI) Efek pada Durasi Menginap di Departemen Darurat". Penelitian ini adalah penelitian Quasi Eksperimen Desain menggunakan Post Test Only Non-equivalent Control Group Design, teknik purposive sampling. Jumlah sampel dalam penelitian ini adalah 110 responden yang dibagi ke dalam kelompok perlakuan menggunakan triage Emergency Severity Index (ESI) sebanyak 55 responden dan kelompok kontrol menggunakan responden Triage klasik 55. Hasil analisis Uji Mann Whitney, nilai p 0,000 <0,05. Kesimpulan Ada pengaruh penerapan Triage Emergency Severity Index (ESI) terhadap Lama tinggal di ED. Triage Emergency Severity Index sebagai alat untuk menyortir pasien ini lebih efektif digunakan.
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Yuksen, Chaiyaporn, Sorravit Sawatmongkornkul, Supakrid Suttabuth, Kittisak Sawanyawisuth, and Yuwares Sittichanbuncha. "Emergency severity index compared with 4-level triage at the emergency department of Ramathibodi University Hospital." Asian Biomedicine 10, no. 2 (January 31, 2017): 155–61. http://dx.doi.org/10.5372/1905-7415.1002.477.
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Abstract Background Emergency department (ED) triage is important for categorizing and prioritizing patients. Effective triage may assist in crowd reduction in the ED and appropriate patient management. There are several systems, including the 5-level Emergency Severity Index (ESI) and the 4-level Ramathibodi-nurse triage. Currently, there are limited data by which to compare the 5- versus 4-level triage; particularly on health outcomes, such as length of stay in the ED, mortality, and resource needs. Objective To compare the accuracy of 5- and 4-level triage in an ED. Method This observational study was conducted on a cross-section of patients in the ED at Ramathibodi Hospital of Mahidol University, Bangkok, Thailand. Eligible patients were those who visited the ED and were evaluated by ESI and nurse triage. Each evaluation was blinded to the results of the other. Discrimination performance between the 5- and 4-level triage was compared by using the area under a receiver operating characteristic (ROC) curve and concordance statistic for prediction of life saving intervention. Net reclassification improvement (NRI) of the 5-level ESI over the 4-level triage was performed. Result Study criteria were met by 520 patients. The areas under the ROC curves of the ESI and nurse triage on life-saving intervention were 92.2% (95% confidence intervals were 87.3%, 96.9%) and 81.3% (95% CI 75.2%, 87.3%), respectively. Areas under the ROC curve differed significantly (P < 0.001). The overall reclassification improvement was 42.4%. Conclusion The 5-level emergency severity index was more accurate than the 4-level triage in terms of lifesaving intervention.
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Kuriyama, Akira, Tetsunori Ikegami, Toshie Kaihara, Toshio Fukuoka, and Takeo Nakayama. "Validity of the Japan Acuity and Triage Scale in adults: a cohort study." Emergency Medicine Journal 35, no. 6 (March 13, 2018): 384–88. http://dx.doi.org/10.1136/emermed-2017-207214.
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ObjectiveThe Japan Acuity and Triage Scale (JTAS) was developed based on Canadian Triage and Acuity Scale in 2012 and has been implemented in many Japanese EDs. We assessed the validity of JTAS by examining the association between JTAS triage levels and throughput and clinical outcomes in adult patients.MethodsWe conducted a retrospective analysis of prospectively collected clinical data in the ED of a Japanese tertiary-care hospital. We included self-presenting patients who were ≥16 years of age and triaged between June 2013 and May 2014. We assessed the association between the triage level and overall admission and admission to the intensive care units (ICUs) with multivariable logistic regression analysis adjusted with patients’ age and the time of visit and ED length of stay using the Kruskal-Wallis rank-sum test. We examined the predictive ability of JTAS for determining overall and ICU admission using receiver operating characteristic curves.ResultsWe included a total of 27 120 adult patients in our study. The OR for overall admission was greater with a higher triage level compared with the lowest urgency levels. ED length of stay was significantly longer with a higher JTAS level (p<0.001). The OR for ICU admission was greater in JTAS 1 (117.93 (95% CI 69.07 to 201.38)) and JTAS 2 (9.43 (95% CI 13.74 to 29.30)) compared with the lowest urgency levels. The areas under the curve for the predictive ability of JTAS for overall and ICU admission were 0.726 and 0.792, respectively.ConclusionOur study suggests an association of JTAS acuity with overall admission, ICU admission and ED length of stay, thereby demonstrating the predictive validity of JTAS.
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Sittichanbuncha, Yuwares, Patchaya Sanpha-asa, Theerayut Thongkrau, Chaiyapon Keeratikasikorn, Noppadol Aekphachaisawat, and Kittisak Sawanyawisuth. "An Online Tool for Nurse Triage to Evaluate Risk for Acute Coronary Syndrome at Emergency Department." Emergency Medicine International 2015 (2015): 1–4. http://dx.doi.org/10.1155/2015/413047.
