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Concept: Triage

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OBJECTIVES: To assess whether the flowcharts and discriminators of the Manchester Triage System (MTS) can be used as indicators of alarming signs of serious febrile illness to predict the risk of hospitalization for febrile children who present at the emergency department (ED). STUDY DESIGN: Observational study, which included 2455 children (<16 years) who came to the ED of a university hospital with fever as their main complaint (May 2007-July 2009). Alarming signs for serious febrile illness were matched with MTS flowcharts and discriminators. At triage, the percentage of alarming signs positive was calculated. The diagnostic ability of the percentage of alarming signs positive to identify children at risk of hospitalization was assessed by calculating positive and negative likelihood ratios. RESULTS: Thirty percent of children had at least 1 alarming sign positive at triage. Twenty-three percent were hospitalized. Positive likelihood ratios of hospitalization were 5.0 (95% CI: 3.9-6.5) for children with >20% of alarming signs positive at triage and 12.0 (95% CI: 5.2-27.6) for those with >40% of alarming signs positive. Negative likelihood ratios were 0.8 (95% CI: 0.8-0.8) and 1.0 (95% CI: 0.9-1.0), respectively. CONCLUSIONS: By alternatively using the flowcharts and discriminators of the MTS as alarming signs, rather than urgency classifiers, the MTS can function as a simple, readily available tool to identify febrile children at risk of hospitalization early in the care process. This knowledge may help to improve ED throughput times as well as admission and discharge management at pediatric EDs.

Concepts: Scientific method, Hospital, Fever, 0, Integer, Triage

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Phone triaging patients with suspected malignant pleural mesothelioma (MPM) within the Veterans Healthcare Administration (VHA) system offers a model for rapid, expert guided evaluation for patients with rare and treatable diseases within a national integrated healthcare system. To assess feasibility of national open access telephone triage using evidence-based treatment recommendations for patients with MPM, measure timelines of the triage and referral process and record the impact on “intent to treat” for patients using our service.

Concepts: Health economics, Medicine, Healthcare, Cancer, Evidence-based medicine, Mesothelioma, Telephone, Triage

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ABSTRACTObjectives:To identify factors known prior to triage that might have predicted hospital admission for patients triaged by the Canadian Triage Acuity Scale (CTAS) as level 5 (CTAS 5, nonurgent) and to determine whether inappropriate triage occurred in the admitted CTAS 5 patients.Methods:We reviewed the triage records of patients triaged as CTAS 5 at the emergency departments (EDs) of three tertiary care hospitals between April 2002 and September 2009. Two triage nurses unaware of the study objective independently assigned the CTAS level in 20% of randomly selected CTAS 5 patients who were admitted. We used the kappa statistic (κ) to measure the agreement among the raters in CTAS level between the assessment of the research nurses and the original triage assessment and regression analysis to identify independent predictors of admission to hospital.Results:Of the 37,416 CTAS 5 patients included in this study, 587 (1.6%) were admitted. Agreement on CTAS assignment in CTAS 5 patients who were admitted was κ -0.9, (95% confidence interval [CI] -0.96 to -0.84). Age over 65 (odds ratio [OR] 5.46, 95% CI 4.57 to 6.53) and arrival by ambulance (OR 7.42, 95% CI 6.15 to 8.96) predicted hospital admission in CTAS 5 patients.Conclusions:Most of the CTAS 5 patients who were subsequently admitted to hospital may have qualified for a higher triage category. Two potential modifiers, age over 65 and arrival by ambulance, may have improved the prediction of admission in CTAS 5 patients. However, the consistent application of existing CTAS criteria may also be important to prevent incorrect triage.

