Christopher M.B. Fernandes

Assessment of inter-observer reliability of two five-level triage and acuity scales: a randomized controlled trial

INTRODUCTION The Emergency Severity Index (ESI) is an initial measure of patient assessment in the emergency department (ED). It rates patients based on acuity and predicted resource intensity from Level 1 (most ill) to Level 5 (least resource intensive). Already implemented and evaluated in several US hospitals, ESI has yet to be evaluated in a Canadian setting or compared with the five-level Canadian Emergency Department Triage and Acuity Scale (CTAS). OBJECTIVE To compare the inter-observer reliability of 2 five-level triage and acuity scales. METHODS Ten triage nurses, who had all been trained in the use of CTAS, from 4 urban, academic Canadian EDs were randomly assigned either to training in ESI version 3 (ESI v.3) or to refresher training in CTAS. They independently assigned triage scores to 200 emergency cases, unaware of the rating by the other nurses. RESULTS Number of years of nursing practice was the only significant demographic difference found between the 2 groups (p = 0.014). A quadratically weighted kappa to measure the inter-observer reliability of the CTAS group was 0.91 (0.90, 0.99) and not significantly different from that of the ESI group 0.89 (0.88, 0.99). An inter-test generalizability (G) study performed on the variance components derived from an analysis of variance (ANOVA) revealed G(5) = 0.90 (0.82, 0.99). CONCLUSIONS After 3 hours of training, experienced triage nurses were able to perform triage assessments using ESI v.3 with the same inter-observer reliability as those with experience and refresher training in using the CTAS.

How does fast track affect quality of care in the emergency department

Study objectives Use of fast track has been shown to improve the emergency department flow of less urgent patients. It has been speculated, however, that this could negatively affect the care of urgent patients. The objective of this study was to determine whether a dedicated fast track for less urgent patients [Canadian Triage and Acuity scale category 4/5 (CTAS 4/5)] affected (1) the time to assessment for urgent patients (CTAS 3), (2) the length of stay for less urgent patients (CTAS 4 and 5), and (3) the left-without-being-seen rate. Methods In June 2003, fast track was opened in our emergency department from 13:00 to 19:00 h. A before–after intervention comparison analysis was completed for 1 week in Aug 2002 and the same week in Aug 2003. Data collected included (1) time to assessment of CTAS 3 patients, (2) the length of stay for CTAS 4/5 patients, and (3) percentage of patients who left without being seen. Results A total of 368 patients were reviewed for 2002 and 380 patients were reviewed for 2003. Median time to assessment of CTAS 3 patients presenting from 13:00 to 19:00 h was reduced from 66 min (Interquartile range: 40, 94 min) in 2002 to 60 min (IQR: 38, 108 min) after fast track was open in 2003 (P=0.95). Median length of stay of CTAS 4 and 5 patients was reduced from 170 min (IQR: 111, 256 min) to 110 min (IQR: 69, 185 min) (P<0.001). The overall left-without-being-seen rate decreased from 5% (20/368) to 2% (9/380). Conclusion A dedicated fast track for CTAS 4/5 patients can reduce the length of stay and the left-without-being-seen rate with no impact on CTAS 3 patients seen in the main emergency department.

Predictive validity comparison of two five-level triage acuity scales.

Introduction Each of the two most commonly used five-level triage tools in North America, the Emergency Severity Index and the Canadian Triage and Acuity Scale have been used as a measure of emergency department resource utilization in addition to acuity. In both cases, it is believed that patients triaged as having a higher level of acuity require a greater number of emergency department resources. We compared the ability of each tool to predict the emergency department resources for each emergency department visit and associated hospital admission and in-hospital mortality rates. Methods This is an observational, cohort study of a population-based random sample of patients triaged at two emergency departments over a 4-month period. Correlational analyses were performed to examine the relationship between the triage assessment and: (i) resource utilization, (ii) hospital admission, and (iii) in-hospital mortality. Results From 486 patients, analyses revealed the greatest correlation was between Emergency Severity Index and diagnostic resources [−0.54 (95% confidence intervals: −0.58, −0.50)] and the poorest correlation was between Canadian Triage and Acuity Scale and mortality [−0.16 (95% confidence intervals: −0.20, −0.12)]. No statistically significant differences (P<0.005) were observed between each tool s ability to predict any of the outcomes measured. Conclusion No statistically significant difference was observed in the ability of Emergency Severity Index v. 3 and Canadian Triage and Acuity Scale to predict emergency department resource utilization or immediate patient outcomes. This ability is, at best, only moderate indicating that other, more accurate tools than measures of triage acuity are required for this purpose.

Root cause analysis of laboratory turnaround times for patients in the emergency department.

INTRODUCTION Laboratory investigations are essential to patient care and are conducted routinely in emergency departments (EDs). This study reports the turnaround times at an academic, tertiary care ED, using root cause analysis to identify potential areas of improvement. Our objectives were to compare the laboratory turnaround times with established benchmarks and identify root causes for delays. METHODS Turnaround and process event times for a consecutive sample of hemoglobin and potassium measurements were recorded during an 8-day study period using synchronized time stamps. A log transformation (ln [minutes + 1]) was performed to normalize the time data, which were then compared with established benchmarks using one-sample t tests. RESULTS The turnaround time for hemoglobin was significantly less than the established benchmark (n = 140, t = -5.69, p < 0.001) and that of potassium was significantly greater (n = 121, t = 12.65, p < 0.001). The hemolysis rate was 5.8%, with 0.017% of samples needing recollection. Causes of delays included order-processing time, a high proportion (43%) of tests performed on patients who had been admitted but were still in the ED waiting for a bed, and excessive laboratory process times for potassium. CONCLUSIONS The turnaround time for hemoglobin (18 min) met the established benchmark, but that for potassium (49 min) did not. Root causes for delay were order-processing time, excessive queue and instrument times for potassium and volume of tests for admitted patients. Further study of these identified causes of delays is required to see whether laboratory TATs can be reduced.

