Mohsen Ebrahimi

The reliability of the Australasian Triage Scale: a meta-analysis

BACKGROUND Although the Australasian Triage Scale (ATS) has been developed two decades ago, its reliability has not been defined; therefore, we present a meta-analyis of the reliability of the ATS in order to reveal to what extent the ATS is reliable. DATA SOURCES Electronic databases were searched to March 2014. The included studies were those that reported samples size, reliability coefficients, and adequate description of the ATS reliability assessment. The guidelines for reporting reliability and agreement studies (GRRAS) were used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models, and meta-regression was done based on the method of moments estimator. RESULTS Six studies were included in this study at last. Pooled coefficient for the ATS was substantial 0.428 (95%CI 0.340-0.509). The rate of mis-triage was less than fifty percent. The agreement upon the adult version is higher than the pediatric version. CONCLUSION The ATS has shown an acceptable level of overall reliability in the emergency department, but it needs more development to reach an almost perfect agreement.

Outcomes for Emergency Severity Index Triage Implementation in the Emergency Department

INTRODUCTION Hospital triage scale in emergency departments needs to be valid and reliable. Lack of sufficient data exists on triage scale rigor in emergency departments of Iran. This study aimed to determine the impact of the emergency severity index (ESI) triage scale in the emergency department. MATERIALS AND METHODS A single-center study was conducted. Proportion of triage categories allocated to high-risk patients admitted to high-acuity departments was examined in observational period in June 2012 and May 2013. True triage score was reported based on patients` paper- based scenario questionnaire. Interrater reliability was assessed using unweighted kappa. Concordance among experts, nurses and physicians was examined. The Chi-square test and Kappa statistics was used for statistical analysis. RESULTS Triage decisions regarding high-risk patients before and after implementation period are independent from each other (χ2= 22.254; df=1; p<0.05) and more high-risk patients were recognized after implementation of the ESI. Overall agreement and concordance were (79%) and (κ=0.54) among nurses; (71%) and (κ=0.45) among physicians, (85%) and (κ=0.81) among experts, respectively. Correct triage decisions among clinicians were increased after implementation of the ESI. CONCLUSION The ESI as valid and reliable tool improving desirable outcomes` in the emergency department has been recommended but it may not reveal optimal outcomes in developing countries comparing to what have been achieved in the developed countries. In addition, patient influx in ESI level II could create considerable controversy with clinicians.

The Reliability of the Manchester Triage System (MTS): A Meta‐analysis

Although the Manchester Triage System (MTS) was first developed two decades ago, the reliability of the MTS has not been questioned through comparison with a moderating variable; therefore, the aim of this study is to determine the extent of the reliability of MTS using a meta‐analytic review.

The Role Descriptions of Triage Nurse in Emergency Department: A Delphi Study

Background. Triage nurses play a pivotal role in the emergency department. However some researchers have attempted to expand triage nurses role; remarkable discrepancies exist among scholarly communities. The aim was to develop a role description of triage nurse relying on the experts. Methods. A modified Delphi study consisting of 3 rounds was performed from March to October 2014. In the first round, an extensive review of the literature was conducted. Expert selection was conducted through a purposeful sample of 38 emergency medicine experts. Results. Response rates for the second and third rounds were 37% and 58%. Average age of panelists was (38.42 ± 5.94) years. Thirty-nine out of 54 items reached to the final round. Prioritizing had the higher agreement rate and least agreement on triage related interventions. Conclusion. Triage nursing as a relatively new role for nurses needs significant development to be practiced. Comprehensive educational programs and developmental research are required to support diagnostic and therapeutic interventions in triage practice by nurses.

Nonemergent Patients in the Emergency Department: An Ethnographic Study

Background Triage in the interactive atmosphere of the emergency department (ED) has been described as complex and challenging. Nonemergent ED visits have been accompanied by ethical and legal conflicts. Objectives The aim of this study was to gain an understanding of ED nurses’ practice regarding triage of nonemergent patients. Patients and Methods Focused micro-ethnography based on Spradley’s developmental research sequence (DRS) was used. This study was conducted in an emergency department. Data was collected through complete participant observations along with formal and informal interviews, and then analyzed using DRS. Results Nine key informants were interviewed formally. Four main categories emerged from the nurses’ culture: nonemergent patient as an uninvited guest, nonemergent patient as an elephant in a dark room, nonemergent patient as an aggressive client, and being nonemergency unless at risk of death. Conclusions Providing care in the emergency department is significantly affected by nonemergent patients, as the emergency department is a place for critically ill patients thus awareness training program is recommended.

