The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study.

PubMed

Kauppila, Timo; Seppänen, Katri; Mattila, Juho; Kaartinen, Johanna

2017-06-01

Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor's list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors' services in collaborative parts of the health care system. An observational study. Register-based retrospective quasi-experimental longitudinal follow-up study based on a before-after setting in a Finnish city. Patients who consulted different doctors in a local health care unit. Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage. The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased. The data suggested that the reverse triage causes redistribution of the use of doctors' services rather than a true decrease in the use of these services.

[Case mix analysis of patients who can be referred from emergency department triage to primary care].

PubMed

Gómez-Jiménez, Josep; Becerra, Oscar; Boneu, Francisco; Burgués, Lluís; Pàmies, Salvador

2006-01-01

Structured emergency department (ED) triage scales can be used to develop patient referral strategies from the ED to primary care. The objectives of the present study were to evaluate the percentage of patients who could potentially be referred from triage to primary care and to describe their clinical characteristics. We analyzed all patients with low acuity (triage levels IV and V) and low complexity (patients discharged from the ED) triaged during 2003 with the Andorran Triage Model in the ED and estimated the percentage of patients who could potentially be referred on the basis of three primary care models: A, centers unable to deal with emergencies or perform complementary investigations; B, centers able to deal with emergencies and perform complementary investigations, and C, centers able to deal with emergencies but unable to perform complementary investigations. Of the 25,319 patients included in the study, 5.63% could be referred to model A, 75.22% to model B and 33.36% to model C. A total of 81.04% of these model C patients were classified in seven symptomatic categories: wounds and traumatisms, inflammation or fever, pediatric problems, rhinolaryngological infection or alterations, ocular symptoms, pain and cutaneous allergy or reactions. Casemix analysis, based on the level of acuity and discharge criteria, can be used to establish the percentage of patients that could potentially be referred to primary care. Analysis of their clinical profile is useful to design referral protocols.

Causes and occurrences of interruptions during ED triage.

PubMed

Johnson, Kimberly D; Motavalli, Michele; Gray, Dean; Kuehn, Connie

2014-09-01

Interruptions have been shown to cause errors and delays in the treatment of emergency patients and pose a real threat during the triage process. Missteps during the triage assessment can send a patient down the wrong treatment path and lead to delays. The purpose of this project was to identify the types and frequency of interruptions during the ED triage interview process. A focus group of emergency nurses was organized to identify the types of interruptions that commonly occur during the triage interview. These interruptions would be validated through observations in triage. A tally sheet was developed and implemented to determine how often each interruption occurred during an 8-hour shift. Triage nurses completed the tally sheets while working the first shift (7 am to 3 pm). This shift was selected because patient intake in the US Department of Veterans Affairs Emergency Department is highest during this time. The categories of interruptions identified included provision of conveniences to visitors, coworker-related interruptions, patient care-related interruptions, locating of family members in the emergency department, and other miscellaneous interruptions. Tally sheets were completed by the triage nurses during 10 shifts. On average, triage nurses were interrupted 48.2 times during an 8-hour shift (7 interruptions per hour). After reviewing the data, we found that only 22% of interruptions were related to patient care. More frequently, the causes of interruptions were not related to patient care: opening the door (33%), providing conveniences to visitors (21%), waiting patients or family members asking "How much longer?" (14%), and other causes (10%). Frequent interruptions can interfere with concentration and may affect patient care. Non-patient care-related interruptions not only can be frustrating to the triage nurse but also can be offensive to triage patients; they ultimately delay care and may even affect the quality of care. However, because scarce

Rehabilitation as "destination triage": a critical examination of discharge planning.

PubMed

Durocher, Evelyne; Gibson, Barbara E; Rappolt, Susan

2017-06-01

In this paper we examine how the intersection of various social and political influences shapes discharge planning and rehabilitation practices in ways that may not meet the espoused aims of rehabilitation programs or the preferences of older adults and their families. Taking a critical bioethics perspective, we used microethnographic case study methods to examine discharge-planning processes in a well-established older adult inpatient rehabilitation setting in Canada. The data included observations of discharge-planning family conferences and semi-structured interviews conducted with older adults facing discharge, their family members and rehabilitation professionals involved in discharge planning. From the time of admission, a contextual push to focus on discharge superseded program aims of providing interventions to increase older adults' functional capabilities. Professionals' primary commitment to safety limited consideration of discharge options and resulted in costly and potentially unnecessary recommendations for 24-hour care. The resulting "rehabilitation" stay was more akin to an extended process of "destination triage" biased towards the promotion of physical safety than optimizing functioning. The resulting reduction of rehabilitation into "destination triage" has significant social, financial and occupational implications for older adults and their families, and broader implications for healthcare services and overarching healthcare systems. Implications for Rehabilitation Current trends promoting consideration of discharge planning from the point of admission and prioritizing physical safety are shifting the focus of rehabilitation away from interventions to maximize recovery of function, which are the stated aims of rehabilitation. Such practices furthermore promote assessments to determine prognosis early in the rehabilitation stay when accurate prognosis is difficult, which can lead to overly conservative recommendations for discharge from

Role of telephone triage in obstetrics.

PubMed

Manning, Nirvana Afsordeh; Magann, Everett F; Rhoads, Sarah J; Ivey, Tesa L; Williams, Donna J

2012-12-01

The telephone has become an indispensable method of communication in the practice of obstetrics. The telephone is one of the primary methods by which the patient makes her appointments and contacts her health care provider for advice, reassurance, and referrals. Current methods of telephone triage include personal at the physicians' office, telephone answering services, labor and delivery nurses, and a dedicated telephone triage system using algorithms. Limitations of telephone triage include the inability of the provider to see the patient and receive visual clues from the interaction and the challenges of obtaining a complete history over the telephone. In addition, there are potential safety and legal issues with telephone triage. To date, there is insufficient evidence to either validate or refute the use of a dedicated telephone triage system compared with a traditional system using an answering service or nurses on labor and delivery. Obstetricians and gynecologists, family physicians. After completing this CME activity, physicians should be better able to analyze the scope of variation in telephone triage across health care providers and categorize the components that go into a successful triage system, assess the current scope of research in telephone triage in obstetrics, evaluate potential safety and legal issues with telephone triage in obstetrics, and identify issues that should be addressed in any institution that is using or implementing a system of telephone triage in obstetrics.

Identifying the core competencies of mental health telephone triage.

PubMed

Sands, Natisha; Elsom, Stephen; Gerdtz, Marie; Henderson, Kathryn; Keppich-Arnold, Sandra; Droste, Nicolas; Prematunga, Roshani K; Wereta, Zewdu W

2013-11-01

The primary aim of this study was to identify the core competencies of mental health telephone triage, including key role tasks, skills, knowledge and responsibilities, in which clinicians are required to be competent to perform safe and effective triage. Recent global trends indicate an increased reliance on telephone-based health services to facilitate access to health care across large populations. The trend towards telephone-based health services has also extended to mental health settings, evidenced by the growing number of mental health telephone triage services providing 24-hour access to specialist mental health assessment and treatment. Mental health telephone triage services are critical to the early identification of mental health problems and the provision of timely, appropriate interventions. In spite of the rapid growth in mental health telephone triage and the important role these services play in the assessment and management of mental illness and related risks, there has been very little research investigating this area of practice. An observational design was employed to address the research aims. Structured observations (using dual wireless headphones) were undertaken on 197 occasions of mental health telephone triage over a three-month period from January to March 2011. The research identified seven core areas of mental health telephone triage practice in which clinicians are required to be competent in to perform effective mental health telephone triage, including opening the call; performing mental status examination; risk assessment; planning and action; termination of call; referral and reporting; and documentation. The findings of this research contribute to the evidence base for mental health telephone triage by articulating the core competencies for practice. The mental health telephone triage competencies identified in this research may be used to define an evidence-based framework for mental health telephone triage practice that aims to

Integrated care management: aligning medical call centers and nurse triage services.

PubMed

Kastens, J M

1998-01-01

Successful integrated delivery systems must aggressively design new approaches to managing patient care. Implementing a comprehensive care management model to coordinate patient care across the continuum is essential to improving patient care and reducing costs. The practice of telephone nursing and the need for experienced registered nurses to staff medical call centers, nurse triage centers, and outbound telemanagement is expanding as the penetration of full-risk capitated managed care contracts are signed. As health systems design their new care delivery approaches and care management models, medical call centers will be an integral approach to managing demand for services, chronic illnesses, and prevention strategies.

[Triage: a key tool in emergency care].

PubMed

Soler, Wifredo; Gómez Muñoz, M; Bragulat, E; Alvarez, A

2010-01-01

"Triage" is a process that enables us to manage clinical risk in order to safely and suitably handle patient flows when demand and clinical needs exceed resources. At present, triage systems that are employed are structured according to five levels of priority. Levels are allocated according to the concept that what is urgent is not always serious and that what is serious is not always urgent. This makes it possible to classify patients according to "degree of urgency", so that the more urgent patients will be attended to first and the rest will be re-evaluated until they are seen by the doctor. The Spanish triage system (SET) and the Manchester triage system (MTS) are the two standardised systems most implemented in our country. We also discuss the system of triage devised in Navarre--integrated in the computerised clinical history--and used in the hospital network of Navarre. All are multidisciplinary systems based on the reasons and urgency of consultation, but not on diagnoses, and are carried out by nursing staff with medical support when required. In addition, they all include monitoring of the quality of the accident and emergency service itself, and can be applied in the outpatient field.

Triage: an investigation of the process and potential vulnerabilities.

PubMed

Hitchcock, Maree; Gillespie, Brigid; Crilly, Julia; Chaboyer, Wendy

2014-07-01

To explore and describe the triage process in the Emergency Department to identify problems and potential vulnerabilities that may affect the triage process. Triage is the first step in the patient journey in the Emergency Department and is often the front line in reducing the potential for errors and mistakes. A fieldwork study to provide an in-depth appreciation and understanding of the triage process. Fieldwork included unstructured observer-only observation, field notes, informal and formal interviews that were conducted over the months of June, July and August 2012. Over 170 hours of observation were performed covering day, evening and night shifts, 7 days of the week. Sixty episodes of triage were observed; 31 informal interviews and 14 formal interviews were completed. Thematic analysis was used. Three themes were identified from the analysis of the data and included: 'negotiating patient flow and care delivery through the Emergency Department'; 'interdisciplinary team communicating and collaborating to provide appropriate and safe care to patients'; and 'varying levels of competence of the triage nurse'. In these themes, vulnerabilities and problems described included over and under triage, extended time to triage assessment, triage errors, multiple patients arriving simultaneously, emergency department and hospital overcrowding. Findings suggest that vulnerabilities in the triage process may cause disruptions to patient flow and compromise care, thus potentially impacting nurses' ability to provide safe and effective care. © 2013 John Wiley & Sons Ltd.

Clinical decision support improves quality of telephone triage documentation--an analysis of triage documentation before and after computerized clinical decision support.

PubMed

North, Frederick; Richards, Debra D; Bremseth, Kimberly A; Lee, Mary R; Cox, Debra L; Varkey, Prathibha; Stroebel, Robert J

2014-03-20

Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN©. We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety. Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68). CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS can improve documentation, further study is needed

Accuracy of prehospital triage protocols in selecting severely injured patients: A systematic review.

PubMed

van Rein, Eveline A J; Houwert, R Marijn; Gunning, Amy C; Lichtveld, Rob A; Leenen, Luke P H; van Heijl, Mark

2017-08-01

Prehospital trauma triage ensures proper transport of patients at risk of severe injury to hospitals with an appropriate corresponding level of trauma care. Incorrect triage results in undertriage and overtriage. The American College of Surgeons Committee on Trauma recommends an undertriage rate below 5% and an overtriage rate below 50% for prehospital trauma triage protocols. To find the most accurate prehospital trauma triage protocol, a clear overview of all currently available protocols and corresponding outcomes is necessary. The aim of this systematic review was to evaluate the current literature on all available prehospital trauma triage protocols and determine accuracy of protocol-based triage quality in terms of sensitivity and specificity. A search of Pubmed, Embase, and Cochrane Library databases was performed to identify all studies describing prehospital trauma triage protocols before November 2016. The search terms included "trauma," "trauma center," or "trauma system" combined with "triage," "undertriage," or "overtriage." All studies describing protocol-based triage quality were reviewed. To assess the quality of these type of studies, a new critical appraisal tool was developed. In this review, 21 articles were included with numbers of patients ranging from 130 to over 1 million. Significant predictors for severe injury were: vital signs, suspicion of certain anatomic injuries, mechanism of injury, and age. Sensitivity ranged from 10% to 100%; specificity from 9% to 100%. Nearly all protocols had a low sensitivity, thereby failing to identify severely injured patients. Additionally, the critical appraisal showed poor quality of the majority of included studies. This systematic review shows that nearly all protocols are incapable of identifying severely injured patients. Future studies of high methodological quality should be performed to improve prehospital trauma triage protocols. Systematic review, level III.

Machine-Learning-Based Electronic Triage More Accurately Differentiates Patients With Respect to Clinical Outcomes Compared With the Emergency Severity Index.

PubMed

Levin, Scott; Toerper, Matthew; Hamrock, Eric; Hinson, Jeremiah S; Barnes, Sean; Gardner, Heather; Dugas, Andrea; Linton, Bob; Kirsch, Tom; Kelen, Gabor

2018-05-01

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. A multisite, retrospective, cross-sectional study of 172,726 ED visits from urban and community EDs was conducted. E-triage is composed of a random forest model applied to triage data (vital signs, chief complaint, and active medical history) that predicts the need for critical care, an emergency procedure, and inpatient hospitalization in parallel and translates risk to triage level designations. Predicted outcomes and secondary outcomes of elevated troponin and lactate levels were evaluated and compared with the Emergency Severity Index (ESI). E-triage predictions had an area under the curve ranging from 0.73 to 0.92 and demonstrated equivalent or improved identification of clinical patient outcomes compared with ESI at both EDs. E-triage provided rationale for risk-based differentiation of the more than 65% of ED visits triaged to ESI level 3. Matching the ESI patient distribution for comparisons, e-triage identified more than 10% (14,326 patients) of ESI level 3 patients requiring up triage who had substantially increased risk of critical care or emergency procedure (1.7% ESI level 3 versus 6.2% up triaged) and hospitalization (18.9% versus 45.4%) across EDs. E-triage more accurately classifies ESI level 3 patients and highlights opportunities to use predictive analytics to support triage decisionmaking. Further prospective validation is needed. Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Patients' experience of being triaged directly to a psychologist in primary care: a qualitative study.

