Debbie Travers

The emergency severity index triage algorithm version 2 is reliable and valid.

OBJECTIVES Initial studies have shown improved reliability and validity of a new triage tool, the Emergency Severity Index (ESI), over conventional three-level scales at two university medical centers. After pilot implementation and validation, the ESI was revised to include pediatric and updated vital signs criteria. The goal of this study was to assess ESI version (v.) 2 reliability and validity at seven emergency departments (EDs) in three states. METHODS In part 1, interrater reliability was assessed using weighted kappa analysis of written training cases and postimplementation by a random sampling of actual patient triages. In part 2, validity was analyzed using a prospective cohort with stratified random sampling at each site. The ESI was compared with outcomes including resource consumption, inpatient admission, ED length of stay, and 60-day all-cause mortality. RESULTS Weighted kappa analysis of interrater reliability ranged from 0.70 to 0.80 for the written scenarios (n = 3289) and 0.69 to 0.87 for patient triages (n = 386). Outcomes for the validity cohort (n = 1042) included hospitalization rates by ESI triage level: level 1, 83%; 2, 67%; 3, 42%; 4, 8%; level 5, 4%. Sixty-day all-cause mortality by triage level was as follows: level 1, 25%; 2, 4%; 3, 2%; 4, 1%; and 5, 0%. CONCLUSIONS ESI v. 2 triage produced reliable, valid stratification of patients across seven sites. ESI triage should be evaluated as an ED casemix identification system for uniform data collection in the United States and compared with other major ED triage methods.

Why Do Patients With Cancer Visit Emergency Departments? Results of a 2008 Population Study in North Carolina

PURPOSE Emergency departments (EDs) in the United States are used by patients with cancer for disease or treatment-related problems and unrelated issues. The North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) collects information about ED visits through a statewide database. PATIENTS AND METHODS After approval by the institutional review board, 2008 NC DETECT ED visit data were acquired and cancer-related visits were identified. Descriptive statistics and logistic regressions were performed. Of 4,190,911 ED visits in 2008, there were 37,760 ED visits by 27,644 patients with cancer. RESULTS Among patients, 77.2% had only one ED visit in 2008, the mean age was 64 years, and there were slightly more men than women. Among visits, the payor was Medicare for 52.4% and Medicaid for 12.1%. More than half the visits by patients with cancer occurred on weekends or evenings, and 44.9% occurred during normal hours. The top three chief complaints were related to pain, respiratory distress, and GI issues. Lung, breast, prostate, and colorectal cancers were identified in 26.9%, 6.3%, 6%, and 7.7% of visits, respectively, with diagnosis. A total of 63.2% of visits resulted in hospital admittance. When controlling for sex, age, time of day, day of week, insurance, and diagnosis position, patients with lung cancer were more likely to be admitted than patients with other types of cancer. CONCLUSION To the best of our knowledge, this is the first study to provide a population-based snapshot of ED visits by patients with cancer in North Carolina. Efforts that target clinical problems and specific populations may improve delivery of quality cancer care and avoid ED visits.

Accuracy of the Emergency Severity Index triage instrument for identifying elder emergency department patients receiving an immediate life-saving intervention.

OBJECTIVES The study objective was to determine the sensitivity and specificity of the Emergency Severity Index (ESI) triage instrument for the identification of elder patients receiving an immediate life-saving intervention in the emergency department (ED). METHODS The authors reviewed medical records for consecutive patients 65 years or older who presented to a single academic ED serving a large community of elders during a 1-month period. ESI triage scores were compared to actual ED course with attention to the occurrence of an immediate life-saving intervention. The sensitivity and specificity of an ESI triage level of 1 for the identification of patients receiving an immediate intervention was calculated. For 50 cases, the triage nurse ESI designation was compared to the triage level determined by an expert triage nurse based on retrospective record review. RESULTS Of 782 consecutive patients 65 years or older who presented to the ED, 18 (2%) had an ESI level of 1, 176 (23%) had an ESI level of 2, 461 (60%) had an ESI level of 3, 100 (13%) had an ESI level of 4, and 18 (2%) had an ESI level of 5. Twenty-six patients received an immediate life-saving intervention. ESI triage scores for these 26 individuals were as follows: ESI 1, 11 patients; ESI 2, nine patients; and ESI 3, six patients. The sensitivity of ESI to identify patients receiving an immediate intervention was 42.3% (95% confidence interval [CI]=23.3% to 61.3%); the specificity was 99.2% (95% CI=98.0% to 99.7%). For 17 of 50 cases in which actual triage nurse and expert nurse ESI levels disagreed, undertriage by the triage nurses was more common than overtriage (13 vs. 4 patients). CONCLUSIONS The ESI triage instrument identified fewer than half of elder patients receiving an immediate life-saving intervention. Failure to follow established ESI guidelines in the triage of elder patients may contribute to apparent undertriage.