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Background. To differentiate acute coronary syndrome (ACS) from other causes in patients presenting with chest pain at the emergency department (ED) is crucial and can be performed by the nurse triage. We evaluated the effectiveness of the ED nurse triage for ACS of the tertiary care hospital.Methods. We retrospectively enrolled consecutive patients who were identified as ACS at risk patients by the ED nurse triage. Patients were categorized as ACS and non-ACS group by the final diagnosis. Multivariate logistic analysis was used to predict factors associated with ACS. An online model predictive of ACS for the ED nurse triage was constructed.Results. There were 175 patients who met the study criteria. Of those, 28 patients (16.0%) were diagnosed with ACS. Patients with diabetes, patients with previous history of CAD, and those who had at least one character of ACS chest pain were independently associated with having ACS by multivariate logistic regression. The adjusted odds ratios (95% confidence interval) were 4.220 (1.445, 12.327), 3.333 (1.040, 10.684), and 12.539 (3.876, 40.567), respectively.Conclusions. The effectiveness of the ED nurse triage for ACS was 16%. The online tool is available for the ED triage nurse to evaluate risk of ACS in individuals.
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Hendin, Ariel, Debra Eagles, Victoria Myers, and Ian G. Stiell. "Characteristics and outcomes of older emergency department patients assigned a low acuity triage score." CJEM 20, no. 5 (March 5, 2018): 762–69. http://dx.doi.org/10.1017/cem.2018.17.
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AbstractObjectiveAlthough older patients are a high-risk population in the emergency department (ED), little is known about those identified as “less acute” at triage. We aimed to describe the outcomes of patients ages 65 years and older who receive low acuity triage scores.MethodsThis health records review assessed ED patients who were ages 65 years and above or ages 40 to 55 years (controls) who received a Canadian Triage Acuity Scale score of 4 or 5. Data collected included patient demographics, ED management, disposition, and a return visit or hospital admission at 14 days. Data were analysed descriptively and chi-square testing performed. A pre-planned stratified analysis of patients ages 65 to 74, 75 to 84, and 85 and older was conducted.ResultsThree hundred fifty older patients with a mean age of 76.5 years and 150 control patients were included. Most patients presented with musculoskeletal or skin complaints and were triaged to the ambulatory care area. Older patients were significantly more likely than controls to be admitted on the index visit (5.0% v. 0.3%, p=0.016) and on re-presentation (4.0% v. 0.7%, p=0.045). In a subgroup analysis, patients ages 85 years and above were most likely to be admitted (8.9%, p=0.003).ConclusionsOlder patients who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients ages 85 years and up are the primary drivers of this higher admission rate. Our study indicates that even “low acuity” elders presenting to the ED are at risk for re-presentation and admission within 14 days.
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Ferreira, Letícia Ali Figueiredo, Igor Leão dos Santos, Ana Carla De Souza Gomes dos Santos, and Augusto Da Cunha Reis. "Discrete event simulation for problem solving in the context of an emergency department." Independent Journal of Management & Production 11, no. 5 (September 1, 2020): 1515. http://dx.doi.org/10.14807/ijmp.v11i5.1286.
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Emergency departments (ED) are responsible for the immediate care and stabilization of patients in critical health conditions. Several factors have caused overcrowding in the emergency care system, but the variability of patient arrival and the triage process requires special attention. The criticality of these components and their configuration directly impact the waiting times, length of stay and quality of service, being the subject of several studies. So, this paper aims to understand by means of Discrete Event Simulation how ED works with the variation of patient arrival and how this variation highlights the bottlenecks of the triage process. Varying the patient arriving interval between 0.1 and 7.6 in a 4-hour scenario, the system saturation point was established in β = 1.1. Besides, with the variation in the number of triages points, a considerable decrease in the total length of stay spent and the waiting times were noticed, mainly when there was two triage points operating simultaneously.
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Howlett, Michael K., and Paul R. T. Atkinson. "A Method for Reviewing the Accuracy and Reliability of a Five-Level Triage Process (Canadian Triage and Acuity Scale) in a Community Emergency Department Setting: Building the Crowding Measurement Infrastructure." Emergency Medicine International 2012 (2012): 1–5. http://dx.doi.org/10.1155/2012/636045.
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Objectives.Triage data are widely used to evaluate patient flow, disease severity, and emergency department (ED) workload, factors used in ED crowding evaluation and management. We defined an indicator-based methodology that can be easily used to review the accuracy of Canadian Triage and Acuity Scale (CTAS) performance.Methods.A trained nurse reviewer (NR) retrospectively triaged two separate month’s ED charts relative to a set of clinical indicators based on CTAS Chief Complaints. Interobserver reliability and accuracy were compared using Kappa and comparative statistics.Results.There were 2838 patients in Trial 1 and 3091 in Trial 2. The rate of inconsistent triage was 14% and 16% (Kappa 0.596 and 0.604). Clinical Indicators “pain scale, chest pain, musculoskeletal injury, respiratory illness, and headache” captured 68% and 62% of visits.Conclusions.We have demonstrated a system to measure the levels of process accuracy and reliability for triage over time. We identified five key clinical indicators which captured over 60% of visits. A simple method for quality review uses a small set of indicators, capturing a majority of cases. Performance consistency and data collection using indicators may be important areas to direct training efforts.