PubMed

Dahlöf, Linda; Simonsson, Anna; Thorn, Jörgen; Larsson, Maria Eh

2014-10-01

In a primary health-care centre (PHCC) situated in a segregated area with low socio-economic status, 'primary care triage' has increased efficiency and accessibility. In the primary-care triage, the nurse sorts the patient to the appropriate PHCC profession according to described symptoms. Aim The aim of this study was to examine the patients' experience of being triaged directly to a psychologist for assessment. Interviews were conducted with 20 patients and then analysed using qualitative content analysis. The results show that patients contacting the PHCC for mental health issues often are active agents with their own intent to see a psychologist, not a doctor, as a first-hand choice when contacting the PHCC. Seeking help for mental health issues is described as a sensitive issue that demands building up strength before contacting. The quick access to the preferred health-care professional is appreciated. The nurse was perceived as a caring facilitator rather than a decision maker. It is the patient's wish rather than the symptoms that directs the sorting. The patients' expectations when meeting the psychologist were wide and diverse. The structured assessment sometimes collided and sometimes united with these expectations, yielding different outcome satisfaction. The results could be seen in line with the present goal to increase patients' choice in the health-care system. The improved accessibility to the psychologist seems to meet community expectations. The results also indicate a need for providing more prior information about the assessment and potential outcomes.

A multicentre evaluation of two intensive care unit triage protocols for use in an influenza pandemic.

PubMed

Cheung, Winston K; Myburgh, John; Seppelt, Ian M; Parr, Michael J; Blackwell, Nikki; Demonte, Shannon; Gandhi, Kalpesh; Hoyling, Larissa; Nair, Priya; Passer, Melissa; Reynolds, Claire; Saunders, Nicholas M; Saxena, Manoj K; Thanakrishnan, Govindasamy

2012-08-06

To determine the increase in intensive care unit (ICU) bed availability that would result from the use of the New South Wales and Ontario Health Plan for an Influenza Pandemic (OHPIP) triage protocols. Prospective evaluation study conducted in eight Australian, adult, general ICUs, between September 2009 and May 2010. All patients who were admitted to the ICU, excluding those who had elective surgery, were prospectively evaluated using the two triage protocols, simulating a pandemic situation. Both protocols were originally developed to determine which patients should be excluded from accessing ICU resources during an influenza pandemic. Increase in ICU bed availability. At admission, the increases in ICU bed availability using Tiers 1, 2 and 3 of the NSW triage protocol were 3.5%, 14.7% and 22.7%, respectively, and 52.8% using the OHPIP triage protocol (P < 0.001). Re-evaluation of patients at 12 hours after admission using Tiers 1, 2 and 3 of the NSW triage protocol incrementally increased ICU bed availability by 19.2%, 16.1% and 14.1%, respectively (P < 0.001). The maximal cumulative increases in ICU bed availability using Tiers 1, 2 and 3 of the NSW triage protocol were 23.7%, 31.6% and 37.5%, respectively, at 72 hours (P < 0.001), and 65.0% using the OHPIP triage protocol, at 120 hours (P < 0.001). Both triage protocols resulted in increases in ICU bed availability, but the OHPIP protocol provided the greatest increase overall. With the NSW triage protocol, ICU bed availability increased as the protocol was escalated.

Clinical decision support improves quality of telephone triage documentation - an analysis of triage documentation before and after computerized clinical decision support

PubMed Central

2014-01-01

Background Clinical decision support (CDS) has been shown to be effective in improving medical safety and quality but there is little information on how telephone triage benefits from CDS. The aim of our study was to compare triage documentation quality associated with the use of a clinical decision support tool, ExpertRN©. Methods We examined 50 triage documents before and after a CDS tool was used in nursing triage. To control for the effects of CDS training we had an additional control group of triage documents created by nurses who were trained in the CDS tool, but who did not use it in selected notes. The CDS intervention cohort of triage notes was compared to both the pre-CDS notes and the CDS trained (but not using CDS) cohort. Cohorts were compared using the documentation standards of the American Academy of Ambulatory Care Nursing (AAACN). We also compared triage note content (documentation of associated positive and negative features relating to the symptoms, self-care instructions, and warning signs to watch for), and documentation defects pertinent to triage safety. Results Three of five AAACN documentation standards were significantly improved with CDS. There was a mean of 36.7 symptom features documented in triage notes for the CDS group but only 10.7 symptom features in the pre-CDS cohort (p < 0.0001) and 10.2 for the cohort that was CDS-trained but not using CDS (p < 0.0001). The difference between the mean of 10.2 symptom features documented in the pre-CDS and the mean of 10.7 symptom features documented in the CDS-trained but not using was not statistically significant (p = 0.68). Conclusions CDS significantly improves triage note documentation quality. CDS-aided triage notes had significantly more information about symptoms, warning signs and self-care. The changes in triage documentation appeared to be the result of the CDS alone and not due to any CDS training that came with the CDS intervention. Although this study shows that CDS

Accuracy of Pediatric Trauma Field Triage: A Systematic Review.

PubMed

van der Sluijs, Rogier; van Rein, Eveline A J; Wijnand, Joep G J; Leenen, Luke P H; van Heijl, Mark

2018-05-16

Field triage of pediatric patients with trauma is critical for transporting the right patient to the right hospital. Mortality and lifelong disabilities are potentially attributable to erroneously transporting a patient in need of specialized care to a lower-level trauma center. To quantify the accuracy of field triage and associated diagnostic protocols used to identify children in need of specialized trauma care. MEDLINE, Embase, PsycINFO, and Cochrane Register of Controlled Trials were searched from database inception to November 6, 2017, for studies describing the accuracy of diagnostic tests to identify children in need of specialized trauma care in a prehospital setting. Identified articles with a study population including patients not transported by emergency medical services were excluded. Quality assessment was performed using a modified version of the Quality Assessment of Diagnostic Accuracy Studies-2. After deduplication, 1430 relevant articles were assessed, a full-text review of 38 articles was conducted, and 5 of those articles were included. All studies were observational, published between 1996 and 2017, and conducted in the United States, and data collection was prospective in 1 study. Three different protocols were studied that analyzed a combined total of 1222 children in need of specialized trauma care. One protocol was specifically developed for a pediatric out-of-hospital cohort. The percentage of pediatric patients requiring specialized trauma care in each study varied between 2.6% (110 of 4197) and 54.7% (58 of 106). The sensitivity of the prehospital triage tools ranged from 49.1% to 87.3%, and the specificity ranged from 41.7% to 84.8%. No prehospital triage protocol alone complied with the international standard of 95% or greater sensitivity. Undertriage and overtriage rates, representative of the quality of the full diagnostic strategy to transport a patient to the right hospital, were not reported for inclusive trauma systems or

Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?

PubMed

Giesen, Paul; Ferwerda, Rosa; Tijssen, Roelie; Mokkink, Henk; Drijver, Roeland; van den Bosch, Wil; Grol, Richard

2007-06-01

In recent years, there has been a growth in the use of triage nurses to decrease general practitioner (GP) workloads and increase the efficiency of telephone triage. The actual safety of decisions made by triage nurses has not yet been assessed. To investigate whether triage nurses accurately estimate the urgency level of health complaints when using the national telephone guidelines, and to examine the relationship between the performance of triage nurses and their education and training. A cross-sectional, multicentre, observational study employing five mystery (simulated) patients who telephoned triage nurses in four GP cooperatives. The mystery patients played standardised roles. Each role had one of four urgency levels as determined by experts. The triage nurses called were asked to estimate the level of urgency after the contact. This level of urgency was compared with a gold standard. Triage nurses estimated the level of urgency of 69% of the 352 contacts correctly and underestimated the level of urgency of 19% of the contacts. The sensitivity and specificity of the urgency estimates provided by the triage nurses were found to be 0.76 and 0.95, respectively. The positive and negative predictive values of the urgency estimates were 0.83 and 0.93, respectively. A significant correlation was found between correct estimation of urgency and specific training on the use of the guidelines. The educational background (primary or secondary care) of the nurses had no significant relationship with the rate of underestimation. Telephone triage by triage nurses is efficient but possibly not safe, with potentially severe consequences for the patient. An educational programme for triage nurses is recommended. Also, a direct second safety check of all cases by a specially trained GP telephone doctor is advisable.

Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?

PubMed Central

Giesen, Paul; Ferwerda, Rosa; Tijssen, Roelie; Mokkink, Henk; Drijver, Roeland; van den Bosch, Wil; Grol, Richard

2007-01-01

Background In recent years, there has been a growth in the use of triage nurses to decrease general practitioner (GP) workloads and increase the efficiency of telephone triage. The actual safety of decisions made by triage nurses has not yet been assessed. Objectives To investigate whether triage nurses accurately estimate the urgency level of health complaints when using the national telephone guidelines, and to examine the relationship between the performance of triage nurses and their education and training. Method A cross‐sectional, multicentre, observational study employing five mystery (simulated) patients who telephoned triage nurses in four GP cooperatives. The mystery patients played standardised roles. Each role had one of four urgency levels as determined by experts. The triage nurses called were asked to estimate the level of urgency after the contact. This level of urgency was compared with a gold standard. Results Triage nurses estimated the level of urgency of 69% of the 352 contacts correctly and underestimated the level of urgency of 19% of the contacts. The sensitivity and specificity of the urgency estimates provided by the triage nurses were found to be 0.76 and 0.95, respectively. The positive and negative predictive values of the urgency estimates were 0.83 and 0.93, respectively. A significant correlation was found between correct estimation of urgency and specific training on the use of the guidelines. The educational background (primary or secondary care) of the nurses had no significant relationship with the rate of underestimation. Conclusion Telephone triage by triage nurses is efficient but possibly not safe, with potentially severe consequences for the patient. An educational programme for triage nurses is recommended. Also, a direct second safety check of all cases by a specially trained GP telephone doctor is advisable. PMID:17545343

Reorganising the pandemic triage processes to ethically maximise individuals' best interests.

PubMed

Tillyard, Andrew

2010-11-01

To provide a revised definition, process and purpose of triage to maximise the number of patients receiving intensive care during a crisis. Based on the ethical principle of virtue ethics and the underlying goal of providing individual patients with treatment according to their best interests, the methodology of triage is reassessed and revised. The decision making processes regarding treatment decisions during a pandemic are redefined and new methods of intensive care provision recommended as well as recommending the use of a 'ranking' system for patients excluded from intensive care, defining the role of non-intensive care specialists, and applying two types of triage as 'organisational triage' and 'treatment triage' based on the demand for intensive care. Using a different underlying ethical basis upon which to plan for a pandemic crisis could maximise the number of patients receiving intensive care based on individual patients' best interests.

Triage and the Lost Art of Decoding Vital Signs: Restoring Physiologically Based Triage Skills in Complex Humanitarian Emergencies.

PubMed

Burkle, Frederick M

2018-02-01

Triage management remains a major challenge, especially in resource-poor settings such as war, complex humanitarian emergencies, and public health emergencies in developing countries. In triage it is often the disruption of physiology, not anatomy, that is critical, supporting triage methodology based on clinician-assessed physiological parameters as well as anatomy and mechanism of injury. In recent times, too many clinicians from developed countries have deployed to humanitarian emergencies without the physical exam skills needed to assess patients without the benefit of remotely fed electronic monitoring, laboratory, and imaging studies. In triage, inclusion of the once-widely accepted and collectively taught "art of decoding vital signs" with attention to their character and meaning may provide clues to a patient's physiological state, improving triage sensitivity. Attention to decoding vital signs is not a triage methodology of its own or a scoring system, but rather a skill set that supports existing triage methodologies. With unique triage management challenges being raised by an ever-changing variety of humanitarian crises, these once useful skill sets need to be revisited, understood, taught, and utilized by triage planners, triage officers, and teams as a necessary adjunct to physiologically based triage decision-making. (Disaster Med Public Health Preparedness. 2018;12:76-85).

Concept of operations for triage of mechanical ventilation in an epidemic.

PubMed

Hick, John L; O'Laughlin, Daniel T

2006-02-01

The recent outbreak of severe acute respiratory syndrome and the growing potential of an influenza pandemic force us to consider the fact that despite great advances in critical care medicine, we lack the capacity to provide intensive care to the large number of patients that may be generated in an epidemic or multisite bioterrorism event. Because many epidemic and bioterrorist agent illnesses involve respiratory failure, mechanical ventilation is a frequently required intervention but one that is in limited supply. In advance of such an event, we must develop triage criteria that depend on clinical indicators of survivability and resource utilization to allocate scarce health care resources to those who are most likely to benefit. These criteria must be tiered, flexible, and implemented regionally, rather than institutionally, with the backing of public health agencies and relief of liability. This report provides a sample concept of operations for triage of mechanical ventilation in epidemic situations and discusses some of the ethical principles and pitfalls of such systems.

Patient and referring health care provider satisfaction with a physiotherapy spinal triage assessment service

PubMed Central

Bath, Brenna; Janzen, Bonnie

2012-01-01

Purpose To evaluate participant and referring care provider satisfaction associated with a spinal triage assessment service delivered by physiotherapists in collaboration with orthopedic surgeons. Methods People with low back-related complaints were recruited from those referred to a spinal triage assessment program delivered by physiotherapists. Measures of patient and provider satisfaction were completed at approximately 4 weeks after the assessment. The satisfaction surveys were analyzed quantitatively with descriptive statistics and qualitatively with an inductive thematic approach of open and axial coding. Results A total of 108/115 participants completed the posttest satisfaction survey. Sixty-six percent of participants were “very satisfied” with the service and 55% were “very satisfied” with the recommendations that were made. Only 18% of referring care providers completed the satisfaction survey and 90.5% of those were “very satisfied” with the recommendations. Sixty-one participants and 14 care providers provided comments which revealed a diverse range of themes which were coded into positive (ie, understanding the problem, communication, customer service, efficiency, and management direction), negative (ie, lack of detail, time to follow-up, cost) and neutral related to the triage service, and an “other” category unrelated to the service (ie, chronic symptoms, comorbidities, and limited access to health care.) Conclusion The quantitative results of the participant survey demonstrated very high levels of satisfaction with the service and slightly less satisfaction with the recommendations that were made. Satisfaction of referring care providers with the recommendations and report was also high, but given the low response rate, these results should be interpreted with caution. Qualitative analysis of participant and provider comments revealed a diverse range of themes. These other issues may be important contextual factors that have the

Patient and referring health care provider satisfaction with a physiotherapy spinal triage assessment service.

