CJEM Articles: triage
Displaying 1-10 of 18 results
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March
2010
12
2
Aikta Verma, David J. Gladstone, Jiming Fang, Jordan Chenkin, Richard Verbeek, Sandra E. Black
Objective: Prehospital Code Stroke triage has the potential to overwhelm stroke centres by falsely identifying patients as eli gible for fibrinolysis. We sought to determine whether online medical control (whereby paramedics contact the medical control physician before a Code Stroke triage is assigned) reduced the proportion of false-positive Code Stroke patients.
Methods: Following the introduction of a protocol for prehospi tal Code Stroke triage in an urban centre, online medical control alternated with off-line medical control (whereby paramedics implement Code Stroke triage independently) over 4 discreet intervals. We reviewed data for patients triaged to 3 regional stroke centres to compare the proportion of false-positive Code Stroke patients during online versus off-line medical control. We predefined false positives as patients triaged as Code Stroke who had symptoms discovered on awakening, were last seen in their usual state of health greater than 2 hours before assess ment or had a final diagnosis other than stroke.
Results: The proportion of false positives was lower during online medical control (31% v. 42%, p = 0.003). This was explained by a lower proportion of patients whose symptoms were discovered on awakening (8% v. 14%, p < 0.001) and who were last seen in their usual state of health greater than 2 hours before assessment (22% v. 32%, p = 0.005). A final diagnosis of stroke was similar in the 2 groups (77% v. 79%, p = 0.39), as was the proportion of patients receiving fibrinol ysis (35% v. 33%, p = 0.72). Eighteen percent of patients were denied Code Stroke triage during online control, most com monly because of the time of symptom onset.
Conclusion: Online medical control is associated with a reduced proportion of false-positive Code Stroke triage.
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March
2010
12
2
André Lavoie, Lynne Moore, Marcel Émond, Moishe Liberman, Stéphanie Camden
Objective: We sought to evaluate the performance of the Prehos pital Index (PHI), the high velocity impact (HVI) criterion and emergency medical technician (EMT) judgment for the prehospital triage of injured patients.
Methods: The study population included all prehospital trauma patients transported by an emergency medical service to 2 level I trauma centres for adults. All prehospital run sheets were linked to trauma registry data. The main outcome was severe trauma, defined as death within 72 hours, admission to the intensive care unit within 24 hours or an Injury Severity Score greater than 15. We assessed sensitivity, specificity and rates of overtriage.
Results: Of 16 805 patients in the study population, 1113 (6.62%) had severe trauma. The combination of all 3 triage criteria (PHI score ≥ 4, HVI presence and EMT judgment) performed best for identifying patients with severe trauma, with a sensitivity of 74.2% but with an overtriage rate of 85.1%. Alone, EMT judgment had the highest sensitivity and a PHI score of 4 or greater had the low est rate of overtriage.
Conclusion: Although the combination of PHI score, HVI pres ence and EMT judgment offers the highest sensitivity for the iden tification of patients that could benefit from direct transport to a level I trauma centre, overall sensitivity remains low and over triage is high. More research is required to improve prehospital triage.
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January
2010
12
1
A. Lavoie, C. Dallaire, G. Audet, J. Poitras, K. Aubin, L. Moore
Objective: 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 agree ment 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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January
2009
11
1
Jocelyn Gravel, Michael Arsenault, Sergio Manzano
Objective: We evaluated the validity of the Canadian Paediatric Triage and Acuity Scale (PaedCTAS) 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 a χ2 test 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 (both p < 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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May
2008
10
3
Anna Jarvis, CTAS National Working Group, David W. Warren, Jocelyn Gravel, Louise LeBlanc
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May
2008
10
3
Anna Jarvis, David W. Warren, groupe de travail national sur l'ÉTG, Jocelyn Gravel, Louise LeBlanc
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March
2008
10
2
Bernard Unger, Eric Grafstein, Julie Spence, Michael J. Bullard
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March
2008
10
2
Bernard Unger, Eric Grafstein, Julie Spence, Michael J. Bullard
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January
2008
10
1
Jocelyn Gravel, Michael Arsenault, Sergio Manzano
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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November
2007
9
6
Alice Han, Brian H. Rowe, Maria B. Ospina, Sandra Blitz, Trevor Strome
Objective: Some low-acuity emergency department (ED) presentations are considered convenience visits and potentially avoidable with improved access to primary care services. This study assessed the frequency and determinants of patients' efforts to access alternative care before ED presentation.
Methods: Patients aged 17 years and older were randomly selected from 2 urban ED sites in Edmonton. Survey data were collected on use and characteristics of alternative care before the ED visit. Information was also collected on patient demographics and factors influencing their perception of whether the ED was the best care option.
Results: Of the 1389 patients approached, 905 (65%) completed the survey and data from 894 participants were analyzed. Sixty-one percent reported that they sought alternative care before visiting the ED. Eighty-nine of the patients who attempted alternative access before the ED visit felt that the ED was their best care option. Results of the multivariate logistic regression analysis showed that injury presentation, living arrangements, smoking status and whether or not patients had a family practitioner were predictors for seeking alternative care before visiting the ED.
Conclusion: Most ambulatory patients attempt to look for other sources of care before presenting to the ED. Despite this attempted access to alternative care, while patients wait for ED care, they perceive that the ED is their best care option at that point in time.