Lateral Sinus Thrombosis Complicating Mastoiditis

Although otitis media is easily recognized in the emergency department, its complications can often be missed. We present the case of a patient with mastoiditis with lateral sinus thrombosis that was not diagnosed until a digital subtraction angiogram revealed the occlusion.

Clinical research in the emergency department conducted by non-emergency physicians: potential problems and proposed recommendations.

The emergency department (ED) is often seen as a desirable place to conduct clinical research due to the broad and undifferentiated spectrum of acute conditions encountered. As a result, ED administrators are often faced with requests for patient access by non-ED researchers. Conflict may arise between these 2 groups regarding which studies should be conducted in the ED. Non-emergency (outside) researchers may perceive that their institutional affiliation, and the overhead fees charged by their hospital afford them the “right” to conduct clinical research in the ED, while ED administrators may counter that it is their responsibility to evaluate research protocols with respect to their effects on patient care, work-flow, and resources. The challenges of conducting clinical research in the ED may not be fully appreciated by those not regularly working in this environment. The constant re-evaluation of priorities, and the necessity for clinical care to take precedence over research, makes conducting clinical studies difficult. Unless consideration is given to staff education and facilitating patient enrolment when designing clinical studies, even motivated ED staff may not enrol patients. The purpose of this paper is to explore the key issues of concern when non-emergency–based researchers wish to conduct clinical studies in the ED.

La qualité en médecine d'urgence: progrès réalisés jusqu'à maintenant, défis à venir

Les médecins travaillant dans les services d’urgence (SU) étaient souvent considérés comme des médecins de passage, qu’il fallait suivre de près en ce qui concerne l’utilisation des ressources et la gestion des risques. Au cours des premières années, les médecins débutants pouvaient gagner plus d’argent en cumulant les postes aux SU. Souvent, les patients étaient vus par des spécialistes non préparés à affronter le tout nouveau champ de pratique appelé « médecine d’urgence ». Il s’est produit inévitablement des erreurs, et des protocoles ont été élaborés et mis en œuvre dans le but de limiter les erreurs. Les spécialistes étrangers à la médecine d’urgence s’appuyaient sur leur bon jugement pour essayer de diminuer les erreurs. On nous a enseigné les techniques spécialisées de maintien des fonctions vitales des grands blessés (Advanced Trauma Life Support [ATLS])—un cours élaboré uniquement par des chirurgiens, avec le concours minimal de médecins travaillant dans les SU. Les anesthésistes ont dicté quels médicaments utilisés pour l’intubation ou la sédation, les radiologistes ont décidé quels examens d’imagerie diagnostique étaient urgents et les cardiologues ont exigé d’être appelés pour l’instauration du traitement thrombolytique. Aucune autre spécialité n’a reçu plus de lignes directrices et d’avis de sociétés professionnelles que la nôtre. En médecine, la mesure habituelle de recours de tous les spécialistes et de tous les généralistes qui ne peuvent résoudre un problème durant les heures normales de travail est d’envoyer les patients aux SU; alors, pourquoi avoir délégué des pouvoirs aux autres dans tant de domaines? En rétrospective, certains conseils et certaines recommandations étaient malavisés ou erronés. Souvent, nous faisons mieux lorsque nous élaborons nos propres lignes de conduite que lorsque d’autres tracent les limites pour nous. Rien d’étonnant à cela— souvent notre environnement et notre travail ont un caractère tellement unique ou ont tellement l’air désordonné que seul un médecin d’urgence peut y voir clair. Alors, avons-nous peur encore de parler franchement? Un aspect fondamental du concept de la qualité est la définition des soins appropriés; les soins inappropriés n’ont pas de qualité. Le caractère approprié des soins, ou leur pertinence, comprend l’innocuité, l’efficacité, l’efficience, et la prestation équitable de soins axés sur le patient. La pertinence, c’est également se demander si on a fait la bonne chose. Par exemple, on nous a souvent reproché que nous ne disposions pas de bonnes données probantes sur les demandes de tomodensitométrie (TDM) de la tête, mais les auteurs de l’article « Canadian CT Head Rule » et d’autres chercheurs ont démontré qu’il en était autrement. Pourtant, l’argument est encore avancé par certains pour soutenir que bon nombre des examens par imagerie demandés par nos spécialistes sont inutiles. L’étude de Dhanoa et de ses collègues, contenue dans le présent numéro du JCMU, donne à penser que cela ne serait pas vrai pour au moins une organisation. Malgré les possibilités accrues de demande de TDM, échelonnées sur plusieurs années, il n’y a pas eu d’augmentation du recours à l’examen. L’article porte sur l’évaluation d’une règle double sur le recours à la neuroradiologie aux SU, concernant l’autorisation préalable de certains examens par TDM. Il s’agit d’un

Vasopressin versus epinephrine for out-of-hospital cardiopulmonary resuscitation

Objective To determine whether vasopressin is more effective than epinephrine in improving rates of survival to hospital admission and, secondarily, survival to hospital discharge in adults requiring cardiopulmonary resuscitation (CPR) and vasopressor therapy after suffering non-traumatic, out-ofhospital cardiac arrest with ventricular fibrillation (VF), pulseless electrical activity (PEA) or asystole.