PubMed

Bath, Brenna; Janzen, Bonnie

2012-01-01

To evaluate participant and referring care provider satisfaction associated with a spinal triage assessment service delivered by physiotherapists in collaboration with orthopedic surgeons. People with low back-related complaints were recruited from those referred to a spinal triage assessment program delivered by physiotherapists. Measures of patient and provider satisfaction were completed at approximately 4 weeks after the assessment. The satisfaction surveys were analyzed quantitatively with descriptive statistics and qualitatively with an inductive thematic approach of open and axial coding. A total of 108/115 participants completed the posttest satisfaction survey. Sixty-six percent of participants were "very satisfied" with the service and 55% were "very satisfied" with the recommendations that were made. Only 18% of referring care providers completed the satisfaction survey and 90.5% of those were "very satisfied" with the recommendations. Sixty-one participants and 14 care providers provided comments which revealed a diverse range of themes which were coded into positive (ie, understanding the problem, communication, customer service, efficiency, and management direction), negative (ie, lack of detail, time to follow-up, cost) and neutral related to the triage service, and an "other" category unrelated to the service (ie, chronic symptoms, comorbidities, and limited access to health care.) The quantitative results of the participant survey demonstrated very high levels of satisfaction with the service and slightly less satisfaction with the recommendations that were made. Satisfaction of referring care providers with the recommendations and report was also high, but given the low response rate, these results should be interpreted with caution. Qualitative analysis of participant and provider comments revealed a diverse range of themes. These other issues may be important contextual factors that have the potential to impact patient relevant outcomes.

Telephone triage by GPs in out-of-hours primary care in Denmark: a prospective observational study of efficiency and relevance

PubMed Central

Huibers, Linda; Moth, Grete; Carlsen, Anders H; Christensen, Morten B; Vedsted, Peter

2016-01-01

Background In the UK, telephone triage in out-of-hours primary care is mostly managed by nurses, whereas GPs perform triage in Denmark. Aim To describe telephone contacts triaged to face-to-face contacts, GP-assessed relevance, and factors associated with triage to face-to-face contact. Design and setting A prospective observational study in Danish out-of-hours primary care, conducted from June 2010 to May 2011. Method Information on patients was collected from the electronic patient administration system and GPs completed electronic questionnaires about the contacts. The GPs conducting the face-to-face contacts assessed relevance of the triage to face-to-face contacts. The authors performed binomial regression analyses, calculating relative risk (RR) and 95% confidence intervals. Results In total, 59.2% of calls ended with a telephone consultation. Factors associated with triage to a face-to-face contact were: patient age >40 years (40–64: RR = 1.13; >64: RR = 1.34), persisting problem for 12–24 hours (RR = 1.15), severe problem (RR = 2.60), potentially severe problem (RR = 5.81), and non-severe problem (RR = 2.23). Face-to-face contacts were assessed as irrelevant for 12.7% of clinic consultations and 11.7% of home visits. A statistically significantly higher risk of irrelevant face-to-face contact was found for a persisting problem of >24 hours (RR = 1.25), contact on weekday nights (RR = 1.25), and contact <2 hours before the patient’s own GP’s opening time (RR = 1.80). Conclusion Around 12% of all face-to-face consultations in the study are assessed as irrelevant by GP colleagues, suggesting that GP triage is efficient. Knowledge of the factors influencing triage can provide better education for GPs, but future studies are needed to investigate other quality aspects of GP telephone triage. PMID:27432608

Teleconsultation in children with abdominal pain: a comparison of physician triage recommendations and an established paediatric telephone triage protocol.

PubMed

Staub, Gabrielle Marmier; von Overbeck, Jan; Blozik, Eva

2013-09-30

Quality assessment and continuous quality feedback to the staff is crucial for safety and efficiency of teleconsultation and triage. This study evaluates whether it is feasible to use an already existing telephone triage protocol to assess the appropriateness of point-of-care and time-to-treat recommendations after teleconsultations. Based on electronic patient records, we retrospectively compared the point-of-care and time-to-treat recommendations of the paediatric telephone triage protocol with the actual recommendations of trained physicians for children with abdominal pain, following a teleconsultation. In 59 of 96 cases (61%) these recommendations were congruent with the paediatric telephone protocol. Discrepancies were either of organizational nature, due to factors such as local referral policies or gatekeeping insurance models, or of medical origin, such as milder than usual symptoms or clear diagnosis of a minor ailment. A paediatric telephone triage protocol may be applicable in healthcare systems other than the one in which it has been developed, if triage rules are adapted to match the organisational aspects of the local healthcare system.

ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research.

PubMed

Nates, Joseph L; Nunnally, Mark; Kleinpell, Ruth; Blosser, Sandralee; Goldner, Jonathan; Birriel, Barbara; Fowler, Clara S; Byrum, Diane; Miles, William Scherer; Bailey, Heatherlee; Sprung, Charles L

2016-08-01

To update the Society of Critical Care Medicine's guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research. An appointed Task Force followed a standard, systematic, and evidence-based approach in reviewing the literature to develop these guidelines. The assessment of the evidence and recommendations was based on the principles of the Grading of Recommendations Assessment, Development and Evaluation system. The general subject was addressed in sections: admission criteria and benefits of different levels of care, triage, discharge timing and strategies, use of outreach programs to supplement ICU care, quality assurance/improvement and metrics, nonbeneficial treatment in the ICU, and rationing considerations. The literature searches yielded 2,404 articles published from January 1998 to October 2013 for review. Following the appraisal of the literature, discussion, and consensus, recommendations were written. Although these are administrative guidelines, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. A limited amount of high-quality evidence made it difficult to answer all the questions asked related to ICU admission, discharge, and triage. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing. We need to further develop preventive strategies to reduce the burden of critical illness, educate our noncritical care colleagues about these interventions, and improve our outreach, developing early identification and intervention systems.

Novel Application of a Reverse Triage Protocol Providing Increased Access to Care in an Outpatient, Primary Care Clinic Setting.

PubMed

Sacino, Amanda N; Shuster, Jonathan J; Nowicki, Kamil; Carek, Peter J; Wegman, Martin P; Listhaus, Alyson; Gibney, Joseph M; Chang, Ku-Lang

2016-02-01

As the number of patients with access to care increases, outpatient clinics will need to implement innovative strategies to maintain or enhance clinic efficiency. One viable alternative involves reverse triage. A reverse triage protocol was implemented during a student-run free clinic. Each patient's chief complaint(s) were obtained at the beginning of the clinic session and ranked by increasing complexity. "Complexity" was defined as the subjective amount of time required to provide a full, thorough evaluation of a patient. Less complex cases were prioritized first since they could be expedited through clinic processing and allow for more time and resources to be dedicated to complex cases. Descriptive statistics were used to characterize and summarize the data obtained. Categorical variables were analyzed using chi-square. A time series analysis of the outcome versus centered time in weeks was also conducted. The average number of patients seen per clinic session increased by 35% (9.5 versus 12.8) from pre-implementation of the reverse triage protocol to 6 months after the implementation of the protocol. The implementation of a reverse triage in an outpatient setting significantly increased clinic efficiency as noted by a significant increase in the number of patients seen during a clinic session.

The impact of using computer decision-support software in primary care nurse-led telephone triage: interactional dilemmas and conversational consequences.

PubMed

Murdoch, Jamie; Barnes, Rebecca; Pooler, Jillian; Lattimer, Valerie; Fletcher, Emily; Campbell, John L

2015-02-01

Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse-caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting 'telling cases' of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the 'interactional workability' of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care. Copyright © 2014 Elsevier Ltd. All rights reserved.

Disaster triage after the Haitian earthquake.

PubMed

Smith, R M; Dyer, G S M; Antonangeli, K; Arredondo, N; Bedlion, H; Dalal, A; Deveny, G M; Joseph, G; Lauria, D; Lockhart, S H; Lucien, S; Marsh, S; Rogers, S O; Salzarulo, H; Shah, S; Toussaint, R J; Wagoner, J

2012-11-01

In the aftermath of the devastating Haitian earthquake, we became the primary relief service for a large group of severely injured earthquake victims. Finding ourselves virtually isolated with extremely limited facilities and a group of critically injured patients whose needs vastly outstripped the available resources we employed a disaster triage system to organize their clinical care. This report describes the specific injury profile of this group of patients, their clinical course, and the management philosophy that we employed. It provides useful lessons for similar situations in the future. Copyright © 2011 Elsevier Ltd. All rights reserved.

Outcomes of nighttime refusal of admission to the intensive care unit: The role of the intensivist in triage.

PubMed

Hinds, Nicholas; Borah, Amit; Yoo, Erika J

2017-06-01

To compare outcomes of patients refused medical intensive care unit (MICU) admission overnight to those refused during the day and to examine the impact of the intensivist in triage. Retrospective, observational study of patients refused MICU admission at an urban university hospital. Of 294 patients, 186 (63.3%) were refused admission overnight compared to 108 (36.7%) refused during the day. Severity-of-illness by the Mortality Probability Model was similar between the two groups (P=.20). Daytime triage refusals were more likely to be staffed by an intensivist (P=.01). After risk-adjustment, daytime refusals had a lower odds of subsequent ICU admission (OR 0.46, 95% CI 0.22-0.95, P=.04) than patients triaged at night. There was no evidence for interaction between time of triage and intensivist staffing of the patient (P=.99). Patients refused MICU admission overnight are more likely to be later admitted to an ICU than patients refused during the day. However, the mechanism for this observation does not appear to depend on the intensivist's direct evaluation of the patient. Further investigation into the clinician-specific effects of ICU triage and identification of potentially modifiable hospital triage practices will help to improve both ICU utilization and patient safety. Copyright © 2017 Elsevier Inc. All rights reserved.

Musculoskeletal triage: a mixed methods study, integrating systematic review with expert and patient perspectives.

PubMed

Joseph, C; Morrissey, D; Abdur-Rahman, M; Hussenbux, A; Barton, C

2014-12-01

Triage is implemented in healthcare settings to optimise access to appropriate care and manage waiting times. To determine the optimum features of triage systems for patients with musculoskeletal conditions. AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, MEDLINE, Cochrane Library, Web of Science and Google Scholar. Studies that included non-musculoskeletal conditions, concerned patients aged <18 years or were set in emergency departments were excluded. Study quality was graded using the Downs and Black quality index. Qualitative methods were used to further inform the findings of the literature review. Thirty-four studies met the inclusion criteria, with study quality ranging from eight to 24 out of a possible 27. Musculoskeletal triage is conducted via face-to-face consultation, paper referral letter or telephone consultation. Triage performed by physiotherapists, general practitioners, multidisciplinary teams, nurses, occupational therapists and speech therapists has been shown to be effective using a range of outcomes. Qualitative data revealed the value of supportive interdisciplinary teams, and suggested that this support is more important than choice of clinician. Patients trusted, and expressed preferences for, experienced clinicians to perform triage. Triage can be performed effectively via a number of methods and by a range of clinicians. Satisfaction, cost, diagnostic agreement, appropriateness of referral and waiting list time have been improved though triage. Multidisciplinary support mechanisms are critical elements of successful triage systems. Patients are more concerned with access issues than professional boundaries. Copyright © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults.

PubMed

Ichwan, Brian; Darbha, Subrahmanyam; Shah, Manish N; Thompson, Laura; Evans, David C; Boulger, Creagh T; Caterino, Jeffrey M

2015-01-01

We evaluate the sensitivity of Ohio's 2009 emergency medical services (EMS) geriatric trauma triage criteria compared with the previous adult triage criteria in identifying need for trauma center care among older adults. We studied a retrospective cohort of injured patients aged 16 years or older in the 2006 to 2011 Ohio Trauma Registry. Patients aged 70 years or older were considered geriatric. We identified whether each patient met the geriatric and the adult triage criteria. The outcome measure was need for trauma center care, defined by surrogate markers: Injury Severity Score greater than 15, operating room in fewer than 48 hours, any ICU stay, and inhospital mortality. We calculated sensitivity and specificity of both triage criteria for both age groups. We included 101,577 patients; 33,379 (33%) were geriatric. Overall, 57% of patients met adult criteria and 68% met geriatric criteria. Using Injury Severity Score, for older adults geriatric criteria were more sensitive for need for trauma center care (93%; 95% confidence interval [CI] 92% to 93%) than adult criteria (61%; 95% CI 60% to 62%). Geriatric criteria decreased specificity in older adults from 61% (95% CI 61% to 62%) to 49% (95% CI 48% to 49%). Geriatric criteria in older adults (93% sensitivity, 49% specificity) performed similarly to the adult criteria in younger adults (sensitivity 87% and specificity 44%). Similar patterns were observed for other outcomes. Standard adult EMS triage guidelines provide poor sensitivity in older adults. Ohio's geriatric trauma triage guidelines significantly improve sensitivity in identifying Injury Severity Score and other surrogate markers of the need for trauma center care, with modest decreases in specificity for older adults. Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Mass-casualty triage: time for an evidence-based approach.

PubMed

Jenkins, Jennifer Lee; McCarthy, Melissa L; Sauer, Lauren M; Green, Gary B; Stuart, Stephanie; Thomas, Tamara L; Hsu, Edbert B

2008-01-01

Mass-casualty triage has developed from a wartime necessity to a civilian tool to ensure that constrained medical resources are directed at achieving the greatest good for the most number of people. Several primary and secondary triage tools have been developed, including Simple Treatment and Rapid Transport (START), JumpSTART, Care Flight Triage, Triage Sieve, Sacco Triage Method, Secondary Assessment of Victim Endpoint (SAVE), and Pediatric Triage Tape. Evidence to support the use of one triage algorithm over another is limited, and the development of effective triage protocols is an important research priority. The most widely recognized mass-casualty triage algorithms in use today are not evidence-based, and no studies directly address these issues in the mass-casualty setting. Furthermore, no studies have evaluated existing mass-casualty triage algorithms regarding ease of use, reliability, and validity when biological, chemical, or radiological agents are introduced. Currently, the lack of a standardized mass-casualty triage system that is well validated, reliable, and uniformly accepted, remains an important gap. Future research directed at triage is recognized as a necessity, and the development of a practical, universal, triage algorithm that incorporates requirements for decontamination or special precautions for infectious agents would facilitate a more organized mass-casualty medical response.