Reliability and Validity of the Emergency Severity Index for Pediatric Triage

OBJECTIVES The Emergency Severity Index (ESI) triage algorithm is a five-level triage acuity tool used by emergency department (ED) triage nurses to rate patients from Level 1 (most acute) to Level 5 (least acute). ESI has established reliability and validity in an all-age population, but has not been well studied for pediatric triage. This study assessed the reliability and validity of the ESI for pediatric triage at five sites. METHODS Interrater reliability was measured with weighted kappa for 40 written pediatric case scenarios and 100 actual patient triages at each of five research sites (independently rated by both a triage nurse and a research nurse). Validity was evaluated with a sample of 200 patients per site. The ESI ratings were compared with outcomes, including hospital admission, resource consumption, and ED length of stay. RESULTS Interrater reliability was 0.77 (95% confidence interval [CI] = 0.76 to 0.78) for the scenarios (n = 155 nurses) and 0.57 (95% CI = 0.52 to 0.62) for actual patients (n = 498 patients). Inconsistencies in triage were noted for the most acute and least acute patients, as well as those less than 1 year of age and those with medical (rather than trauma) chief complaints. For the validity cohort (n = 1,173 patients), outcomes differed by ESI level, including hospital admission, which went from 83% for Level 1 patients to 0% for Level 5 (chi-square, p < 0.0001). Nurses from dedicated pediatric EDs were 31% less likely to undertriage patients than nurses in general EDs (odds ratio [OR] = 0.31, 95% CI = 0.14 to 0.67). CONCLUSIONS Reliability of the ESI for pediatric triage is moderate. The ESI provides a valid stratification of pediatric patients into five distinct groups. We found several areas in which nurses have difficulty triaging pediatric patients consistently. The study results are being used to develop pediatric-specific ESI educational materials to strengthen reliability and validity for pediatric triage.

Why Do Cancer Patients Die in the Emergency Department? An Analysis of 283 Deaths in NC EDs

Emergency department (ED) visits are made by cancer patients for symptom management, treatment effects, oncologic emergencies, or end of life care. While most patients prefer to die at home, many die in health care institutions. The purpose of this study is to describe visit characteristics of cancer patients who died in the ED and their most common chief complaints using 2008 ED visit data from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). Of the 37,760 cancer-related ED visits, 283 resulted in death. For lung cancer patients, 104 died in the ED with 70.9% dying on their first ED visit. Research on factors precipitating ED visits by cancer patients is needed to address end of life care needs.

Evaluation of preprocessing techniques for chief complaint classification

OBJECTIVE To determine whether preprocessing chief complaints before automatically classifying them into syndromic categories improves classification performance. METHODS We preprocessed chief complaints using two preprocessors (CCP and EMT-P) and evaluated whether classification performance increased for a probabilistic classifier (CoCo) or for a keyword-based classifier (modification of the NYC Department of Health and Mental Hygiene chief complaint coder (KC)). RESULTS CCP exhibited high accuracy (85%) in preprocessing chief complaints but only slightly improved CoCos classification performance for a few syndromes. EMT-P, which splits chief complaints into multiple problems, substantially increased CoCos sensitivity for all syndromes. Preprocessing with CCP or EMT-P only improved KCs sensitivity for the Constitutional syndrome. CONCLUSION Evaluation of preprocessing systems should not be limited to accuracy of the preprocessor but should include the effect of preprocessing on syndromic classification. Splitting chief complaints into multiple problems before classification is important for CoCo, but other preprocessing steps only slightly improved classification performance for CoCo and a keyword-based classifier.

Pediatric Triage: A Review of Emergency Education Literature

Children represent about a fourth of the population treated each year in US hospital emergency departments. This means that approximately 30 million children enter the emergency health care system and undergo a triage assessment by a nurse. Pediatric triage involves rapid recognition of seriously ill or injured children, assigning an acuity rating level, and anticipating appropriate emergency care and referral. Acuity rating levels are used to prioritize patients for care and typically involve assigning a numeric score to patients, such as level 1 (most acute) to level 5 (least acute). Although no standard system for triage acuity rating exists in the United States, ENA and the American College of Emergency Physicians have recommended that emergency departments use a valid, reliable 5-level acuity system.2 Two such systems are the Emergency Severity Index (ESI) and the Canadian Triage and Acuity Scale (CTAS). Both systems recommend that triage nurses undergo general triage education in addition to acuity system-specific education. Furthermore, ENA and the ESI and CTAS materials recommend that triage be performed only by experienced ED nurses. Children often present with subtle signs and symptoms of illnesses and injuries, and emergency nurses must possess strong pediatric assessment skills to perform prompt, accurate triage of children. The pediatric triage process is critically important and may even warrant recognition as a specialty within emergency nursing. Yet, with the exception of a few programs, current pediatric emergency education resources include only a brief definition of what it is rather than on how to actually do it. Courses that have some focus on pediatric triage often are limited to describing specific disease states or categories such as trauma or medical resuscitation. This article is part of a larger project to improve pediatric triage acuity rating in ED settings. We sought to perform a comprehensive review of the literature to identify best practices and the best evidence that is relevant to pediatric triage. Our goal was to identify existing resources that we could recommend as a foundation for ED nurses, upon which we would provide education specific to pediatric triage acuity rating processes.