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Mowbray, Fabrice, Audrey-Anne Brousseau, Eric Mercier, Don Melady, Marcel Émond, and Andrew P. Costa. "Examining the relationship between triage acuity and frailty to inform the care of older emergency department patients: Findings from a large Canadian multisite cohort study." CJEM 22, no. 1 (November 13, 2019): 74–81. http://dx.doi.org/10.1017/cem.2019.432.
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ABSTRACTBackgroundThe 2016 Canadian Triage and Acuity Scale (CTAS) updates introduced frailty screening within triage to more accurately code frail patients who may deteriorate waiting for care. The relationship between triage acuity and frailty is not well understood, but may help inform which supplemental geriatric assessments are beneficial to support care in the emergency department (ED). Our objectives were to investigate the relationship between triage acuity and frailty, and to compare their associations with a series of patient outcomes.MethodsWe conducted a secondary analysis of the Canadian cohort from a multinational prospective study. Data were collected on ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Triage acuity was assigned using the CTAS, whereas frailty was measured using an ED frailty index. Spearman rank and binary logistic regression were used to examine associations.ResultsA total of 2,153 ED patients were analyzed. No association was found between the CTAS and ED frailty index scores assigned to patients (r = .001; p = 0.99). The ED frailty index was associated with hospital admission (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.4–1.6), hospital length of stay (OR = 1.4; 95% CI = 1.2–1.6), future hospitalization (OR = 1.1; 95% CI = 1.05–1.2), and ED recidivism (OR = 1.1; 95% CI = 1.04–1.2). The CTAS was associated with hospital admission (e.g., CTAS 2 v. 5; OR = 6; 95% CI = 3.3–11.4).ConclusionOur findings demonstrate that frailty and triage acuity are independent but complementary measures. EDs may benefit from comprehensive frailty screening post-triage, as frailty and its associated geriatric syndromes drive outcomes separate from traditional measures of acuity.
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Zachariasse, Joany M., Vera van der Hagen, Nienke Seiger, Kevin Mackway-Jones, Mirjam van Veen, and Henriette A. Moll. "Performance of triage systems in emergency care: a systematic review and meta-analysis." BMJ Open 9, no. 5 (May 2019): e026471. http://dx.doi.org/10.1136/bmjopen-2018-026471.
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ObjectiveTo assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED).DesignSystematic review and meta-analysis.Data sourcesEMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018.Eligibility criteriaStudies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded.Review methodsReviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems’ performance.ResultsSixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems’ performance.ConclusionsEstablished triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems’ performance and how the performance of existing triage systems can be improved.
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Kelly, Anne-Maree, Michael Bryant, Lisa Cox, and Damien Jolley. "Improving emergency department efficiency by patient streaming to outcomes-based teams." Australian Health Review 31, no. 1 (2007): 16. http://dx.doi.org/10.1071/ah070016.
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Objective: To describe the process and results of a process redesign based on task analysis and lean thinking approaches aimed at improving emergency department (ED) efficiency. Methods: Before-and-after study comparing 12- month periods before and after the process redesign for total episodes of ambulance bypass, waiting times (overall and by triage category) and total ED time (overall and by triage category). Time data were analysed using non-parametric methods. Results: The years were broadly comparable, with the exception that there was an 8.4% increase in total hours of care delivered (a marker of ED workload) in the year after the change. Episodes of ambulance bypass reduced by 55% (120 v 54). There were statistically significant waiting times reductions for triage categories 3 and 5 (median reductions 5 and 11 minutes respectively). There was an increase in total ED time for triage category 3 (median increase 7 min) and a decrease for categories 4 and 5 (median reduction 14 and 18 min, respectively). Conclusion: ED process redesign based on task analysis and lean thinking approaches can result in improved ED efficiency.
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Debono, Pharrah, Juanita Debattista, Simon Attard-Montalto, and David Pace. "Adequacy of Pediatric Triage." Disaster Medicine and Public Health Preparedness 6, no. 2 (June 2012): 151–54. http://dx.doi.org/10.1001/dmp.2012.32a.
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ABSTRACTObjective:To assess the adequacy of the pediatric triage system in an acute care general hospital.Methods:All children younger than 14 years of age who presented with a primary medical condition to the accident and emergency department (ED) during January to March 2009 were recruited. Suitability of the triage system was assessed according to the vital parameters taken and the priority code assigned. Triage workload was assessed from the number of children presenting to ED and the timing of presentation.Results:Of 2269 children presenting to ED, 1617 (71.3%) were younger than 5 years, and 883 (38.9%) were younger than 2 years. Only 0.26% (6/2269) had four vital parameters crucial for priority assignment measured, and 19.3% (437/2269) had at least one parameter measured. A priority code was assigned to 10% (225/2269).Conclusions:Our study revealed inadequacies in the pediatric triage system. A simple and objective triage system that is based on the measurement of crucial vital parameters and on prompt recognition of warning signs and symptoms to correctly identify high-risk groups has been introduced to ensure appropriate and effective triage of sick children.(Disaster Med Public Health Preparedness. 2012;6:151–154)
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Phukubye, Thabo Arthur, Masenyani Oupa Mbombi, and Tebogo Maria Mothiba. "Knowledge and Practices of Triage Amongst Nurses Working in the Emergency Departments of Rural Hospitals in Limpopo Province." Open Public Health Journal 12, no. 1 (November 22, 2019): 439–48. http://dx.doi.org/10.2174/1874944501912010439.