Pediatric Disaster Triage: Multiple Simulation Curriculum Improves Prehospital Care Providers' Assessment Skills.

PubMed

Cicero, Mark Xavier; Whitfill, Travis; Overly, Frank; Baird, Janette; Walsh, Barbara; Yarzebski, Jorge; Riera, Antonio; Adelgais, Kathleen; Meckler, Garth D; Baum, Carl; Cone, David Christopher; Auerbach, Marc

2017-01-01

Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT). Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK. The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p < 0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073). This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10

Critical care cardiology.

PubMed

Marks, S L; Abbott, J A

1998-11-01

Emergency management of the patient with cardiac disease is an important part of veterinary practice. Although the causes of cardiac disease may be diverse, the understanding of basic pathophysiology will enable the clinician to formulate a rational diagnostic and therapeutic plan. The veterinary clinician must be able to triage the emergency patient, assess the clinical condition, and provide appropriate therapy. Close monitoring of the critically ill patient is crucial to patient survival and will help tailor therapy.

Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting.

PubMed

Molyneux, Elizabeth; Ahmad, Shafique; Robertson, Ann

2006-04-01

Early assessment, prioritization for treatment and management of sick children attending a health service are critical to achieving good outcomes. Many hospitals in developing countries see large numbers of patients and have few staff, so patients often have to wait before being assessed and treated. We present the example of a busy Under-Fives Clinic that provided outpatient services, immunizations and treatment for medical emergencies. The clinic was providing an inadequate service resulting in some inappropriate admissions and a high case-fatality rate. We assessed the deficiencies and sought resources to improve services. A busy paediatric outpatient clinic in a public tertiary care hospital in Blantyre, Malawi. The main changes we made were to train staff in emergency care and triage, improve patient flow through the department and to develop close cooperation between inpatient and outpatient services. Training coincided with a restructuring of the physical layout of the department. The changes were put in place when the department reopened in January 2001. Improvements in the process and delivery of care and the ability to prioritize clinical management are essential to good practice. Making the changes described above has streamlined the delivery of care and led to a reduction in inpatient mortality from 10-18% before the changes were made (before 2001) to 6-8% after.

Point-of-care test identifies diabetic ketoacidosis at triage.

PubMed

Naunheim, Rosanne; Jang, Timothy J; Banet, Gerald; Richmond, Alec; McGill, Janet

2006-06-01

Diabetic ketoacidosis (DKA) is a common, life-threatening complication of diabetes. The diagnosis of DKA relies on signs and symptoms, plus laboratory findings of blood glucose (BG) of > 250 mg/dL, an anion gap (AG) of > or = 15 mmol/L, and carbon dioxide (CO2) of < or = 18 mmol/L when other causes of acidosis are excluded. To compare the results of a point-of-care test for the ketone beta-hydroxybutyrate (beta-OHB) with standard measures for accuracy in predicting DKA. After providing informed consent, 160 patients who presented with BG of > 250 mg/dL underwent testing for beta-OHB with the Precision Xtra meter (Abbott Laboratories, North Chicago, IL) at triage in a large urban hospital emergency department. The diagnosis of DKA was made by clinicians by using standard clinical criteria without knowledge of the beta-OHB test. A diagnosis of DKA was made in 57 of 160 subjects. The beta-OHB values correlated strongly with AG (r = 0.66, p < 0.001) and with CO2 (r = -0.69, p < 0.001), as well as with glucose (r = 0.31, p < 0.001). Cross-classification of DKA vs. beta-OHB yielded sensitivity of 98% (95% CI = 91% to 100%), specificity of 85% (95% CI = 78% to 91%), with a positive likelihood ratio of 6.7 (95% CI = 4.22 to 10.78), and negative likelihood ratio of 0.021 (95% CI = 0.003 to 0.144) at the manufacturer-suggested beta-OHB level of 1.5. The point-of-care test for beta-OHB was as sensitive as more established indicators of DKA. It is more useful than glucose alone for the diagnosis of DKA and offers immediate diagnosis of patients at triage.

Employees' views on home-based, after-hours telephone triage by Dutch GP cooperatives.

PubMed

Backhaus, Ramona; van Exel, Job; de Bont, Antoinette

2013-11-04

Dutch out-of-hours (OOH) centers find it difficult to attract sufficient triage staff. They regard home-based triage as an option that might attract employees. Specially trained nurses are supposed to conduct triage by telephone from home for after-hours medical care. The central aim of this research is to investigate the views of employees of OOH centers in The Netherlands on home-based telephone triage in after-hours care. The study is a Q methodology study. Triage nurses, general practitioners (GPs) and managers of OOH centers ranked 36 opinion statements on home-based triage. We interviewed 10 participants to help develop and validate the statements for the Q sort, and 77 participants did the Q sort. We identified four views on home-based telephone triage. Two generally favor home-based triage, one highlights some concerns and conditions, and one opposes it out of concern for quality. The four views perceive different sources of credibility for nurse triagists working from home. Home-based telephone triage is a controversial issue among triage nurses, GPs and managers of OOH centers. By identifying consensus and dissension among GPs, triagists, managers and regulators, this study generates four perspectives on home-based triage. In addition, it reveals the conditions considered important for home-based triage.

Triage level assignment and nurse characteristics and experience.

PubMed

Gómez-Angelats, Elisenda; Miró, Òscar; Bragulat Baur, Ernesto; Antolín Santaliestra, Alberto; Sánchez Sánchez, Miquel

2018-06-01

To study the relation between nursing staff demographics and experience and their assignment of triage level in the emergency department. One-year retrospective observational study in the triage area of a tertiary care urban university hospital that applies the Andorran-Spanish triage model. Variables studied were age, gender, nursing experience, triage experience, shift, usual level of emergency work the nurse undertakes, number of triage decisions made, and percentage of patients assigned to each level. Fifty nurses (5 men, 45 women) with a mean (SD) age of 45 (9) years triaged 67 803 patients during the year. Nurses classified more patients in level 5 on the morning shift (7.9%) than on the afternoon shift (5.5%) (P=.003). The difference in the rate of level-5 triage classification became significant when nurses were older (β = 0.092, P=.037) and experience was greater (β = 0.103, P=.017). The number of triages recorded by a nurse was significantly and directly related to the percentage of patients assigned to level 3 (β = 0.003, P=.006) and inversely related to the percentages assigned to level 4 (β = -0.002, P=.008) and level 5 (β = -0.001, P=.017). We found that triage level assignments were related to age, experience, shift, and total number of patients triaged by a nurse.

Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource-limited hospitals.

PubMed

Agulnik, Asya; Nadkarni, Anisha; Mora Robles, Lupe Nataly; Soberanis Vasquez, Dora Judith; Mack, Ricardo; Antillon-Klussmann, Federico; Rodriguez-Galindo, Carlos

2018-04-10

Pediatric oncology patients hospitalized in resource-limited settings are at high risk for clinical deterioration resulting in mortality. Intermediate care units (IMCUs) provide a cost-effective alternative to pediatric intensive care units (PICUs). Inappropriate IMCU triage, however, can lead to poor outcomes and suboptimal resource utilization. In this study, we sought to characterize patients with clinical deterioration requiring unplanned transfer to the IMCU in a resource-limited pediatric oncology hospital. Patients requiring subsequent early PICU transfer had longer PICU length of stay. PEWS results prior to IMCU transfer were higher in patients requiring early PICU transfer, suggesting PEWS can aid in triage between IMCU and PICU care. © 2018 Wiley Periodicals, Inc.

Employees’ views on home-based, after-hours telephone triage by Dutch GP cooperatives

PubMed Central

2013-01-01

Background Dutch out-of-hours (OOH) centers find it difficult to attract sufficient triage staff. They regard home-based triage as an option that might attract employees. Specially trained nurses are supposed to conduct triage by telephone from home for after-hours medical care. The central aim of this research is to investigate the views of employees of OOH centers in The Netherlands on home-based telephone triage in after-hours care. Methods The study is a Q methodology study. Triage nurses, general practitioners (GPs) and managers of OOH centers ranked 36 opinion statements on home-based triage. We interviewed 10 participants to help develop and validate the statements for the Q sort, and 77 participants did the Q sort. Results We identified four views on home-based telephone triage. Two generally favor home-based triage, one highlights some concerns and conditions, and one opposes it out of concern for quality. The four views perceive different sources of credibility for nurse triagists working from home. Conclusion Home-based telephone triage is a controversial issue among triage nurses, GPs and managers of OOH centers. By identifying consensus and dissension among GPs, triagists, managers and regulators, this study generates four perspectives on home-based triage. In addition, it reveals the conditions considered important for home-based triage. PMID:24188407

Rethinking transitions of care: An interprofessional transfer triage protocol in post-acute care.

PubMed

Patel, Radha V; Wright, Lauri; Hay, Brittany

2017-09-01

Readmissions to hospitals from post-acute care (PAC) units within long-term care settings have been rapidly increasing over the past decade, and are drivers of increased healthcare costs. With an average of $11,000 per admission, there is a need for strategies to reduce 30-day preventable hospital readmission rates. In 2018, incentives and penalties will be instituted for long-term care facilities failing to meet all-cause, all-condition hospital readmission rate performance measures. An interprofessional team (IPT) developed and implemented a Transfer Triage Protocol used in conjunction with the INTERACT programme to enhance clinical decision-making and assess the potential to reduce the facility's 30-day preventable hospital readmission rates by 10% within 6 weeks of implementation. Results from quantitative analysis demonstrated an overall 35.2% reduction in the 30-day preventable hospital readmission rate. Qualitative analysis revealed the need for additional staff education, improved screening and communication upon admission and prior to hospital transfer, and the need for more IPT on-site availability. This pilot study demonstrates the benefits and implications for practice of an IPT to improve the quality of care within PAC and decrease 30-day preventable hospital readmissions.

Web-based triage in a college health setting.

PubMed

Sole, Mary Lou; Stuart, Patricia L; Deichen, Michael

2006-01-01

The authors describe the initiation and use of a Web-based triage system in a college health setting. During the first 4 months of implementation, the system recorded 1,290 encounters. More women accessed the system (70%); the average age was 21.8 years. The Web-based triage system advised the majority of students to seek care within 24 hours; however, it recommended self-care management in 22.7% of encounters. Sore throat was the most frequent chief complaint (14.2%). A subset of 59 students received treatment at student health services after requesting an appointment via e-mail. The authors used kappa statistics to compare congruence between chief complaint and 24/7 WebMed classification (kappa = .94), between chief complaint and student health center diagnosis (kappa = .91), and between 24/7 WebMed classification and student health center diagnosis (kappa = .89). Initial evaluation showed high use and good accuracy of Web-based triage. This service provides education and advice to students about their health care concerns.

The effects of technology on triage in A & E.

PubMed

Roberts, J

1998-04-01

Within the specialty of Accident and Emergency (A & E) nursing, triage is a term meaning to classify or sort patients according to their need for care (Blythin 1988). Burgess (1992) views this process as a means of prioritizing patients in order, so that the more seriously ill or injured are seen first (Table 1). Triage performance is measured in the author's department by computer. This technological source is used to record the patient's arrival time and the time at which the patient is triaged. Technology is defined by the Oxford Dictionary (1996) as 'the study of mechanical arts and science, their application in industry'. This paper explores the impact of this technology and the related issues on the A & E triage nurse, and will focus on issues related to the Patients' Charter (1991), resource implications, safety and staff training. In conclusion, the quality of a patient's total care, in which the author participated, is discussed with reference to the related issues and implications for future practice.

Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting.

PubMed Central

Molyneux, Elizabeth; Ahmad, Shafique; Robertson, Ann

2006-01-01

PROBLEM: Early assessment, prioritization for treatment and management of sick children attending a health service are critical to achieving good outcomes. Many hospitals in developing countries see large numbers of patients and have few staff, so patients often have to wait before being assessed and treated. APPROACH: We present the example of a busy Under-Fives Clinic that provided outpatient services, immunizations and treatment for medical emergencies. The clinic was providing an inadequate service resulting in some inappropriate admissions and a high case-fatality rate. We assessed the deficiencies and sought resources to improve services. LOCAL SETTING: A busy paediatric outpatient clinic in a public tertiary care hospital in Blantyre, Malawi. RELEVANT CHANGES: The main changes we made were to train staff in emergency care and triage, improve patient flow through the department and to develop close cooperation between inpatient and outpatient services. Training coincided with a restructuring of the physical layout of the department. The changes were put in place when the department reopened in January 2001. LESSONS LEARNED: Improvements in the process and delivery of care and the ability to prioritize clinical management are essential to good practice. Making the changes described above has streamlined the delivery of care and led to a reduction in inpatient mortality from 10-18% before the changes were made (before 2001) to 6-8% after. PMID:16628305

Physiotherapy in Primary Care Triage - the effects on utilization of medical services at primary health care clinics by patients and sub-groups of patients with musculoskeletal disorders: a case-control study.

PubMed

Bornhöft, Lena; Larsson, Maria E H; Thorn, Jörgen

2015-01-01

Primary Care Triage is a patient sorting system used in some primary health care clinics (PHCCs) in Sweden where patients with musculoskeletal disorders (MSD) are triaged directly to physiotherapists. The purpose of this study was to investigate whether sorting/triaging patients seeking a PHCC for MSD directly to physiotherapists affects their utilization of medical services at the clinic for the MSD and to determine whether the effects of the triaging system vary for different sub-groups of patients. A retrospective case-control study design was used at two PHCCs. At the intervention clinic, 656 patients with MSD were initially triaged to physiotherapists. At the control clinic, 1673 patients were initially assessed by general practitioners (GPs). The main outcome measures were the number of patients continuing to visit GPs after the initial assessment, the number of patients receiving referrals to specialists/external examinations, doctors' notes for sick-leave or prescriptions for analgesics during one year, all for the original MSD. Significantly fewer patients triaged to physiotherapists required multiple GP visits for the MSD or received MSD-related referrals to specialists/external examinations, sick-leave recommendations or prescriptions during the following year compared to the GP-assessed group. This applies to all sub-groups except for the group with lower extremity disorders, which did not reach significance for either multiple GP visits or sick-leave recommendations. The reduced utilization of medical services by patients with MSD who were triaged to physiotherapists at a PHCC is likely due to altered management of MSD with initial assessment by physiotherapists.

