Revision of the Canadian Emergency Department Information System (CEDIS) Presenting Complaint List Version 1.1

ED Administration

CJEM 2008;10(2):151-161

Introduction

The original Canadian Emergency Department Information System (CEDIS) Presenting Complaint List was published in 2003. It has 161 complaints and is divided into 18 major categories.1 At the time of its development, there were a number of Canadian emergency departments (EDs) that had implemented partial emergency department information system (EDIS) solutions. Many departments were at the nascent stages of EDIS development. Since then, there has been a proliferation of ED information technology initiatives spearheaded by a national movement to address ED patient flow and efficiency issues. The 9/11 attack, bioterrorism threats, pandemic influenza concerns, and SARS have provided the impetus to develop syndromic surveillance systems that use a presenting complaint list, often derived electronically from a free-text complaint field.2-5 The adoption of the CEDIS Presenting Complaint List in various regions and provinces across the country underscores the utility and acceptance of a coded presenting complaint list.

As the trend toward the implementation of EDIS progresses, the development of performance indicators has also occurred. This allows the measurement of various aspects of ED care. There is a strong reliance on the Canadian Emergency Department Triage and Acuity Scale (CTAS) in Canadian EDs to help identify the sickest patients in situations of overcrowding and limited manpower. As well, CTAS has become a measurement tool for identifying casemix groups for funding models and for comparing performance across different institutions. There has been a recent trend to marry the presenting complaint with the CTAS levels in order to increase the reliability of triage measurement across sites.6 The increase in use of the ED presenting complaint for ancillary reporting reflects the importance of having an accurate complaint list that is reliable, easy to use, understandable and still clinically useful for emergency care providers.

The paediatric emergency medicine community has evaluated and adopted the idea of using a paediatric version of CTAS.7 There has also been work done on improving the interrater reliability of triage by introducing a computerized version.8 Although, the initial version of the CEDIS Presenting Complaint List had paediatric input, the need for refinement of the coded CEDIS list was recognized by the paediatric community. There has been a significant amount of work done to bring to close scrutiny the needs of the Canadian paediatric emergency medicine community. The ultimate goal is to modify the current complaint list to meet the needs of the paediatric community and to allow linkage of the presenting complaint to CTAS to increase the reliability of triage.9

As well, feedback from other ED presenting complaint users identified potential omissions in the first version. There is also a major need to understand and deal with the needs of the mental health population. This group tends to be underresourced in many institutions, especially in EDs that service inner-city communities.

Methods

The CEDIS Working Group and the CTAS National Working Group are composed of nurses, physicians, administrators and researchers who are active in the field of patient care and ED informatics. This group, sanctioned by the Canadian Association of Emergency Physicians (CAEP), the National Emergency Nurses Affiliation (NENA) and l'Associations des médecins d'urgence du Québec (AMUQ), has broad national representation from large and small hospitals in all regions of the country. This group met to review the current Presenting Complaint List and identify omissions and items that required clarification. These changes were based on feedback from constituents and, in some cases (mental health complaints), there was additional feedback provided by an interdisciplinary expert panel.

The paediatric CTAS subgroup is composed of physicians representing major national paediatric EDs and the Canadian Paediatric Society (CPS). Through a series of meetings they reviewed the current Presenting Complaint List in order to identify the complaints that represent the majority of the population in their communities. The following hierarchical considerations were used in deciding to include or exclude potential presenting complaints:

1. Is there a potential protocol or pathway that could be initiated based on a given complaint?

2. Would an appropriate discharge diagnosis more accurately capture the patient's problem?

3. Would an appropriate mechanism of injury code more accurately capture the patient's problem?

4. Does the potential complaint describe an otherwise unidentified important cohort of patients?

5. Is the potential complaint too rare to be useful?

6. Would the presenting complaint create more than 1 possible choice for coding a complaint thereby increasing complexity and decreasing reliability?

Results

Appendix 1 summarizes Version 1.1 of the updated CEDIS Presenting Complaint List. Overall, there were a total of 22 changes, including 6 additions and 2 deletions for a total of 165 presenting complaints. These changes appear in italicized, bolded text in Appendix 1. There were 16 complaints for which the descriptor was modified to provide clarity around the complaint. There were significant changes to the mental health complaints where some of the definitions were made more succinct. These included "Depression/suicidal/deliberate self-harm" and "Violence/ homicidal behaviour."

In Appendix 1 there are corresponding ICD-10 codes (International Classification of Diseases and Related Health Problems, 10th revision) and ICD-10 descriptors for each presenting complaint. New to this version is an additional 3-number code for each presenting complaint to more easily identify these complaints. The reason for the inclusion of this new coding structure is the inability of the ICD-10 codes alone to adequately describe these presenting complaints. Despite the National Ambulatory Care Reporting System (NACRS) requirement to include an ICD-10 code with the submission of data to the Canadian Institute for Health Information (CIHI), the codes often do not match the complaint, especially when complaints are too specific. For example, there is no differentiation between traumatic and atraumatic cardiac arrest, so a code was created. Likewise, there is no obvious ICD-10 code to choose when the "Minor complaint not otherwise specified" code is used. If one peruses the various complaints, one can see other examples where the ICD-10 codes do not give the intended meaning of the descriptor. The 3-character coding structure presented in the CEDIS list is currently being used in an NACRS trial project. The goal of the coding structure is to be able to create a simple search strategy. For example, if one wants to review all cardiac complaints, one would search for all complaint codes between 000 and 050. In the future, the need to submit an ICD-10 code to describe a presenting complaint may be replaced by these 3-character codes. In addition, there is a 2-character identifier at the top of the group that can be used as a prefix to help search functionality if an EDIS lacks appropriate search functionality (e.g., "CV" for Cardiovascular complaints). This 2-character header is not part of the complaint code but represents another option for individual EDs to improve search functionality. Appendix 2 has some relevant definitions for certain complaints that might require clarification for the user.