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Background: Many deaths in hospitals occur within 24 hours of admission. Some of these deaths could be prevented if the patients were effectively triaged, identified quickly, and treatment initiated without delay. Triage and emergency care have always been weak and under-emphasized components of healthcare systems in rural areas of Limpopo Province, and yet, if well organised, it could lead to saving many lives and reducing the ultimate costs of care. There have been few studies, and there is little information focusing on nurses’ knowledge about triage in rural hospitals. Objective: This study aims to assess the knowledge and practices of triage amongst nurses working in the Emergency Departments (ED) of the Sekhukhune District, Limpopo Province, South Africa. Methods: By employing a quantitative, non-experimental research method, 84 nurses working in the Emergency Departments, completed and submitted structured questionnaires. The validity and reliability were ensured by pre-testing the data collection instrument on respondents who were not part of the main study. Data were analyzed by using the SPSS version 25, Excel computer programs and score methods. Results: The findings indicate that there is a correlation between triage knowledge and job title (p-value = 0.046). Registered nurses, specialty nurses, and enrolled nurses, were found to know more than auxiliary nurses. However, the study discovered that, among the nurses with knowledge, 61% exercised poor triage practice, while only 30% showed evidence of good practice. Conclusion: The study aims at defining triage knowledge and practice amongst nurses in the Emergency Departments. The results indicate that nurses have knowledge regarding triage but have difficulty in converting their factual knowledge into practice, as they scored poorly on questions about the practice. In addition, there emerged a significantly positive relationship between triage knowledge and job titles. The study recommends the development of strategies to enhance the conversion of factual knowledge into practice regarding triage in the ED. This could be implemented through sustainable training courses regarding triage for all the categories of nurses.
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MacKay, J., P. R. Atkinson, M. Howlett, E. Palmer, J. Fraser, and E. Vaillancourt. "P084: Waiting makes me sick: is it time for formal triage in primary care?" CJEM 18, S1 (May 2016): S106. http://dx.doi.org/10.1017/cem.2016.260.
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Introduction: Patient morbidity and mortality are influenced by delay in access to care and lack of continuity of care. Patients frequently present to the emergency department (ED) for care despite being registered with a primary care (PC) provider. Advanced access is an open scheduling system promoted by the College of Family Physicians of Canada that triages primary care (PC) patients to be seen within 24 hours, reducing care delay. We wished to determine the prevalence of formal triage systems in PC appointment allocation. Methods: We performed linked cross sectional surveys to quantify the number of ambulatory patients presenting to a tertiary urban ED (with an annual census of 56,000 visits) who felt unable to access primary care. PC practices were also surveyed to assess use of formal triage methods and measure access using the metric of time to third next available appointment. Descriptive statistics were calculated. Results: In the patient survey, 381 of 580 patients consented to participate. Of those, 324 patients reported reasons for their ED visit. Perception that wait time for PC was “too long” was reported in 73/324 (23%); 86% reported wait times of greater than 48 hours. The PC practice response rate was 63.8% (46/ 72). The mean time to third next available appointment was 7.7 (95% CI 4.9-10.5) days (median 5 days, range 0-50 days). No PC practice reported utilizing a formal triage system when booking appointments. Conclusion: No primary care practices in the surveyed region used a formal triage system to allocate appointments, despite a range of wait times that extended up to 50 days. The safety of primary care appointment allocation may be improved with introduction of a formal triage system, especially if overall wait times cannot be reduced.
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Hendin, A., D. Eagles, V. R. Myers, and I. G. Stiell. "MP13: Characteristics and outcomes of older emergency department patients assigned a low acuity triage score." CJEM 19, S1 (May 2017): S69. http://dx.doi.org/10.1017/cem.2017.179.
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Introduction: Older patients are a high-risk population in the Emergency Department (ED) for poor outcomes after ED visit, including return presentation and hospital admission. Little is known however about outcomes in older patients identified as “low acuity” by triage. We aim to describe the characteristics, ED workup, disposition, and 14-day outcomes of ED patients 65 years and up who are triaged as low acuity and compare them to a younger cohort. Methods: This health records review was done in a Canadian tertiary care ED. Included patients received a Canadian Triage Acuity score (CTAS) of 4 or 5 and were either 65 years and up (“older” group), or 40-55 years (controls). Data collected included patient demographics, tests and services involved in ED, and disposition. Return ED visit and hospital admission rates at 14 days were tracked. Data were analyzed descriptively and chi-square testing conducted to assess for differences (p < 0.05) between groups. A pre-planned stratified analysis of patients 65-74 years, 75-84, and 85 and older was conducted. Results: 350 patients (mean age 76.5, 56.6% female) were included in the older group and 150 in the control group (mean age 47.3, 55.3% female). Most patients presented with musculoskeletal or skin complaints (older cohort: 28.6% extremity pain/injury, 10% rash, 8.9% laceration, versus control 30% extremity pain/injury, 14.7% rash, 14.0% laceration) and were triaged to the ambulatory care area (88.6% elderly, 99.3% control). Older patients were significantly more likely than younger controls to be admitted on index visit (5.0% vs 0.3% admit rate, p=0.016). They had a trend towards increased re-presentation rates within 14 days (13.7% vs 8.7% control, p=0.11) and were more likely to be admitted on re-presentation (4.0% vs 0.7%, p=0.045). In sub-group analysis, very elderly patients (85 years and up, n=79) were more likely to be admitted (8.9%, p=0.003). Conclusion: Patients 65 years of age and older who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients 85 years and up are the primary drivers of this higher admit rate. This study characterizes “low acuity” elders presenting to ED and indicates these patients are high risk for re-presentation and admission within 14 days.