Traditional Nurse Triage vs. Physician Tele-Presence in a Pediatric Emergency Department

PubMed Central

Marconi, Greg P.; Chang, Todd; Pham, Phung K.; Grajower, Daniel N.; Nager, Alan L.

2014-01-01

Objectives To compare traditional nurse triage (TNT) in a Pediatric Emergency Department (PED) to physician tele-presence (PTP). Methods Prospective, 2×2 crossover study with random assignment using a sample of walk-in patients seeking care in a PED at a large, tertiary care children’s hospital, from May 2012 to January 2013. Outcomes of triage times, documentation errors, triage scores, and survey responses were compared between TNT and PTP. Comparison between PTP to actual treating PED physicians regarding the accuracy of ordering blood and urine tests, throat cultures, and radiologic imaging was also studied. Results Paired samples t-tests showed a statistically significant difference in triage time between TNT and PTP (p=0.03), but no significant difference in documentation errors (p=0.10). Triage scores of TNT were 71% accurate, compared to PTP, which were 95% accurate. Both parents and children had favorable scores regarding PTP and the majority indicated they would prefer PTP again at their next PED visit. PTP diagnostic ordering was comparable to the actual PED physician ordering, showing no statistical differences. Conclusions Utilizing physician tele-presence technology to remotely perform triage is a feasible alternative to traditional nurse triage, with no clinically significant differences in time, triage scores, errors and patient and parent satisfaction. PMID:24445223

Web-Based Triage in a College Health Setting

ERIC Educational Resources Information Center

Sole, Mary Lou; Stuart, Patricia L.; Deichen, Michael

2006-01-01

The authors describe the initiation and use of a Web-based triage system in a college health setting. During the first 4 months of implementation, the system recorded 1,290 encounters. More women accessed the system (70%); the average age was 21.8 years. The Web-based triage system advised the majority of students to seek care within 24 hours;…

The need for pediatric-specific triage criteria: results from the Florida Trauma Triage Study.

PubMed

Phillips, S; Rond, P C; Kelly, S M; Swartz, P D

1996-12-01

The objective of the Florida Trauma Triage Study was to assess the performance of state-adopted field triage criteria. The study addressed three specific age groups: pediatric (age < 15 years), adult (age 15-54 years), and geriatric (age 55+ years). Since 1990, Florida has used a uniform set of eight triage criteria, known as the trauma scorecard, for triaging adult trauma patients to state-approved trauma centers. However, only five of the criteria are recommended for use with pediatric patients. This article presents the findings regarding the performance of the scorecard when applied to a pediatric population. We used state trauma registry data linked to state hospital discharge data in a retrospective analysis of trauma patients transported by prehospital providers to any acute care hospital within nine selected Florida counties between July 1, 1991, and December 31, 1991. We used cross-table and logistic regression analysis to determine the ability of triage criteria to correctly identify patients who were retrospectively defined as major trauma. We applied the field criteria to physiologic and anatomy/mechanism of injury data contained in the trauma registry to "score" the patient as major or minor trauma. To make our retrospective determination of major or minor trauma we used the protocols developed by an expert medical panel as described by E. J. MacKenzie et al. (1990). We calculated sensitivity, specificity, and the corresponding over- and undertriage rates by comparing patient classifications (major or minor trauma) produced by the triage criteria and the retrospective algorithm. We used logistic regression to identify which triage criteria were statistically significant in predicting major trauma. Pediatric cases accounted for 9.2% of the total study population, 6.0% of all hospitalized cases, and 6.8% of all trauma deaths. Of the 1505 pediatric cases available for analysis, the triage criteria classified 269 cases as expected major trauma and 1236

Impact on patients triage distribution utilizing the Australasian Triage Scale compared with its predecessor the National Triage Scale.

PubMed

Yousif, Khalid; Bebbington, Jane; Foley, Bernard

2005-01-01

To assess the impact of the change from the National Triage Scale (NTS) to the Australasian Triage Scale (ATS) within a hospital ED. A retrospective audit of consecutive adult patients attending the ED of Auckland Hospital from July to September 2001, during which patients were triaged according to the NTS, were compared with patients triaged according to the ATS during July to September 2002. In total, 8715 patients attended the department during July to September 2001 compared with 9047 patients during July to September 2002. There was a significant shift in the triage ratios with patient number increases of 28 and 24% in triage categories two and three, respectively, and decreases of 15 and 67% in categories four and five, respectively. The revision of the ATS has had a significant impact on the triage distribution of patients who present to ED. The change of distribution might have implications for meeting performance criteria and assessing casemix.

The appropriateness of, and compliance with, telephone triage decisions: a systematic review and narrative synthesis.

PubMed

Blank, Lindsay; Coster, Joanne; O'Cathain, Alicia; Knowles, Emma; Tosh, Jonathan; Turner, Janette; Nicholl, Jon

2012-12-01

This paper is a report of the synthesis of evidence on the appropriateness of, and compliance with, telephone triage decisions. Telephone triage plays an important role in managing demand for health care. Important questions are whether triage decisions are appropriate and patients comply with them. CINAHL, Cochrane Clinical Trials Database, Medline, Embase, Web of Science, and Psyc Info were searched between 1980-June 2010. Rapid Evidence Synthesis. The principles of rapid evidence assessment were followed. We identified 54 relevant papers: 26 papers reported appropriateness of triage decision, 26 papers reported compliance with triage decision, and 2 papers reported both. Nurses triaged calls in most of the studies (n=49). Triage decisions rated as appropriate varied between 44-98% and compliance ranged from 56-98%. Variation could not be explained by type of service or method of assessing appropriateness. However, inconsistent definitions of appropriateness may explain some variation. Triage decisions to contact primary care may have lower compliance than decisions to contact emergency services or self care. Telephone triage services can offer appropriate decisions and decisions that callers comply with. However, the association between the appropriateness of a decision and subsequent compliance requires further investigation and further consideration needs to be given to the minority of calls which are inappropriately managed. We suggest that a definition of appropriateness incorporating both accuracy and adequacy of triage decision should be encouraged. © 2012 Blackwell Publishing Ltd.

Development of a triage engine enabling behavior recognition and lethal arrhythmia detection for remote health care system.

PubMed

Sugano, Hiroto; Hara, Shinsuke; Tsujioka, Tetsuo; Inoue, Tadayuki; Nakajima, Shigeyoshi; Kozaki, Takaaki; Namkamura, Hajime; Takeuchi, Kazuhide

2011-01-01

For ubiquitous health care systems which continuously monitor a person's vital signs such as electrocardiogram (ECG), body surface temperature and three-dimensional (3D) acceleration by wireless, it is important to accurately detect the occurrence of an abnormal event in the data and immediately inform a medical doctor of its detail. In this paper, we introduce a remote health care system, which is composed of a wireless vital sensor, multiple receivers and a triage engine installed in a desktop personal computer (PC). The middleware installed in the receiver, which was developed in C++, supports reliable data handling of vital data to the ethernet port. On the other hand, the human interface of the triage engine, which was developed in JAVA, shows graphics on his/her ECG data, 3D acceleration data, body surface temperature data and behavior status in the display of the desktop PC and sends an urgent e-mail containing the display data to a pre-registered medical doctor when it detects the occurrence of an abnormal event. In the triage engine, the lethal arrhythmia detection algorithm based on short time Fourier transform (STFT) analysis can achieve 100 % sensitivity and 99.99 % specificity, and the behavior recognition algorithm based on the combination of the nearest neighbor method and the Naive Bayes method can achieve more than 71 % classification accuracy.

Improving Staff Communication and Transitions of Care Between Obstetric Triage and Labor and Delivery.

PubMed

O'Rourke, Kathleen; Teel, Joseph; Nicholls, Erika; Lee, Daniel D; Colwill, Alyssa Covelli; Srinivas, Sindhu K

2018-03-01

To improve staff perception of the quality of the patient admission process from obstetric triage to the labor and delivery unit through standardization. Preassessment and postassessment online surveys. A 13-bed labor and delivery unit in a quaternary care, Magnet Recognition Program, academic medical center in Pennsylvania. Preintervention (n = 100), postintervention (n = 52), and 6-month follow-up survey respondents (n = 75) represented secretaries, registered nurses, surgical technicians, certified nurse-midwives, nurse practitioners, maternal-fetal medicine fellows, anesthesiologists, and obstetric and family medicine attending and resident physicians from triage and labor and delivery units. We educated staff and implemented interventions, an admission huddle and safety time-out whiteboard, to standardize the admission process. Participants were evaluated with the use of preintervention, postintervention, and 6-month follow-up surveys about their perceptions regarding the admission process. Data tracked through the electronic medical record were used to determine compliance with the admission huddle and whiteboards. A 77% reduction (decrease of 49%) occurred in the perception of incomplete patient admission processes from baseline to 6-month follow-up after the intervention. Postintervention and 6-month follow-up survey results indicated that 100% of respondents responded strongly agree/agree/neutral that the new admission process improved communication surrounding care for patients. Data in the electronic medical record indicated that compliance with use of admission huddles and whiteboards increased from 50% to 80% by 6 months. The new patient admission process, including a huddle and safety time-out board, improved staff perception of the quality of admission from obstetric triage to the labor and delivery unit. Copyright © 2018 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

PubMed

Einav, Sharon; Hick, John L; Hanfling, Dan; Erstad, Brian L; Toner, Eric S; Branson, Richard D; Kanter, Robert K; Kissoon, Niranjan; Dichter, Jeffrey R; Devereaux, Asha V; Christian, Michael D

2014-10-01

. Critical care response to a disaster relies on careful planning for staff and resource augmentation and involves many agencies. Maximizing the 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 predetermined goals. Specialized physician oversight is necessary and if not available on site, may be provided through remote consultation. Triage by experienced providers, reverse triage, and service deescalation may be used to minimize ICU resource consumption. During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.

Development and technical basis of simplified guidelines for emergency triage assessment and treatment in developing countries. WHO Integrated Management of Childhood Illness (IMCI) Referral Care Project.

PubMed

Gove, S; Tamburlini, G; Molyneux, E; Whitesell, P; Campbell, H

1999-12-01

Simplified guidelines for the emergency care of children have been developed to improve the triage and rapid initiation of appropriate emergency treatments for children presenting to hospitals in developing countries. The guidelines are part of the effort to improve referral level paediatric care within the World Health Organisation/Unicef strategy integrated management of childhood illness (IMCI), based on evidence of significant deficiencies in triage and emergency care. Existing emergency guidelines have been modified according to resource limitations and significant differences in the epidemiology of severe paediatric illness and preventable death in developing countries with raised infant and child mortality rates. In these settings, it is important to address the emergency management of diarrhoea with severe dehydration, severe malaria, severe malnutrition, and severe bacterial pneumonia, and to focus attention on sick infants younger than 2 months of age. The triage assessment relies on a few clinical signs, which can be readily taught so that it can be used by health workers with limited clinical background. The assessment has been designed so that it can be carried out quickly if negative, making it functional for triaging children in queues.

Shifting Gears: Triage and Traffic in Urban India.

PubMed

Solomon, Harris

2017-09-01

While studies of triage in clinical medical literature tend to focus on the knowledge required to carry out sorting, this article details the spatial features of triage. It is based on participation observation of traffic-related injuries in a Mumbai hospital casualty ward. It pays close attention to movement, specifically to adjustments, which include moving bodies, changes in treatment priority, and interruptions in care. The article draws on several ethnographic cases of injury and its aftermath that gather and separate patients, kin, and bystanders, all while a triage medical authority is charged with sorting them out. I argue that attention must be paid to differences in movement, which can be overlooked if medical decision-making is taken to be a static verdict. The explanatory significance of this distinction between adjustment and adjudication is a more nuanced understanding of triage as an iterative, spatial process. © 2017 by the American Anthropological Association.

Decision-making in crisis: Applying a healthcare triage methodology to business continuity management.

PubMed

Moore, Bethany; Bone, Eric A

2017-01-01

The concept of triage in healthcare has been around for centuries and continues to be applied today so that scarce resources are allocated according to need. A business impact analysis (BIA) is a form of triage in that it identifies which processes are most critical, which to address first and how to allocate limited resources. On its own, however, the BIA provides only a roadmap of the impacts and interdependencies of an event. When disaster strikes, organisational decision-makers often face difficult decisions with regard to allocating limited resources between multiple 'mission-critical' functions. Applying the concept of triage to business continuity provides those decision-makers navigating a rapidly evolving and unpredictable event with a path that protects the fundamental priorities of the organisation. A business triage methodology aids decision-makers in times of crisis by providing a simplified framework for decision-making based on objective, evidence-based criteria, which is universally accepted and understood. When disaster strikes, the survival of the organisation depends on critical decision-making and quick actions to stabilise the incident. This paper argues that organisations need to supplement BIA processes with a decision-making triage methodology that can be quickly applied during the chaos of an actual event.

Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident.

PubMed

Vassallo, James; Smith, Jason E; Bruijns, Stevan R; Wallis, Lee A

2016-09-01

Triage is a key principle in the effective management of major incidents. The process currently relies on algorithms assigning patients to specific triage categories; there is, however, little guidance as to what these categories represent. Previously, these algorithms were validated against injury severity scores, but it is accepted now that the need for life-saving intervention is a more important outcome. However, the definition of a life-saving intervention is unclear. The aim of this study was to define what constitutes a life-saving intervention, in order to facilitate the definition of an adult priority one patient during the definitive care phase of a major incident. We conducted a modified Delphi study, using a panel of subject matter experts drawn from the United Kingdom and Republic of South Africa with a background in Emergency Care or Major Incident Management. The study was conducted using an online survey tool, over three rounds between July and December 2013. A four point Likert scale was used to seek consensus for 50 possible interventions, with a consensus level set at 70%. 24 participants completed all three rounds of the Delphi, with 32 life-saving interventions reaching consensus. This study provides a consensus definition of what constitutes a life-saving intervention in the context of an adult, priority one patient during the definitive care phase of a major incident. The definition will contribute to further research into major incident triage, specifically in terms of validation of an adult major incident triage tool. Copyright © 2016 Elsevier Ltd. All rights reserved.

Critical care medicine in the United States: addressing the intensivist shortage and image of the specialty.