Diagnosis clusters for emergency medicine.

OBJECTIVES Aggregated emergency department (ED) data are useful for research, ED operations, and public health surveillance. Diagnosis data are widely available as The International Classification of Diseases, version, 9, Clinical Modification (ICD-9-CM) codes; however, there are over 24,000 ICD-9-CM code-descriptor pairs. Standardized groupings (clusters) of ICD-9-CM codes have been developed by other disciplines, including family medicine (FM), internal medicine (IM), inpatient care (Agency for Healthcare Research and Quality [AHRQ]), and vital statistics (NCHS). The purpose of this study was to evaluate the coverage of four existing ICD-9-CM cluster systems for emergency medicine. METHODS In this descriptive study, four cluster systems were used to group ICD-9-CM final diagnosis data from a southeastern university tertiary referral center. Included were diagnoses for all ED visits in July 2000 and January 2001. In the comparative analysis, the authors determined the coverage in the four cluster systems, defined as the proportion of final diagnosis codes that were placed into clusters and the frequencies of diagnosis codes in each cluster. RESULTS The final sample included 7,543 visits with 19,530 diagnoses. Coverage of the ICD-9-CM codes in the ED sample was: AHRQ, 99%; NCHS, 88%; FM, 71%; IM, 68%. Seventy-six percent of the AHRQ clusters were small, defined as grouping <1% of the diagnosis codes in the sample. CONCLUSIONS The AHRQ system provided the best coverage of ED ICD-9-CM codes. However, most of the clusters were small and not significantly different from the raw data.

Population-based burden of COPD-related visits in the ED: return ED visits, hospital admissions, and comorbidity risks.

BACKGROUND Little is known about the population-based burden of ED care for COPD. METHODS We analyzed statewide ED surveillance system data to quantify the frequency of COPD-related ED visits, hospital admissions, and comorbidities. RESULTS In 2008 to 2009 in North Carolina, 97,511 COPD-related ED visits were made by adults ≥ 45 years of age, at an annual rate of 13.8 ED visits/1,000 person-years. Among patients with COPD (n = 33,799), 7% and 28% had a COPD-related return ED visit within a 30- and 365-day period of their index visit, respectively. Compared with patients on private insurance, Medicare, Medicaid, and noninsured patients were more likely to have a COPD-related return visit within 30 and 365 days and have three or more COPD-related visits within 365 days. There were no differences in return visits by sex. Fifty-one percent of patients with COPD were admitted to the hospital from the index ED visit. Subsequent hospital admission risk in the cohort increased with age, peaking at 65 to 69 years (risk ratio [RR], 1.41; 95% CI, 1.26-1.57); there was no difference by sex. Patients with congestive heart failure (RR, 1.29; 95% CI, 1.22-1.37), substance-related disorders (RR, 1.35; 95% CI, 1.13-1.60), or respiratory failure/supplemental oxygen (RR, 1.25; 95% CI, 1.19-1.31) were more likely to have a subsequent hospital admission compared with patients without these comorbidities. CONCLUSIONS The population-based burden of COPD-related care in the ED is significant. Further research is needed to understand variations in COPD-related ED visits and hospital admissions.

Determining appropriate use of an air medical program.

The Therapeutic Intervention Scoring System (TISS) was evaluated as an instrument to determine appropriate use of an air medical program (AMP) from a retrospective standpoint. TISS scores of 376 consecutive patient transports to the sponsor institution were compared to two other methods of judging appropriateness of air transport: a chart review and a review of patient outcome which included length of hospital stay, need for emergency surgery, mortality rates, and Trauma Scores. Statistically significant correlations were found between the TISS and the other two methods. We concluded that the TISS is a valid instrument for use in determining the appropriateness of air medical transports. The TISS is used as a quality assurance tool during retrospective, bi-weekly patient review sessions; and follow-up on appropriate use of the helicopter is provided to referring and receiving agencies accordingly.