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Rose, Charles, and Mary Jagim. "Psychiatric Triage RNs in the ED." AJN, American Journal of Nursing 103, no. 9 (September 2003): 101–2. http://dx.doi.org/10.1097/00000446-200309000-00028.
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Welch, Shari J. "Preventing ED Violence Starts in Triage." Emergency Medicine News 30, no. 12 (December 2008): 4. http://dx.doi.org/10.1097/01.eem.0000342733.39531.f7.
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Walsh, Robin. "Quick reference to triage, 2nd ed." Journal of Emergency Nursing 29, no. 6 (December 2003): 567. http://dx.doi.org/10.1016/s0099-1767(03)00393-3.
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Anbumani, Arun, Moses Kirubairaj Amos Jegaraj, and Reka Karruppusami. "Epidemiological profile of non-urgent patient visits to emergency department in a tertiary care hospital in South India." International Journal Of Community Medicine And Public Health 7, no. 1 (December 25, 2019): 128. http://dx.doi.org/10.18203/2394-6040.ijcmph20195841.
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Background: Non-urgent visits to emergency department (ED) form a significant proportion of ED visits. The reasons vary from minor injuries, fever of short duration, parental anxiety, and even serious conditions like myocardial infarctions presenting atypically. Non-urgent visits stress the ED services while prolonged waiting affects the patients. The aim was to study the profile of non-urgent visits to emergency department of a tertiary care hospital in South India.Methods: Prospective and descriptive study of patients aged 15 years and above categorized as non-urgent after triage was conducted. Data such as age, gender, reason for visit, time of presentation during the day, duration of ED stay and need for referral were recorded. Quantitative variables were presented as Mean±SD and frequency with percentage for qualitative variables.Results: Non-urgent visits contributed to 47.1% of total ED visits. Reasons for non-urgent visits were fever (15.4%), vomiting (13.9%), breathlessness (7.6%), minor trauma (7.3%), giddiness (7.0%) and dysuria (5.5%). 80.8% of all non- urgent visits were seen by ED doctor within two hours of being triaged. Most patients were treated for their immediate symptoms and 64.8% needed follow-up out-patient appointments. Admission rate was 1.2%. Majority of non-urgent visits (55.7%) were daytime visits and 13% were after-hours.Conclusions: Non-urgent visits contribute to about half of all ED visits and can stress ED. A local triage guideline is necessary to run these services in ED. Extended general practice or family physician run urgent care can relieve the stress on ED while rendering to patients accessible and affordable care.
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Carolan, Kelsi, David C. Grabowski, Ateev Mehrotra, and Laura A. Hatfield. "Use of Telemedicine for Emergency Triage in an Independent Senior Living Community: Mixed Methods Study." Journal of Medical Internet Research 22, no. 12 (December 17, 2020): e23014. http://dx.doi.org/10.2196/23014.
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Background Older, chronically ill individuals in independent living communities are frequently transferred to the emergency department (ED) for acute issues that could be managed in lower-acuity settings. Triage via telemedicine could deter unnecessary ED transfers. Objective We examined the effectiveness of a telemedicine intervention for emergency triage in an independent living community. Methods In the intervention community, a 950-resident independent senior living community, when a resident called for help, emergency medical technician–trained staff could engage an emergency medicine physician via telemedicine to assist with management and triage. We compared trends in the proportion of calls resulting in transport to the ED (ie, primary outcome) in the intervention community to two control communities. Secondary outcomes were telemedicine use and posttransport disposition. Semistructured focus groups of residents and staff were conducted to examine attitudes toward the intervention. Qualitative data analysis used thematic analysis. Results Although the service was offered at no cost to residents, use was low and we found no evidence of fewer ED transfers. The key barrier to program use was resistance from frontline staff members, who did not view telemedicine triage as a valuable tool for emergency response, instead perceiving it as time-consuming and as undermining their independent judgment. Conclusions Engagement of, and acceptance by, frontline providers is a key consideration in using telemedicine triage to reduce unnecessary ED transfers.
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Shen, Yuzeng, and Lin Hui Lee. "Improving the wait time to triage at the emergency department." BMJ Open Quality 9, no. 1 (February 2020): e000708. http://dx.doi.org/10.1136/bmjoq-2019-000708.