Re: inter-rater reliability and validity of the Ministry of Health of Turkey's mandatory emergency triage instrument.

required size (slightly bigger than the nostril) (Fig. 4). • With lubricant, pass the catheter into nose along the floor of the nasal cavity, parallel to the palate, past the FB to the posterior nasopharynx, guided by your marker tape (Fig. 5). • Inflate the balloon to the required predetermined size (Fig. 6). • Gently apply traction with the balloon inflated until the FB and balloon exit the nare (Fig. 7). • Ensure that there is no further FB remaining.

Spontaneous Pneumomediastinum with a Rare Presentation

Spontaneous pneumomediastinum is an unusual and benign condition in which air is present in mediastinum. A 20-year-old male patient presented to ED with complaint of hoarseness and odynophagia from the day before, after weightlifting. The patient was nonsmoker and denied history of other diseases. On physical examination he had no dyspnea with normal vital signs. Throat examination and pulmonary auscultation were normal and no crepitation was palpable. We could not find subcutaneous emphysema in neck and chest examination. In neck and chest X-ray we found that air is present around the trachea. There was no apparent pneumothorax in CXR. In cervical and chest CT free air was present around trachea and in mediastinum. Subcutaneous emphysema was also evident. But there was no pneumothorax. The patient was admitted and went under close observation, oxygen therapy, and analgesic. The pneumomediastinum and subcutaneous emphysema gradually resolved within a week by conservative therapy and he was discharged without any complication. Many different conditions could be trigged because of pneumomediastinum but it is rarely seen in intense physical exertion such as weightlifting and bodybuilding. Two most common symptoms are retrosternal chest pain and dyspnea. But the patient here complained of hoarseness and odynophagia.

Comparing the Therapeutic Effectiveness of N-acetylcysteine with the Combination of N-acetyl Cysteine and Cimetidine in Acute Acetaminophen Toxicity: A Double-Blinded Clinical Trial.

Background N-acetylcysteine (NAC) has been used as a classic treatment for hepatotoxicity induced by N-acetyl-p-benzoquinone imine (NAPQI) as a metabolite of acetaminophen. However, cimetidine theoretically can reduce the production of toxic metabolites through the inhibition of cytochrome p450, and it recently was proposed as a complementary treatment for acetaminophen toxicity. Objective The aim of this study was to compare the effects of treating acute acetaminophen toxicity with NAC alone and with a combination of NAC and cimetidine. Methods From October 2013 to March 2014, 105 patients suspected of acetaminophen toxicity who had paraclinical confirmation of toxicity requiring medical treatment (based on the risk assessment nomogram of acetaminophen serum level) were enrolled in this double-blind, randomized, controlled trial at Imam Reza Hospital in Mashhad, Iran. The patients were divided into two groups, i.e., 1) patients who were treated with NAC alone (group A) and 2) patients who were treated with a combination of NAC and cimetidine (group B). The primary outcomes were 1) the serum level of acetaminophen and 2) the serum level of aminotransferases at the time of admission and 4, 12, 24, and 48 hours after admission. Exclusion criteria included multiple toxicities, concurrent diseases that could affect liver enzymes, the use of other drugs, and dissatisfaction with the project. For measuring quantitative data, SPSS version 16 was used for t-test analysis and for analyzing the qualitative data with chi-squared analysis. Results Sixty patients (32 females and 28 males) with a mean age of 25.2 ± 7.3 years were classified in two groups of 30.. There was no difference between the groups in terms of their admission information. The average levels of acetaminophen in both groups at admission, 12, 24, and 48 hours after hospitalization were not significantly different from each other. Twelve hours after hospitalization, the aspartate aminotransferase (AST) level in the group treated with NAC was significantly higher than in the group treated with the combination of NAC and cimetidine (IU/L30.1 ± 110.0 versus IU/L26.38 ± 94.93, p = 0.044). At the other times that the level of liver enzymes was assessed, the serum levels of urea and creatinine were not significantly different in the two groups (p > 0.05) Conclusion The intravenous administration of 300 mg of cimetidine every six hours with NAC did not improve the level of hepatoprotective action significantly compared with the NAC treatment protocol alone.