PubMed

Halpern, Neil A; Pastores, Stephen M; Oropello, John M; Kvetan, Vladimir

2013-12-01

Intensivists are increasingly needed to care for the critically ill and manage ICUs as ICU beds, utilization, acuity of illness, complexity of care and costs continue to rise. However, there is a nationwide shortage of intensivists that has occurred despite years of well publicized warnings of an impending workforce crisis from specialty societies and the federal government. The magnitude of the intensivist shortfall, however, is difficult to determine because there are many perspectives of optimal ICU administration, patient coverage and intensivist availability and a lack of national data on intensivist practices. Nevertheless, the intensivist shortfall is quite real as evidenced by the alternative solutions that hospitals are deploying to provide care for their critically ill patients. In the midst of these manpower struggles, the critical care environment is dynamically changing and becoming more stressful. Severe hospital bed availability and fiscal constraints are forcing ICUs to alter their approaches to triage, throughput and unit staffing. National and local organizations are mandating that hospitals comply with resource intensive and arguably unproven initiatives to monitor and improve patient safety and quality, and informatics systems. Lastly, there is an ongoing sense of professional dissatisfaction among intensivists and a lack of public awareness that critical care medicine is even a distinct specialty. This article offers proposals to increase the adult intensivist workforce through expansion and enhancements of internal medicine based critical care training programs, incentives for recent graduates to enter the critical care medicine field, suggestions for improvements in the critical care profession and workplace to encourage senior intensivists to remain in the field, proactive marketing of critical care, and expanded engagement by the critical care societies in the challenges facing intensivists.

The cognitive processes underpinning clinical decision in triage assessment: a theoretical conundrum?

PubMed

Noon, Amy J

2014-01-01

High quality clinical decision-making (CDM) has been highlighted as a priority across the nursing profession. Triage nurses, in the Accident and Emergency (A&E) department, work in considerable levels of uncertainty and require essential skills including: critical thinking, evaluation and decision-making. The content of this paper aims to promote awareness of how triage nurses make judgements and decisions in emergency situations. By exploring relevant literature on clinical judgement and decision-making theory, this paper demonstrates the importance of high quality decision-making skills underpinning the triage nurse's role. Having an awareness of how judgements and decisions are made is argued as essential, in a time where traditional nurse boundaries and responsibilities are never more challenged. It is hoped that the paper not only raises this awareness in general but also, in particular, engages the triage nurse to look more critically at how they make their own decisions in their everyday practice. Copyright © 2013 Elsevier Ltd. All rights reserved.

Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

PubMed

Biddison, Lee Daugherty; Berkowitz, Kenneth A; Courtney, Brooke; De Jong, Col Marla J; Devereaux, Asha V; Kissoon, Niranjan; Roxland, Beth E; Sprung, Charles L; Dichter, Jeffrey R; Christian, Michael D; Powell, Tia

2014-10-01

Mass critical care entails time-sensitive decisions and changes in the standard of care that it is possible to deliver. These circumstances increase provider uncertainty as well as patients' vulnerability and may, therefore, jeopardize disciplined, ethical decision-making. Planning for pandemics and disasters should incorporate ethics guidance to support providers who may otherwise make ad hoc patient care decisions that overstep ethical boundaries. This article provides consensus-developed suggestions about ethical challenges in caring for the critically ill or injured during pandemics or disasters. The suggestions in this article are important for all of those involved in any pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. We adapted the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestions. Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions. The detailed literature reviews produced 144 articles. Based on their expertise within this domain, panel members also supplemented the literature search with governmental publications, interdisciplinary workgroup consensus documents, and other information not retrieved through PubMed. The literature in this field is not suitable to support evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. We report the suggestions that focus on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. Ethics issues permeate virtually all aspects of pandemic and disaster response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation, ethical

ED Triage Decision-Making With Mental Health Presentations: A "Think Aloud" Study.

PubMed

Clarke, Diana E; Boyce-Gaudreau, Krystal; Sanderson, Ana; Baker, John A

2015-11-01

Triage is the process whereby persons presenting to the emergency department are quickly assessed by a nurse and their need for care and service is prioritized. Research examining the care of persons presenting to emergency departments with psychiatric and mental health problems has shown that triage has often been cited as the most problematic aspect of the encounter. Three questions guided this investigation: Where do the decisions that triage nurses make fall on the intuitive versus analytic dimensions of decision making for mental health presentations in the emergency department, and does this differ according to comfort or familiarity with the type of mental health/illness presentation? How do "decision aids" (i.e., structured triage scales) help in the decision-making process? To what extent do other factors, such as attitudes, influence triage nurses' decision making? Eleven triage nurses participating in this study were asked to talk out loud about the reasoning process they would engage in while triaging patients in 5 scenarios based on mental health presentations to the emergency department. Themes emerging from the data were tweaking the results (including the use of intuition and early judgments) to arrive at the desired triage score; consideration of the current ED environment; managing uncertainty and risk (including the consideration of physical reasons for presentation); and confidence in communicating with patients in distress and managing their own emotive reactions to the scenario. Findings support the preference for using the intuitive mode of decision making with only tacit reliance on the decision aid. Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

Addressing the third delay: implementing a novel obstetric triage system in Ghana.

PubMed

Goodman, David M; Srofenyoh, Emmanuel K; Ramaswamy, Rohit; Bryce, Fiona; Floyd, Liz; Olufolabi, Adeyemi; Tetteh, Cecilia; Owen, Medge D

2018-01-01

Institutional delivery has been proposed as a method for reducing maternal morbidity and mortality, but little is known about how referral hospitals in low-resource settings can best manage the expected influx of patients. In this study, we assess the impact of an obstetric triage improvement programme on reducing hospital-based delay in a referral hospital in Accra, Ghana. An Active Implementation Framework is used to describe a 5-year intervention to introduce and monitor obstetric triage capabilities. Baseline data, collected from September to November 2012, revealed significant delays in patient assessment on arrival. A triage training course and monitoring of quality improvement tools occurred in 2013 and 2014. Implementation barriers led to the construction of a free-standing obstetric triage pavilion, opened January 2015, with dedicated midwives. Data were collected at three time intervals following the triage pavilion opening and compared with baseline including: referral indications, patient and labour characteristics, waiting time from arrival to assessment and the documentation of a care plan. An obstetric triage improvement programme reduced the median (IQR) patient waiting time from facility arrival to first assessment by a midwife from 40 min (15-100) to 5 min (2-6) (p<0.001) over the 5-year intervention. The triage pavilion enhanced performance resulting in the elimination of previous delays associated with the time of admission and disease acuity. Care plan documentation increased from 51% to 96%. Obstetric triage, when properly implemented, reduced delay in a busy, low-resource hospital. The implementation process was sustained under local leadership during transition to a new hospital.

Implementing best practice into the emergency department triage process.

PubMed

Burgess, Luke; Kynoch, Kathryn; Hines, Sonia

2018-05-17

Triage is the process by which emergency departments (EDs) sort patients presenting for medical treatment. The Australasian Triage Scale, validated to measure urgency, answers the question 'This patient should wait for medical assessment and treatment no longer than…' Multiple patients may present within short time frames, and some will have conditions that have outcomes directly related to timeliness of treatment such as stroke, sepsis and myocardial infarction. The safety of patients within the ED is thus directly related to the triage system. This project aimed to compare current triage practice within a metropolitan ED with evidence-based practice guidelines produced by the Australasian College for Emergency Medicine and College of Emergency Nurses Australasia. The clinical audit project was undertaken in an ED in a large metropolitan hospital. Two hundred episodes of triage were audited, 100 in the preimplementation and 100 in the postimplementation phase. Current practice was compared with triage guidelines, barriers to adherence to evidence-based practice identified, and interventions were planned and implemented to address these. The audits of practice focused on five key areas and were assessed against 12 criteria: arrival and triage, documentation, compliance with policy, communication, and triage staff. Overall five criteria showed improvement, with reassessment of patients waiting for treatment, and the time taken for each triage episode achieving the greatest amount of improvement. Four criteria showed no improvement or a decline, and two achieved 100% adherence in both audits. The project sought to undertake a clinical audit of triage practice to evaluate the adherence of practice to evidence-based guidelines. The project has provided strong support for the implementation of a formal nursing role to support the care of waiting room patients, and act as a second triage nurse during periods of high activity. The physical triage environment has been

Delivery room triage of large for gestational age infants of diabetic mothers.

PubMed

Cordero, Leandro; Rath, Krista; Zheng, Katherine; Landon, Mark B; Nankervis, Craig A

2014-01-01

To review our 4-year experience (2008-2011) with delivery room triage of large for gestational age infants of diabetic mothers. Retrospective cohort investigation of 311 large for gestational age infants of diabetic mothers (White's Class A1 (77), A2 (87), B (77), and C-R (70)). Of 311 women, 31% delivered at 34-36 weeks gestational age and 69% at term. While 70% were delivered by cesarean, 30% were vaginal deliveries. A total of 160 asymptomatic infants were triaged from the delivery room to the well baby nursery. Of these, 55 (34%) developed hypoglycemia. In 43 cases, the hypoglycemia was corrected by early feedings; in the remaining 12, intravenous dextrose treatment was required. A total of 151 infants were triaged from the delivery room to the neonatal intensive care unit. Admission diagnoses included respiratory distress (51%), prevention of hypoglycemia (27%), prematurity (21%), and asphyxia (1%). Hypoglycemia affected 66 (44%) of all neonatal intensive care unit infants. Safe triage of asymptomatic large for gestational age infants of diabetic mothers from the delivery room to well baby nursery can be accomplished in the majority of cases. Those infants in need of specialized care can be accurately identified and effectively treated in the neonatal intensive care unit setting.

Ethical issues in pediatric emergency mass critical care.

PubMed

Antommaria, Armand H Matheny; Powell, Tia; Miller, Jennifer E; Christian, Michael D

2011-11-01

As a result of recent events, including natural disasters and pandemics, mass critical care planning has become a priority. In general, planning involves limiting the scope of disasters, increasing the supply of medical resources, and allocating scarce resources. Entities at varying levels have articulated ethical frameworks to inform policy development. In spite of this increased focus, children have received limited attention. Children require special attention because of their unique vulnerabilities and needs. In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subgroups by topic area and performed literature reviews of MEDLINE and Ovid databases. Draft documents were subsequently developed and revised based on the feedback from the Task Force. The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. This document reflects expert input from the Task Force in addition to the most current medical literature. The Ethics Subcommittee recommends that surge planning seek to provide resources for children in proportion to their percentage of the population or preferably, if data are available, the percentage of those affected by the disaster. Generally, scarce resources should be allocated on the basis of need, benefit, and the conservation of resources. Estimates of need, benefit, and resource utilization may be more subjective or objective. While the

CCC meets ICU: redefining the role of critical care of cancer patients.

PubMed

von Bergwelt-Baildon, Michael; Hallek, Michael J; Shimabukuro-Vornhagen, Alexander A; Kochanek, Matthias

2010-11-08

Currently the majority of cancer patients are considered ineligible for intensive care treatment and oncologists are struggling to get their patients admitted to intensive care units. Critical care and oncology are frequently two separate worlds that communicate rarely and thus do not share novel developments in their fields. However, cancer medicine is rapidly improving and cancer is eventually becoming a chronic disease. Oncology is therefore characterized by a growing number of older and medically unfit patients that receive numerous novel drug classes with unexpected side effects. All of these changes will generate more medically challenging patients in acute distress that need to be considered for intensive care. An intense exchange between intensivists, oncologists, psychologists and palliative care specialists is warranted to communicate the developments in each field in order to improve triage and patient treatment. Here, we argue that "critical care of cancer patients" needs to be recognized as a medical subspecialty and that there is an urgent need to develop it systematically. As prognosis of cancer improves, novel therapeutic concepts are being introduced and more and more older cancer patients receive full treatment the number of acutely ill patients is growing significantly. This development a major challenge to current concepts of intensive care and it needs to be redefined who of these patients should be treated, for how long and how intensively.

Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs

PubMed Central

Richards, David A; Meakins, Joan; Tawfik, Jane; Godfrey, Lesley; Dutton, Evelyn; Richardson, Gerald; Russell, Daphne

2002-01-01

Objective To compare the workloads of general practitioners and nurses and costs of patient care for nurse telephone triage and standard management of requests for same day appointments in routine primary care. Design Multiple interrupted time series using sequential introduction of experimental triage system in different sites with repeated measures taken one week in every month for 12 months. Setting Three primary care sites in York. Participants 4685 patients: 1233 in standard management, 3452 in the triage system. All patients requesting same day appointments during study weeks were included in the trial. Main outcome measures Type of consultation (telephone, appointment, or visit), time taken for consultation, presenting complaints, use of services during the month after same day contact, and costs of drugs and same day, follow up, and emergency care. Results The triage system reduced appointments with general practitioner by 29-44%. Compared with standard management, the triage system had a relative risk (95% confidence interval) of 0.85 (0.72 to 1.00) for home visits, 2.41 (2.08 to 2.80) for telephone care, and 3.79 (3.21 to 4.48) for nurse care. Mean overall time in the triage system was 1.70 minutes longer, but mean general practitioner time was reduced by 2.45 minutes. Routine appointments and nursing time increased, as did out of hours and accident and emergency attendance. Costs did not differ significantly between standard management and triage: mean difference £1.48 more per patient for triage (95% confidence interval –0.19 to 3.15). Conclusions Triage reduced the number of same day appointments with general practitioners but resulted in busier routine surgeries, increased nursing time, and a small but significant increase in out of hours and accident and emergency attendance. Consequently, triage does not reduce overall costs per patient for managing same day appointments. What is already known on this topicNurse telephone triage is used to manage

Ethical triage and scarce resource allocation during public health emergencies: tenets and procedures.

PubMed

Kuschner, Ware G; Pollard, John B; Ezeji-Okoye, Stephen C

2007-01-01

Public health emergencies may result in mass casualties and a surge in demand for hospital-based care. Healthcare standards may need to be altered to respond to an imbalance between demands for care and resources. Clinical decisions that involve triage and scarce resource allocation may present unique ethical challenges. To address these challenges, the authors detailed tenets and procedures to guide triage and scarce resource allocation during public health emergencies. The authors propose health care organizations deploy a Triage and Scarce Resource Allocation Team to over-see and guide ethically challenging clinical decision-making during a crisis period. The authors' goal is to help healthcare organizations and clinicians balance public health responsibilities and their duty to individual patients during emergencies in as equitable and humane a manner as possible.

Development and testing of the KERNset: an instrument to assess the quality of telephone triage in out-of-hours primary care services.