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Triaging of patients at the emergency department (ED) is one of the key steps prior to initiation of doctor consult. To improve the overall wait time to consultation, we have identified the need to reduce the wait time to triage for ED patients. We seek to determine if the implementation of a series of plan, do, study, act (PDSA) cycles would improve the wait time to triage within 1 year. The interventions related to the PDSA cycles include the refining of triage criteria, ‘eyeball’ triage by senior nurses to facilitate direct bedding of patients, formation of a triage nurse clinician role, and a needs analysis of required nursing manpower. The baseline period for this study was from January 2017 to April 2017, with the results following implementation of the respective PDSA cycles sequentially tracked from May 2017 to March 2019. There was an improvement in the wait time to triage from a baseline duration of 18 min to the postimplementation period duration of 13 min, with a 25% decrease in variance from 16 to 12 min. The improvements were sustained. Strategies to further reduce wait time to triage at the ED are discussed. We also highlight the importance of adequate triage manpower, data-driven decision making and continued engagement of stakeholders in enabling positive outcomes from this quality improvement effort.
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Stackhouse, S., E. Grafstein, and G. Innes. "LO82: Does triage assignment correlate with outcome for ed patients presenting with chest pain?" CJEM 21, S1 (May 2019): S37. http://dx.doi.org/10.1017/cem.2019.124.
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Introduction: CTAS triage acuity and CEDIS complaint categories are used to prioritize patients for rapid treatment and ED resource allocation. Our objective was to evaluate CTAS and CEDIS validity for risk stratification of ED patients with chest pain using data from two Canadian cities. Methods: This administrative database study included patients seen over a five-year period with a triage complaint of chest pain. Our composite primary outcome included 7-day mortality, cardiac arrest, acute coronary syndrome (ACS) diagnosis (STEMI, NSTEMI, unstable angina{UA}), admission to a critical care unit, or hospitalization with CHF, pulmonary embolism, dysrhythmia, aortic pathology, neurologic or respiratory diagnosis. We dichotomized triage assignments to cardiac vs. noncardiac chest pain and high (CTAS 1,2) vs. low (3,4,5) triage acuity. For our secondary outcome we reported the components of the primary composite outcome. Results: We studied 111,824 patients. The most common overall diagnoses were chest pain NYD (53.8%), ACS (8.9%), musculoskeletal (7.4%), and acute respiratory (5.5%) or GI (5.1%) conditions. Of all patients studied, 85,888 (76.8%) were placed in the “cardiac features” group, and 93,257 (83.4%) fell into high acuity CTAS 1-2. Patients triaged into the “cardiac features” group were more likely to have a composite outcome event (16.6% v. 6.7%; p < 0.001), to be admitted (21.8% v. 9.0%), to require critical care (6.0% v. 0.7%), to receive an ACS diagnosis (11.3% v. 0.9%), and to die within 7 days (0.5% v. 0.2%). Patients in high acuity triage levels were also more likely to have a composite outcome event (15.8% v. 3.3%; p < 0.001), to be admitted (25.4% v. 14.3%), to require critical care (8.2% v. 1.2%), to receive an ACS diagnosis (10.5% v. 0.9%), and to die within 7 days (0.5% v. 0.2%). Conclusion: This study shows that triage assignment is strongly correlated with important patient outcomes and that both the chief complaint and acuity level are powerful risk predictors. These findings may differ at other sites and hospitals should assess and evaluate their data.
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Newton, Amanda S., Sachin Rathee, Simran Grewal, Nadia Dow, and Rhonda J. Rosychuk. "Children’s Mental Health Visits to the Emergency Department: Factors Affecting Wait Times and Length of Stay." Emergency Medicine International 2014 (2014): 1–10. http://dx.doi.org/10.1155/2014/897904.
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Objective. This study explores the association of patient and emergency department (ED) mental health visit characteristics with wait time and length of stay (LOS).Methods. We examined data from 580 ED mental health visits made to two urban EDs by children aged ≤18 years from April 1, 2004, to March 31, 2006. Logistic regressions identified characteristics associated with wait time and LOS using hazard ratios (HR) with 95% confidence intervals (CIs).Results. Sex (male:HR=1.48, 95%CI=1.20–1.84), ED type (pediatric ED:HR=5.91, 95%CI=4.16–8.39), and triage level (Canadian Triage and Acuity Scale (CTAS) 2:HR=3.62, 95%CI=2.24–5.85) were statistically significant predictors of wait time. ED type (pediatric ED:HR=1.71, 95%CI=1.18–2.46), triage level (CTAS 5:HR=2.00, 95%CI=1.15–3.48), number of consultations (HR=0.46, 95%CI=0.31–0.69), and number of laboratory investigations (HR=0.75, 95%CI=0.66–0.85) predicted LOS.Conclusions. Based on our results, quality improvement initiatives to reduce ED waits and LOS for pediatric mental health visits may consider monitoring triage processes and the availability, access, and/or time to receipt of specialty consultations.
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Yoon, Philip, Ivan Steiner, and Gilles Reinhardt. "Analysis of factors influencing length of stay in the emergency department." CJEM 5, no. 03 (May 2003): 155–61. http://dx.doi.org/10.1017/s1481803500006539.