Paediatric complaints

The original CEDIS Presenting Complaint List had 7 items that were specific to the paediatric population. The new version has an additional 5 items. These include: "Concern for patient's welfare," "Stridor," "Congenital problem in children" and "Floppy child."

The "Concern for patient's welfare" is meant to include potential cases of suspected child abuse or neglect, although a less threatening descriptor has been adopted. This complaint can also be applied to potential elder abuse or neglect. There was discussion over the potential inclusion of complaints to deal with specific paediatric medical devices such as ventriculoperitoneal (VP) shunts, and feeding tubes; however, the decision was to group those problems under the existing "Medical device problem" complaint unless an alternate complaint is more appropriate. "Paediatric gait disorder/painful walk" replaces the "Limp" complaint in the older version. "Limp" is a confusing term that can either relate to a gait problem or a problem of overall flaccidity. This second condition is now captured under the complaint "Floppy child." The "Congenital problem in children" complaint is meant to deal with patients who have congenital heart disease, inborn errors of metabolism or other congenital paediatric problems not presenting with a clear alternate complaint.

Discussion

There are a growing number of presenting complaint classification schemes that have been developed in the last several years. The US Department of Health, Education and Welfare originally developed the Reason for Visit Classification in 1979. Its 400-plus complaint list is more suited to family practice and is not entirely relevant to emergency medicine. Newer complaint lists have fairly small clusters or complaint groupings.10,11 Some groupings, constructed for syndromic surveillance are as small as 7.12 There is a trade-off in the decision to create a small or large list of presenting complaints. The fewer the number of codes from which to choose, the higher the likelihood of having increased coding reliability. On the other hand, with decreased granularity, there is greater potential to understand and study more specific cohorts of patients. For example, in trying to understand what happens to a population of patients with suicidal ideation, it becomes difficult if the complaint category is "Psychiatric/behavioural." Having fewer clusters or complaint groups leads to lower specificity around choosing a complaint and greater sensitivity. Nevertheless, we have been very cognizant of the potential for a triage nurse to ascribe a patient's complaints to more than 1 category. To help the triage nurse, we have added a list of definitions in Appendix 2 to avoid some potential confusion. This underscores the need for a significant educational program for nurses who will be triaging patients using CTAS. NENA and CAEP, through the CTAS National Working Group, have developed a triage education course that helps address these and other potential issues around ascribing a presenting complaint.

Other presenting complaint lists have been developed. They employ strategies to convert free text presenting complaints, using novel and complex algorithms, into a structured classification system.13,14 If one has historical free text data, there is an obvious advantage in using this strategy, in that it allows one to categorize unstructured data. However, the perceived need to document a patient's complaint in their own words often drives the decision to use this type of coding system. The provision of a free text field to add additional information or clinical nuance from the patient's own words to the structured presenting complaint diminishes the need to use a strategy of free text conversion.

NACRS supports a burgeoning national ED registry.15 The submission of emergency medicine data is currently mandated in all Ontario hospitals and emergency data are also submitted from a small number of other EDs from around the country. The NACRS group has been supportive in this initiative and is currently undertaking a pilot project using the CEDIS Presenting Complaint List.

One of the more important changes to the CEDIS Presenting Complaint List has been the incorporation of the Paediatric Presenting Complaint List. There are other paediatric emergency presenting complaint lists,11 but the CEDIS list represents one of the few that can accommodate both adult and paediatric populations. In truth, many of the paediatric complaints are similar to those experienced in the adult population. Despite our attempt to have input from the paediatric community in our first version, it became clear that there were some missing elements. As well, the paediatric community wanted to have all complaints incorporated within the specific major categories. For example, "apneic spells" represents a respiratory complaint, not a paediatric one. Specific paediatric centres may wish to use a truncated version of CEDIS within their own EDIS system for ease of operation, but have the full list available. The hope is that this will improve acceptability of the presenting complaint list in both large urban paediatric centres and in community hospitals that have significant paediatric volumes.

Technical considerations

Incorporation of the Presenting Complaint List into the existing EDIS may present a challenge with a list of this size. One of the important attributes that an EDIS requires is the facility to rapidly search through lists. This is important to increase acceptability and improve coding reliability. Using a system that allows aggregating the list by major category, either through a graphic user interface or through alphabetized sorting functionality, is important.

The number of fields ideally required to create a robust system for capturing presenting complaint would be at least 2. There should be at least 1 field for individual presenting complaints, since patients often have more than 1 complaint at presentation to the ED. This does not run cross purpose to the idea that the complaint with the highest triage acuity level should drive ED process. It merely allows for more clinical information to be gathered with the use of the presenting complaint. There should also be 1 free text field with sufficient character length to allow enough additional patient information to be useful to the clinician.

Conclusion

The CEDIS Presenting Complaint List Version 1.1 represents an important improvement from the previous list. We strive to strike a balance between the clinical needs of the emergency physician and the need to collect reliable ED data. The trend toward linking the presenting complaint to a specific acuity level based on a group of modifiers such as vital signs will help improve the reliability of the CTAS triage tool and will allow more meaningful data capture and analysis. A revision of the adult CTAS guidelines is published in this issue of CJEM.16 The ultimate goal is to improve the comparability of EDs so that the quality of care delivery can be accurately measured and meaningfully improved.

References

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