PubMed

Smits, Marleen; Keizer, Ellen; Ram, Paul; Giesen, Paul

2017-12-02

Telephone triage is a core but vulnerable part of the care process at out-of-hours general practitioner (GP) cooperatives. In the Netherlands, different instruments have been used for assessing the quality of telephone triage. These instruments focussed mainly on communicational aspects, and less on the medical quality of triage decisions. Our aim was to develop and test a minimum set of items to assess the quality of telephone triage. A national survey among all GP cooperatives in the Netherlands was performed to examine the most important aspects of telephone triage. Next, corresponding items from existing instruments were searched on these topics. Subsequently, an expert panel judged these items on importance, completeness and formulation. The concept KERNset consisted of 24 items about the telephone conversation: 13 medical, ten communicational and one regarding both types. It was pilot tested on measurement characteristics, reliability, validity and variation between triagists. In this pilot study, 114 anonymous calls from four GP cooperatives spread across the Netherlands were judged by three out of eight raters, both internal and external raters. Cronbach's alpha was .94 for the medical items and .75 for the communicational items. Inter-rater reliability: complete agreement between the external raters was 45% and reasonable agreement 73% (difference of maximally one point on the five-point scale). Intra-rater reliability: complete agreement within raters was 55% and reasonable agreement 84%. There were hardly any differences between internal and external raters, but there were differences in strictness between individual raters. The construct validity was confirmed by the high correlation between the general impression of the call and the items of the KERNset. Of the differences within items 19% could be explained by differences between triage nurses, which means the KERNset is able to demonstrate differences between triage nurses. The KERNset can be used to

Ethics of emergency department triage: SAEM position statement. SAEM Ethics Committee (Society for Academic Emergency Medicine).

PubMed

1995-11-01

Emergency department overcrowding, the growth of managed care, and the high cost of emergency care are creating pressures to triage patients away from U.S. EDs. Paradoxically, this pressure to limit patient access to EDs has increased in spite of federal laws that restrict patient triage and transfer. The latter regulations view EDs as the safety net for the U.S. health care system. The SAEM Ethics Committee evaluated the ethical implications of policies that triage patients out of the ED prior to complete evaluation and treatment. The committee used these implications to develop practical guidelines, which are reported.

Special populations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

PubMed

Dries, David; Reed, Mary Jane; Kissoon, Niranjan; Christian, Michael D; Dichter, Jeffrey R; Devereaux, Asha V; Upperman, Jeffrey S

2014-10-01

Past disasters have highlighted the need to prepare for subsets of critically ill, medically fragile patients. These special patient populations require focused disaster planning that will address their medical needs throughout the event to prevent clinical deterioration. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with multiple critically ill or injured patients, including frontline clinicians, hospital administrators, and public health or government officials. Key questions regarding the care of critically ill or injured special populations during disasters or pandemics were identified, and a systematic literature review (1985-2013) was performed. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. The panel did not include pediatrics as a separate special population because pediatrics issues are embedded in each consensus document. Fourteen suggestions were formulated regarding the care of critically ill and injured patients from special populations during pandemics and disasters. The suggestions cover the following areas: defining special populations for mass critical care, special population planning, planning for access to regionalized service for special populations, triage and resource allocation of special populations, therapeutic considerations, and crisis standards of care for special populations. Chronically ill, technologically dependent, and complex critically ill patients present a unique challenge to preparing and implementing mass critical care. There are, however, unique opportunities to engage patients, primary physicians, advocacy groups, and professional organizations to lessen the impact of disaster on these special populations.

A descriptive study of women presenting to an obstetric triage unit with no prenatal care.

PubMed

Knight, Erin; Morris, Margaret; Heaman, Maureen

2014-03-01

To describe women presenting to an obstetric triage unit with no prenatal care (PNC), to identify gaps in care, and to compare care provided to World Health Organization (WHO) standards. We reviewed the charts of women who gave birth at Women's Hospital in Winnipeg and were discharged between April 1, 2008, and March 31, 2011, and identified those whose charts were coded with ICD-10 code Z35.3 (inadequate PNC) or who had fewer than 2 PNC visits. Three hundred eighty-two charts were identified, and sociodemographic characteristics, PNC history, investigations, and pregnancy outcomes were recorded. The care provided was compared with WHO guidelines. One hundred nine women presented to the obstetric triage unit with no PNC; 96 (88.1%) were in the third trimester. Only 39 women (35.8%) received subsequent PNC, with care falling short of WHO standards. Gaps in PNC included missing time-sensitive screening tests, mid-stream urine culture, and Chlamydia and gonorrhea testing. The mean maternal age was 26.1 years, and 93 women (85.3%) were multigravidas. More than one half of the women (51.4%) were involved with Child and Family Services, 64.2% smoked, 33.0% drank alcohol, and 32.1% used illicit drugs during pregnancy. Two thirds of the women (66.2%) lived in inner-city Winnipeg. Only 63.0% of neonates showed growth appropriate for gestational age. Two pregnancies ended in stillbirth; there was one neonatal death, and over one third of the births were preterm. Most women who present with no PNC do so late in pregnancy, proceed to deliver with little or no additional PNC, and have high rates of adverse outcomes. Thus, efforts to improve PNC must focus on facilitating earlier entry into care. This would also improve compliance with WHO guidelines for continuing care. Treatment protocols could improve gaps in obtaining urine culture and in Chlamydia and gonorrhea testing.

Automatic Pre-Hospital Vital Signs Waveform and Trend Data Capture Fills Quality Management, Triage and Outcome Prediction Gaps

PubMed Central

Mackenzie, Colin F; Hu, Peter; Sen, Ayan; Dutton, Rick; Seebode, Steve; Floccare, Doug; Scalea, Tom

2008-01-01

Trauma Triage errors are frequent and costly. What happens in pre-hospital care remains anecdotal because of the dual responsibility of treatment (resuscitation and stabilization) and documentation in a time-critical environment. Continuous pre-hospital vital signs waveforms and numerical trends were automatically collected in our study. Abnormalities of pulse oximeter oxygen saturation (< 95%) and validated heart rate (> 100/min) showed better prediction of injury severity, need for immediate blood transfusion, intra-abdominal surgery, tracheal intubation and chest tube insertion than Trauma Registry data or Pre-hospital provider estimations. Automated means of data collection introduced the potential for more accurate and objective reporting of patient vital signs helping in evaluating quality of care and establishing performance indicators and benchmarks. Addition of novel and existing non-invasive monitors and waveform analyses could make the pulse oximeter the decision aid of choice to improve trauma patient triage. PMID:18999022

Impact of physician-less pediatric critical care transport: Making a decision on team composition.

PubMed

Kawaguchi, Atsushi; Nielsen, Charlene C; Saunders, L Duncan; Yasui, Yutaka; de Caen, Allan

2018-06-01

To explore the impact of a physician non-accompanying pediatric critical care transport program, and to identify factors associated with the selection of specific transport team compositions. Children transported to a Canadian academic children's hospital were included. Two eras (Physician-accompanying Transport (PT)-era: 2000-07 when physicians commonly accompanied the transport team; and Physician-Less Transport (PLT)-era: 2010-15 when a physician non-accompanying team was increasingly used) were compared with respect to transport and PICU outcomes. Transport and patient characteristics for the PLT-era cohort were examined to identify factors associated with the selection of a physician accompanying team, with multivariable logistic regression with triage physicians as random effects. In the PLT-era (N=1177), compared to the PT-era (N=1490) the probability of PICU admission was significantly lower, and patient outcomes including mortality were not significantly different. Associations were noted between the selection of a physician non-accompanying team and specific transport characteristics. There was appreciable variability among the triage physicians for the selection of a physician non-accompanying team. No significant differences were observed with increasing use of a physician non-accompanying team. Selection of transport team compositions was influenced by clinical and system factors, but appreciable variation still remained among triage physicians. Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.

Triage in military settings.

PubMed

Falzone, E; Pasquier, P; Hoffmann, C; Barbier, O; Boutonnet, M; Salvadori, A; Jarrassier, A; Renner, J; Malgras, B; Mérat, S

2017-02-01

Triage, a medical term derived from the French word "trier", is the practical process of sorting casualties to rationally allocate limited resources. In combat settings with limited medical resources and long transportation times, triage is challenging since the objectives are to avoid overcrowding medical treatment facilities while saving a maximum of soldiers and to get as many of them back into action as possible. The new face of modern warfare, asymmetric and non-conventional, has led to the integrative evolution of triage into the theatre of operations. This article defines different triage scores and algorithms currently implemented in military settings. The discrepancies associated with these military triage systems are highlighted. The assessment of combat casualty severity requires several scores and each nation adopts different systems for triage on the battlefield with the same aim of quickly identifying those combat casualties requiring lifesaving and damage control resuscitation procedures. Other areas of interest for triage in military settings are discussed, including predicting the need for massive transfusion, haemodynamic parameters and ultrasound exploration. Copyright © 2016 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

Momentary fitting in a fluid environment: A grounded theory of triage nurse decision making.

PubMed

Reay, Gudrun; Rankin, James A; Then, Karen L

2016-05-01

Triage nurses control access to the Emergency Department (ED) and make decisions about patient acuity, patient priority, and placement of the patient in the ED. Understanding the processes and strategies that triage nurses use to make decisions is therefore vital for patient safety and the operation of the ED. The aim of the current study was to generate a substantive grounded theory (GT) of decision making by emergency triage Registered Nurses (RNs). Data collection consisted of seven observations of the triage environment at three tertiary care hospitals where RNs conducted triage and twelve interviews with triage RNs. The data were analyzed by constant comparison in accordance with the classical GT method. In the resultant theory, Momentary Fitting in a Fluid Environment, triage is conceptualized as a process consisting of four categories, determining acuity, anticipating needs, managing space, and creating space. The findings indicate that triage RNs continually strive to achieve fit, while simultaneously considering the individual patient and the ED as a whole entity. Triage RNs require appropriately designed triage environments and computer technology that enable them to secure real time knowledge of the ED to maintain situation awareness. Copyright © 2015 Elsevier Ltd. All rights reserved.

[Self-referrals at Emergency Care Access Points and triage by General Practitioner Cooperatives].

PubMed

Smits, M; Rutten, M; Schepers, L; Giesen, P

2017-01-01

There is a trend for General Practitioner Cooperatives (GPCs) to co-locate with emergency departments (EDs) of hospitals at Emergency Care Access Points (ECAPs), where the GPCs generally conduct triage and treat a large part of self-referrals who would have gone to the ED by themselves in the past. We have examined patient and care characteristics of self-referrals at ECAPs where triage was conducted by GPCs, also to determine the percentage of self-referrals being referred to the ED. Retrospective cross-sectional observational study. Descriptive analyses of routine registration data from self-referrals of five ECAPs (n = 20.451). Patient age, gender, arrival time, urgency, diagnosis and referral were analysed. Of the self-referrals, 57.9% was male and the mean age was 32.7 years. The number of self-referrals per hour was highest during weekends, particularly between 11 a.m. and 5 p.m. On weekdays, there was a peak between 5 and 9 p.m. Self-referrals were mostly assigned a low-urgency grade (35.7% - U4 or U5) or a mid-urgency grade (49% - U3). Almost half of the self-referrals had trauma of the locomotor system (28%) or the skin (27.3%). In total, 23% of the patients was referred to the ED. Self-referred patients at GPCs are typically young, male and have low- to mid-urgency trauma-related problems. Many self-referrals present themselves on weekend days or early weekday evenings. Over three quarters of these patients can be treated by the GPCs, without referral to the ED. This reduces the workload at the ED.

Implementing an obstetric triage acuity scale: interrater reliability and patient flow analysis.

PubMed

Smithson, David S; Twohey, Rachel; Rice, Tim; Watts, Nancy; Fernandes, Christopher M; Gratton, Robert J

2013-10-01

A 5-category Obstetric Triage Acuity Scale (OTAS) was developed with a comprehensive set of obstetrical determinants. The objectives of this study were as follows: (1) to test the interrater reliability of OTAS and (2) to determine the distribution of patient acuity and flow by OTAS level. To test the interrater reliability, 110 triage charts were used to generate vignettes and the consistency of the OTAS level assigned by 8 triage nurses was measured. OTAS performed with substantial (Kappa, 0.61 - 0.77, OTAS 1-4) and near perfect correlation (0.87, OTAS 5). To assess patient flow, the times to primary and secondary health care provider assessments and lengths of stay stratified by acuity were abstracted from the patient management system. Two-thirds of triage visits were low acuity (OTAS 4, 5). There was a decrease in length of stay (median [interquartile range], minutes) as acuity decreased from OTAS 1 (120.0 [156.0] minutes) to OTAS 3 (75.0 [120.8]). The major contributor to length of stay was time to secondary health care provider assessment and this did not change with acuity. The percentage of patients admitted to the antenatal or birthing unit decreased from 80% (OTAS 1) to 12% (OTAS 5). OTAS provides a reliable assessment of acuity and its implementation has allowed for triaging of obstetric patients based on acuity, and a more in-depth assessment of the patient flow. By standardizing assessment, OTAS allows for opportunities to improve performance and make comparisons of patient care and flow across organizations. Copyright © 2013 Mosby, Inc. All rights reserved.

Performance characteristics of five triage tools for major incidents involving traumatic injuries to children.

PubMed

Price, C L; Brace-McDonnell, S J; Stallard, N; Bleetman, A; Maconochie, I; Perkins, G D

2016-05-01

Context Triage tools are an essential component of the emergency response to a major incident. Although fortunately rare, mass casualty incidents involving children are possible which mandate reliable triage tools to determine the priority of treatment. To determine the performance characteristics of five major incident triage tools amongst paediatric casualties who have sustained traumatic injuries. Retrospective observational cohort study using data from 31,292 patients aged less than 16 years who sustained a traumatic injury. Data were obtained from the UK Trauma Audit and Research Network (TARN) database. Interventions Statistical evaluation of five triage tools (JumpSTART, START, CareFlight, Paediatric Triage Tape/Sieve and Triage Sort) to predict death or severe traumatic injury (injury severity score >15). Main outcome measures Performance characteristics of triage tools (sensitivity, specificity and level of agreement between triage tools) to identify patients at high risk of death or severe injury. Of the 31,292 cases, 1029 died (3.3%), 6842 (21.9%) had major trauma (defined by an injury severity score >15) and 14,711 (47%) were aged 8 years or younger. There was variation in the performance accuracy of the tools to predict major trauma or death (sensitivities ranging between 36.4 and 96.2%; specificities 66.0-89.8%). Performance characteristics varied with the age of the child. CareFlight had the best overall performance at predicting death, with the following sensitivity and specificity (95% CI) respectively: 95.3% (93.8-96.8) and 80.4% (80.0-80.9). JumpSTART was superior for the triaging of children under 8 years; sensitivity and specificity (95% CI) respectively: 86.3% (83.1-89.5) and 84.8% (84.2-85.5). The triage tools were generally better at identifying patients who would die than those with non-fatal severe injury. This statistical evaluation has demonstrated variability in the accuracy of triage tools at predicting outcomes for children who

Critical Care Organizations: Business of Critical Care and Value/Performance Building.