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ABSTRACTObjectives:Length of stay (LOS) is a key measure of emergency department (ED) throughput and a marker of overcrowding. Time studies that assess key ED processes will help clarify the causes of patient care delays and prolonged LOS. The objectives of this study were to identify and quantify the principal ED patient care time intervals, and to measure the impact of important service processes (laboratory testing, imaging and consultation) on LOS for patients in different triage levels.Methods:In this retrospective review, conducted at a large urban tertiary care teaching hospital and trauma centre, investigators reviewed the records of 1047 consecutive patients treated during a continuous 7-day period in January 1999. Key data were recorded, including patient characteristics, ED process times, tests performed, consultations and overall ED LOS. Of the 1047 patient records, 153 (14.6%) were excluded from detailed analysis because of incomplete documentation. Process times were determined and stratified by triage level, using theCanadian Emergency Department Triage and Acuity Scale(CTAS). Multiple linear regression analysis was performed to determine which factors were most strongly associated with prolonged LOS.Results:Patients in intermediate triage Levels III and IV generally had the longest waiting times to nurse and physician assessment, and the longest ED lengths of stay. CTAS triage levels predicted laboratory and imaging utilization as well as consultation rate. The use of diagnostic imaging and laboratory tests was associated with longer LOS, varying with the specific tests ordered. Specialty consultation was also associated with prolonged LOS, and this effect was highly variable depending on the service consulted.Conclusions:Triage level, investigations and consultations are important independent variables that influence ED LOS. Future research is necessary to determine how these and other factors can be incorporated into a model for predicting LOS. Improved information systems will facilitate similar ED time studies to assess key processes, lengths of stay and clinical efficiency.
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Trivedi, S., J. Littmann, P. Kapur, M. Betz, and J. Stempien. "LO09: Assessing the ability of emergency department patients to self-triage by using an electronic questionnaire: a pilot study." CJEM 19, S1 (May 2017): S30. http://dx.doi.org/10.1017/cem.2017.71.
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Introduction: The process of triage is used to prioritize the care of patients arriving in the emergency department (ED). To our knowledge, self-triage has not been previously studied in the general emergency department (ED) setting. In an attempt to test the feasibility of implementing this in the ED, we sought to assess the ability of ED patients to triage themselves using an electronic questionnaire. Methods: This was a prospective observational study. An iPad-based questionnaire was designed with a series of ‘yes’ or ‘no’ answers related to common chief complaints. A score corresponding to a Canadian Triage and Acuity Scale (CTAS) category was assigned based on their answers, without the knowledge of patients or ED staff. These scores were subsequently compared to the official CTAS score assigned by triage nurses. A convenience sample of ambulatory patients arriving at the ED were enrolled over a four week period. Patients arriving by ambulance were excluded. We also sought to assess patients’ ability to predict their ultimate disposition. Results: A total of 492 patients were enrolled. The mean age of enrolled patients was 43.9. Of enrolled patients, 56 (11.4%) were under 20 years old, 168 (34.1%) between ages 20-39, 116 (23.6%) between ages 40-59 and 152 (30.9%) older than 60 years. We had 245 (49.8%) patients identify as male. Patient-determined CTAS scores were as follows: 146 CTAS 1 (26.7%), 66 CTAS 2 (13.4%), 176 CTAS 3 (35.8%) and 104 CTAS 4 and 5 (21.1%). Formal triage CTAS scores were: 47 CTAS 2 (9.6%), 155 CTAS 3 (31.5%), and 290 CTAS 4 and 5 (59%). With our survey tool, 22.2% of patients matched their official triage scores. We found that that 69.9% of participants over-estimated their CTAS score while 7.9% underestimated it. Two hundred and three patients (41.3%) felt that they needed to be admitted. In fact, 73 patients (17.3%) were admitted to hospital. Conclusion: Using an electronic questionnaire, ambulatory patients frequently overestimated the acuity of their presenting complaint. Patients were also not unable to accurately predict their disposition. Further study of different approaches to self-triage is needed before possible implementation in EDs.
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Kumar, Akshay, Dheeneshbabu Lakshminarayanan, Nitesh Joshi, Sonali Vaid, Sanjeev Bhoi, and Ashok Deorari. "Triaging the triage: reducing waiting time to triage in the emergency department at a tertiary care hospital in New Delhi, India." Emergency Medicine Journal 36, no. 9 (July 31, 2019): 558–63. http://dx.doi.org/10.1136/emermed-2019-208577.
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BackgroundProlonged wait times prior to triage outside the emergency department (ED) were a major problem at our institution, compromising patient safety. Patients often waited for hours outside the ED in hot weather leading to exhaustion and clinical deterioration. The aim was to decrease the median waiting time to triage from 50 min outside ED for patients to <30 min over a 4-month period.MethodsA quality improvement (QI) team was formed. Data on waiting time to triage were collected between 12 pm and 1 pm. Data were collected by hospital attendants and recorded manually. T1 was noted as a time of arrival outside the ED, and T2 was noted as the time of first medical contact. The QI team used plan–do–study–act cycles to test solutions. Change ideas to address these gaps were tested during May and June 2018. Change ideas were focused on improving the knowledge and skills of staff posted in triage and reducing turnover of triage staff. Data were analysed using run chart rules.ResultsWithin 6 weeks, the waiting time to triage reduced to <30 min (median, 12 min; IQR, 11 min) and this improvement was sustained for the next 8 weeks despite an increase in patient load.ConclusionThe authors demonstrated that people new to QI could use improvement methods to address a specific problem. It was the commitment of the frontline staff, with the active support of senior leadership in the department that helped this effort succeed.