Concepts: Regression analysis, Statistics, Hospital, Prediction, Prediction interval, Tertiary referral hospital, Emergency department, Triage

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BACKGROUND:: Nurses lack a standard tool to stratify the risk of chest pain in triage patients. The type of risk stratification may correspond to the type of acuity rating of the 5-level triage scale adopted by nurses for chest pain triage, based on the Front Door Score, simplified from the Thrombolysis in Myocardial Infarction Risk Score for unstable angina or non-ST-segment elevation myocardial infarction. AIM:: This study aimed to evaluate the ability of using the Front Door Score to enhance the accuracy of emergency nurse triage decisions for patients who present with chest pain. DESIGN:: A cross-sectional descriptive design was used. METHODS:: A convenience sample of 200 subjects was obtained from an emergency department in Hong Kong. Data were collected via a questionnaire. The final physician diagnoses were used as the gold standard in justifying the appropriateness of the risk stratification of chest pain. The agreement rates among the final physician diagnoses, Thrombolysis in Myocardial Infarction Risk Score for unstable angina or non-ST-segment elevation myocardial infarction, nurses using the triage scale, and nurses using the Front Door Score were computed using κ statistics. RESULTS:: A significant substantial agreement was observed between the final physician diagnoses and nurses using the Front Door Score. In comparison, the agreement between the final physician diagnoses and nurses using the triage scale was poor. CONCLUSION:: The chest pain triage reliability of nurses using the Front Door Score was found to be much more credible than that of nurses using the triage scale. A suggested conversion of the scales of Front Door Score was established. CLINICAL IMPLICATIONS:: The Front Door Score should be considered as a standard tool to enhance the chest pain triage accuracy of emergency nurse triage decisions.

Concepts: Myocardial infarction, Atherosclerosis, Angina pectoris, Hospital, Acute coronary syndrome, Triage

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The review aims to find the best available evidence on the effectiveness of the Manchester Triage System on time to treatment in the emergency department.

Concepts: Triage

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Standards for emergency department (ED) triage in the United States rely heavily on subjective assessment and are limited in their ability to risk-stratify patients. This study seeks to evaluate an electronic triage system (e-triage) based on machine learning that predicts likelihood of acute outcomes enabling improved patient differentiation.

Concepts: Hospital, United States, Poverty in the United States, U.S. state, Spanish language, Learning, Triage, United States Department of Education

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Introduction:Successful management of a disaster or pandemic requires implementation of pre-existing plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective, and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this chapter are important for all of those involved in a large-scale disaster or pandemic including front line clinicians, hospital administrators, and public health or government officials. Specifically, this paper focuses on surge logistics, those elements that provide the capability to deliver mass critical care. Methodology:The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic and the articles screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, observational or used flawed modeling and hence the level of evidence on which to base recommendations was poor therefore not permitting the development of evidence based recommendations. The Surge Capacity panel subsequently followed the American College of Chest Physician’s (ACCP) Guidelines Oversight Committee’s methodology to develop expert opinion suggestions utilizing a modified Delphi process. Results:This paper presents 22 suggestions pertaining to surge capability mass critical care including: requirements for equipment, supplies and pharmaceuticals, staff preparation and organization, methods of mitigating overwhelming patient loads, the role of deployable critical care services and use of transportation assets to support the surge response. Conclusions:Critical care response to a disaster relies careful planning for staff and resource augmentation and involves many agencies. Maximizing use of regional resources including staff, equipment and supplies extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve pre-determined goals. Specialized physician oversight is necessary and if not available on site it may be provided through remote consultation. Triage by experienced providers, reverse triage, and service de-escalation may be used to minimize ICU resource consumption. During temporary loss of infrastructure or overwhelming of hospital resources, deployable critical care services should be considered.

Concepts: Critical thinking, Evidence-based medicine, Intensive care medicine, Management, Pandemic, Iraq War troop surge of 2007, Triage, Triage tag

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To investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary telephone triage.

Concepts: Cohort study, Cohort, Retrospective, Ambulance, Paramedic, Dublin, Triage, Emergency

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We aimed to evaluate the clinical usefulness of qSOFA as a risk stratification tool for patients admitted with infection compared to traditional SIRS criteria or our triage system; the Rapid Emergency Triage and Treatment System (RETTS).

Concepts: Inflammation, Systemic inflammatory response syndrome, Sepsis, Triage