Digital culture may mediate concordance among medical students

With great interest, I have read the recent publication in the Internal and Emergency Medicine Journal from Savatmongkorngul et al. entitled ‘‘Is a mobile emergency severity index (ESI) triage better than the paper ESI?’’ [1]. The study is remarkable because of emphasizing the applicability of technology-based practice in the emergency department (ED). The triage decision support system has been practiced in the form of computerized models in recent years. Electronic triage systems show superior validity in terms of predicting mortality and resource utilization [2, 3]. In this regard, the current study reported almost perfect agreement with mobile ESI (j 0.84–0.92). It is considerably greater than the pooled coefficients of reliability of 0.791 (95% confidence interval 0.787–0.795) [4]. However, few studies have been conducted to examine the effects of a triage decision support system, and preliminary results are in favor of using technology-based practice in triage. Medical students, emergency physicians, and researchers participated in the current study. It is worth mentioning that it may be challenging for medical students to triage patients in the ED, because it needs significant expertise. Therefore, medical students may produce greater learning effect rather than emergency physicians. However, both emergency physicians and medical students may be affected by the learning effect, and medical students may be influenced more than that of emergency physicians. Certainly, the significant improvements in agreement among medical students may not be justified by this effect alone. We would like to bring your attention to the possible role of digitality as mediator variable in the current study. Digitality refers to the condition of living in a digital culture. Students have grown up in the digital age, so they get accustomed to the digital devices, especially smart phones, in most aspects of their life. It is expected that they may decide more reasonably in their medical profession using digital device. There is no doubt that they have performed significantly better than physicians with older age. They show the greatest improvement in agreement with researcher (0.39–0.84) and emergency physician (0.61–0.92), resulting in two and half times as much as between emergency physician and researcher (0.69–0.87). In line with this argument is the fact that triage system should be compatible with the culture of care [5]. Triage is an interactive process that is highly affected by contextual factors, such as clinicians and patients. Clinicians’ culture may improve or cause error in triage decisions, resulting in perfect or poor agreement, respectively. Therefore, the digital culture may mediate concordance among medical students. This pattern can be extended to the rest of medical specialties. Younger physician may decide for their patients more effectively with the assistance of digital devices. On the other hand, older physicians have a key & Amir Mirhaghi mirhaghi@mail.com

Assessment of mechanism, type and severity of injury in multiple trauma patients: A cross sectional study of a trauma center in Iran

Purpose To accurately assess the mechanism, type and severity of injury in Iranian multiple trauma patients of a trauma center. Methods Patients with multiple traumas referring to the emergency department of Hasheminejad University Hospital in Mashhad, Iran, entered this cross sectional study from March 2013 to December 2013. All the patients with injury severity score (ISS) > 9 were included in this study. Data analysis was performed by SPSS software (Version 11.5) and P values less than 0.05 were considered as significant differences. Results Among the 6306 hospitalized trauma patients during this period, 148 had ISS>9. The male female ratio was 80%. The mean age of the patients was (33.5 ± 19.3) years. And 71% of the patients were younger than 44 years old. There were 19 (13%) deaths from which 68.5% were older than 44 years old. The mean transfer time from the injury scene to hospital was (55 ± 26) minutes. The most frequent mechanisms of injury were motorcycle crashes and falling from height, which together included 66.2% of all the injuries. A total of 84% of hospital deaths occurred after the first 24 h of hospitalization. Head and neck were the most common body injured areas with a prevalence of 111 cases (75%). Conclusion Motorcycle crashes have high frequency in Iran. Since most victims are young males, injury prevention strategies should be considered to reduce the burden of injuries.