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Grant, K., C. Bayley, E. Lang, and G. Innes. "LO29: Interventions at triage to improve emergency department throughput: a systematic review." CJEM 22, S1 (May 2020): S17. http://dx.doi.org/10.1017/cem.2020.85.
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Introduction: Emergency Department (ED) crowding is the primary threat to emergency care quality. Input and outflow factors are important factors, but EDs must optimize throughput efficiency by improving internal processes from triage to disposition, and triage is the first throughput phase. Triage throughput interventions exclude strategies that direct patients away from the ED (these modify input rather than throughput). Previous research has described physicians in triage, team triage, telemedical triage, and nurse practitioner (NP) or physician assistant (PA) led triage, but their impact has never been systematically evaluated. Methods: We conducted systematic database searches in Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials without the use of filters or language restrictions of all triage interventions that effected ED throughput (PROSPERO:CRD42019125651). Two independent reviewers screened studies. Study quality was assessed using the Cochrane Risk of Bias tool (version 2) for randomized controlled trials, and the National Heart, Lung, and Blood Institute quality assessment tool for other designs. Results: 18 studies met inclusion criteria (Cohen's k = 0.69). Study results were not pooled due to high statistical heterogeneity as assessed by chi-squared and I-squared statistics. Studies were grouped into physician led, NP or PA led, and team triage interventions. Six physician in triage interventions reported LOS changes between -82 and + 18 minutes. Five NP/PA led triage interventions resulted in LOS changes of -106 to + 19 minutes. Five team triage interventions reported LOS reductions of 4 to 34 minutes. One telemedicine triage study reported a non-significant 8 minute increase in LOS. Six physician at triage interventions yielded significant LWBS rate improvement (relative risk {RR}= 0.29-0.82). Team triage interventions generated LWBS rate changes ranging from meaningful improvement (RR = 0.58) to substantial deterioration (RR = 1.68). Five studies have low risk of bias, 11 studies have some risk of bias, and 2 studies have high risk of bias (Cohen's kappa = 0.58). Conclusion: Fourteen of 18 triage interventions reduced EDLOS and/or LWBS rate. Physician, NP and PA led triage were the most effective triage interventions. To aid widespread adoption, future research should focus on interrupted time series or RCT designs, and more comprehensive descriptions of the contextual factors affecting implementation of these interventions.
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Lammers, Wim, Willem Folmer, Esther M. M. Van Lieshout, Terry Mulligan, Jan C. Christiaanse, Dennis Den Hartog, Jianjing Tong, Yiming Lu, and Peter Patka. "Demographic Analysis of Emergency Department Patients at the Ruijin Hospital, Shanghai." Emergency Medicine International 2011 (2011): 1–5. http://dx.doi.org/10.1155/2011/748274.
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Emergency medicine is an upcoming discipline that is still under development in many countries. Therefore, it is important to gain insight into the organization and patients presenting to the Emergency Department (ED). The aim of this cross-sectional study was to provide an epidemiological description of complaints and referrals of the patients visiting the ED of the Ruijin Hospital in Shanghai, China. A questionnaire was developed and completed for a convenience sample of all patients presenting to the Triage Desk of the ED. The study was performed in June 2008. A total of 2183 questionnaires were completed. The most common complaints were fever (15%), stomach/abdominal pain (15%), vertigo/dizziness (11%), and cough (10%). Following triage, patients were predominantly referred to an internist (41%), neurologist (14%), pulmonologist (11%), or general surgeon (9%). This study provides a better understanding of the reason for the ED visit and the triage system at the ED of the Ruijin Hospital. The results can be used in order to improve facilities appropriate for the specific population in the ED.
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Coyle, Natalie, Andrew Kennedy, Michael J. Schull, Alex Kiss, Darren Hefferon, Paul Sinclair, and Zuhair Alsharafi. "The use of a self-check-in kiosk for early patient identification and queuing in the emergency department." CJEM 21, no. 6 (May 6, 2019): 789–92. http://dx.doi.org/10.1017/cem.2019.349.
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ABSTRACTObjectiveDelays in triage processes in the emergency department (ED) can compromise patient safety. The aim of this study was to provide proof-of-concept that a self-check-in kiosk could decrease the time needed to identify ambulatory patients arriving in the ED. We compared the use of a novel automated self-check-in kiosk to identify patients on ED arrival to routine nurse-initiated patient identification.MethodsWe performed a prospective trail with random weekly allocation to intervention or control processes during a 10-week study period. During intervention weeks, patients used a self-check-in kiosk to self-identify on arrival. This electronically alerted triage nurses to patient arrival times and primary complaint before triage. During control weeks, kiosks were unavailable and patients were identified using routine nurse-initiated triage. The primary outcome was time-to-first-identification, defined as the interval between ED arrival and identification in the hospital system.ResultsMedian (interquartile range) time-to-first-identification was 1.4 minutes (1.0–2.08) for intervention patients and 9 minutes (5–18) for control patients. Regression analysis revealed that the adjusted time-to-first-identification was 13.6 minutes (95% confidence interval 12.8–14.5) faster for the intervention group.ConclusionA self-check-in kiosk significantly reduced the time-to-first-identification for ambulatory patients arriving in the ED.