PubMed

Leung, Sharon; Gregg, Sara R; Coopersmith, Craig M; Layon, A Joseph; Oropello, John; Brown, Daniel R; Pastores, Stephen M; Kvetan, Vladimir

2018-01-01

New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the viability of hospitals and health systems. The Society of Critical Care Medicine convened a taskforce of Academic Leaders in Critical Care Medicine on February 22, 2016, during the 45th Critical Care Congress to develop a toolkit drawing on the experience of successful leaders of critical care organizations in North America for advancing critical care organizations (Appendix 1). The goal of this article was to provide a roadmap and call attention to key factors that adult critical care medicine leadership in both academic and nonacademic setting should consider when planning for value-based care. Relevant medical literature was accessed through a literature search. Material published by federal health agencies and other specialty organizations was also reviewed. Collaboratively and iteratively, taskforce members corresponded by electronic mail and held monthly conference calls to finalize this report. The business and value/performance critical care organization building section comprised of leaders of critical care organizations with expertise in critical care administration, healthcare management, and clinical practice. Two phases of critical care organizations care integration are described: "horizontal," within the system and regionalization of care as an initial phase, and "vertical," with a post-ICU and postacute care continuum as a succeeding phase. The tools required for the clinical and financial transformation are provided, including the essential prerequisites of forming a critical care organization; the manner in which a critical care organization can help manage transformational domains is considered. Lastly, how to achieve organizational health system support for critical care organization implementation is discussed. A critical care organization that incorporates functional clinical horizontal and

Critical Care

MedlinePlus

Critical care helps people with life-threatening injuries and illnesses. It might treat problems such as complications from surgery, ... attention by a team of specially-trained health care providers. Critical care usually takes place in an ...

Manchester Triage System: main flowcharts, discriminators and outcomes of a pediatric emergency care 1

PubMed Central

Amthauer, Camila; da Cunha, Maria Luzia Chollopetz

2016-01-01

ABSTRACT Objetive: to characterize the care services performed through risk rating by the Manchester Triage System, identifying demographics (age, gender), main flowcharts, discriminators and outcomes in pediatric emergency Method: cross-sectional quantitative study. Data on risk classification were obtained through a search of computerized registration data from medical records of patients treated in the pediatric emergency within one year. Descriptive statistics with absolute and relative frequencies was used for the analysis. Results: 10,921 visits were conducted in the pediatric emergency, mostly male (54.4%), aged between 29 days and two years (44.5%). There was a prevalence of the urgent risk category (43.6%). The main flowchart used in the care was worried parents (22.4%) and the most prevalent discriminator was recent event (15.3%). The hospitalization outcome occurred in 10.4% of care performed in the pediatric emergency, however 61.8% of care needed to stay under observation and / or being under the health team care in the pediatric emergency. Conclusion: worried parents was the main flowchart used and recent events the most prevalent discriminator, comprising the hospitalization outcomes and permanency in observation in the pediatric emergency before discharge from the hospital. PMID:27579934

Comparison between Canadian Triage and Acuity Scale and Taiwan Triage System in emergency departments.

PubMed

Ng, Chip-Jin; Hsu, Kuang-Hung; Kuan, Jen-Tze; Chiu, Te-Fa; Chen, Wei-Kong; Lin, Hung-Jung; Bullard, Michael J; Chen, Jih-Chang

2010-11-01

Since the implementation of National Health Insurance in Taiwan, Emergency Department (ED) volume has progressively increased, and the current triage system is insufficient and needs modification. This study compared the prioritization and resource utilization differences between the four-level Taiwan Triage System (TTS) and the standardized five-level Canadian Triage and Acuity Scale (CTAS) among ED patients. This was a prospective observational study. All adult ED patients who presented to three different medical centers during the study period were included. Patients were independently triaged by the duty triage nurse using TTS, and a single trained research nurse using CTAS with a computer support software system. Hospitalization, length of stay (LOS), and medical resource consumption were analyzed by comparing TTS and CTAS by acuity levels. There was significant disparity in patient prioritization between TTS and CTAS among the 1851 enrolled patients. With TTS, 7.8%, 46.1%, 45.9% and 0.2% were assigned to levels 1, 2, 3, and 4, respectively. With CTAS, 3.5%, 24.4%, 44.3%, 22.4% and 5.5% were assigned to levels 1, 2, 3, 4, and 5, respectively. The hospitalization rate, LOS, and medical resource consumption differed significantly between the two triage systems and correlated better with CTAS. CTAS provided better discrimination for ED patient triage, and also showed greater validity when predicting hospitalization, LOS, and medical resource consumption. An accurate five-level triage scale appeared superior in predicting patient acuity and resource utilization. Copyright © 2010 Formosan Medical Association & Elsevier. Published by Elsevier B.V. All rights reserved.

Pediatric disaster triage education and skills assessment: a coalition approach.

PubMed

Kenningham, Katherine; Koelemay, Kathryn; King, Mary A

2014-01-01

This study aims to 1) demonstrate one method of pediatric disaster preparedness education using a regional disaster coalition organized workshop and 2) evaluate factors reflecting the greatest shortfall in pediatric mass casualty incident (MCI) triage skills in a varied population of medical providers in King County, WA. Educational intervention and cross-sectional survey. Pediatric disaster preparedness conference created de novo and offered by the King County Healthcare Coalition, with didactic sessions and workshops including a scored mock pediatric MCI triage. Ninety-eight providers from throughout the King County, WA, region selected by their own institutions following invitation to participate, with 88 completing exit surveys. Didactic lectures regarding pediatric MCI triage followed by scored exercises. Mock triage scores were analyzed and compared according to participant characteristics and workplace environment. A half-day regional pediatric disaster preparedness educational conference convened in September 2011 by the King County Healthcare Coalition in partnership with regional pediatric experts was so effective and well-received that it has been rescheduled yearly (2012 and 2013) and has expanded to three Washington State venues sponsored by the Washington State Department of Health. Emergency department (ED) or intensive care unit (ICU) employment and regular exposure to pediatric patients best predicted higher mock pediatric MCI triage scores (ED/ICU 80 percent vs non-ED/ICU 73 percent, p = 0.026; regular pediatric exposure 80 percent vs less exposure 77 percent, p = 0.038, respectively). Pediatric Advanced Life Support training was not found to be associated with improved triage performance, and mock patients whose injuries were not immediately life threatening tended to be over-triaged (observed trend). A regional coalition can effectively organize member hospitals and provide education for focused populations using specialty experts such as

Impact of triage in accident and emergency departments in Bahrain.

PubMed

Fateha, B E; Hamza, A Y

2001-01-01

We aimed to assess the impact of triage by physicians on the workload and expenditure of the Accident and Emergency (AE) Department of Salmaniya Medical Complex, Bahrain. We analysed three sets of data: patient visits to the AE Department over a 9-month period; patient visits 1 year previously; and forecast patient visits over 9 months starting from July 1999. The referral of patients to AE cubicles was reduced by 54.4% after the implementation of the triage, and reduction in the workload was statistically significant. The reduction in health care expenditure was estimated at between 15.3% and 17.3%. We conclude that triage by physicians can be cost-effective and can reduce the AE Department workload, freeing more time to manage life-threatening and urgent cases.

A review of factors affecting patient satisfaction with nurse led triage in emergency departments.

PubMed

Rehman, Salma Abdul; Ali, Parveen Azam

2016-11-01

To determine the factors that affect patient satisfaction with nurse-led-triage in EDs using a systematic review. Nurses' involvement in the triage services provided in the Emergency Department has been an integral part of practice for several decades in some countries. Although studies exploring patient satisfaction with nurse-led ED triage exist, no systematic review of this evidence is available. MEDLINE, CINAHL, PsycInfo, EMBASE, the Cochrane Library, Joanna Briggs Library and Google Scholar were searched (January 1980-June 2013). Eighteen studies that met the inclusion criteria were reviewed. Factors that affect patient satisfaction with nurse-led-triage include nurses' abilities to provide patient centred care, communication skills, nurses' caring abilities, concern for the patient and competence in diagnosing and treating the health problem. Other factors include availability and visibility of nurses, provision of appropriate health related information in a jargon-free language, nurses' ability to answer questions, and an ability to provide patients with an opportunity to ask questions. There is continued scope for nurse-led-triage services in the ED. Patients are generally satisfied with the service provided by nurses in EDs and report a willingness to see the same professional again in the future if needed. Copyright © 2015 Elsevier Ltd. All rights reserved.

Simulation training with structured debriefing improves residents' pediatric disaster triage performance.

PubMed

Cicero, Mark X; Auerbach, Marc A; Zigmont, Jason; Riera, Antonio; Ching, Kevin; Baum, Carl R

2012-06-01

); five months later, there was maintenance of triage improvement, with a mean triage score of 7.8/10 patients (SD = 1.33, P < .0001). Over-triage of an uninjured child with special health care needs (CSHCN) (67.8% of learners prior to debriefing, 49.0% one week post-debriefing, 26.2% five months post-debriefing) and under-triage of head-injured, unresponsive patients (41.2% of learners pre-debriefing, 37.5% post-debriefing, 11.0% five months post-debriefing) were the most common errors. Structured debriefings are a key component of PDM simulation education, and resulted in improved triage accuracy; the improvement was maintained five months after the educational intervention. Future curricula should emphasize assessment of CSHCN and head-injured patients.

Prediction of Emergent Heart Failure Death by Semi-Quantitative Triage Risk Stratification

PubMed Central

Van Spall, Harriette G. C.; Atzema, Clare; Schull, Michael J.; Newton, Gary E.; Mak, Susanna; Chong, Alice; Tu, Jack V.; Stukel, Thérèse A.; Lee, Douglas S.

2011-01-01

Objectives Generic triage risk assessments are widely used in the emergency department (ED), but have not been validated for prediction of short-term risk among patients with acute heart failure (HF). Our objective was to evaluate the Canadian Triage Acuity Scale (CTAS) for prediction of early death among HF patients. Methods We included patients presenting with HF to an ED in Ontario from Apr 2003 to Mar 2007. We used the National Ambulatory Care Reporting System and vital statistics databases to examine care and outcomes. Results Among 68,380 patients (76±12 years, 49.4% men), early mortality was stratified with death rates of 9.9%, 1.9%, 0.9%, and 0.5% at 1-day, and 17.2%, 5.9%, 3.8%, and 2.5% at 7-days, for CTAS 1, 2, 3, and 4–5, respectively. Compared to lower acuity (CTAS 4–5) patients, adjusted odds ratios (aOR) for 1-day death were 1.32 (95%CI; 0.93–1.88; p = 0.12) for CTAS 3, 2.41 (95%CI; 1.71–3.40; p<0.001) for CTAS 2, and highest for CTAS 1: 9.06 (95%CI; 6.28–13.06; p<0.001). Predictors of triage-critical (CTAS 1) status included oxygen saturation <90% (aOR 5.92, 95%CI; 3.09–11.81; p<0.001), respiratory rate >24 breaths/minute (aOR 1.96, 95%CI; 1.05–3.67; p = 0.034), and arrival by paramedic (aOR 3.52, 95%CI; 1.70–8.02; p = 0.001). While age/sex-adjusted CTAS score provided good discrimination for ED (c-statistic = 0.817) and 1-day (c-statistic = 0.724) death, mortality prediction was improved further after accounting for cardiac and non-cardiac co-morbidities (c-statistics 0.882 and 0.810, respectively; both p<0.001). Conclusions A semi-quantitative triage acuity scale assigned at ED presentation and based largely on respiratory factors predicted emergent death among HF patients. PMID:21853068

The effect of nurses’ preparedness and nurse practitioner status on triage call management in primary care: A secondary analysis of cross-sectional data from the ESTEEM trial

PubMed Central

Varley, Anna; Warren, Fiona C.; Richards, Suzanne H.; Calitri, Raff; Chaplin, Katherine; Fletcher, Emily; Holt, Tim A.; Lattimer, Valerie; Murdoch, Jamie; Richards, David A.; Campbell, John

2016-01-01

Background Nurse-led telephone triage is increasingly used to manage demand for general practitioner consultations in UK general practice. Previous studies are equivocal about the relationship between clinical experience and the call outcomes of nurse triage. Most research is limited to investigating nurse telephone triage in out-of-hours settings. Objective To investigate whether the professional characteristics of primary care nurses undertaking computer decision supported software telephone triage are related to call disposition. Design Questionnaire survey of nurses delivering the nurse intervention arm of the ESTEEM trial, to capture role type (practice nurse or nurse practitioner), prescriber status, number of years’ nursing experience, graduate status, previous experience of triage, and perceived preparedness for triage. Our main outcome was the proportion of triaged patients recommended for follow-up within the practice (call disposition), including all contact types (face-to-face, telephone or home visit), by a general practitioner or nurse. Settings 15 general practices and 7012 patients receiving the nurse triage intervention in four regions of the UK. Participants 45 nurse practitioners and practice nurse trained in the use of clinical decision support software. Methods We investigated the associations between nursing characteristics and triage call disposition for patient ‘same-day’ appointment requests in general practice using multivariable logistic regression modelling. Results Valid responses from 35 nurses (78%) from 14 practices: 31/35 (89%) had ≥10 years’ experience with 24/35 (69%) having ≥20 years. Most patient contacts (3842/4605; 86%) were recommended for follow-up within the practice. Nurse practitioners were less likely to recommend patients for follow-up odds ratio 0.19, 95% confidence interval 0.07; 0.49 than practice nurses. Nurses who reported that their previous experience had prepared them less well for triage were more

The introduction of a midwife-led obstetric triage system into a regional referral hospital in Ghana.

PubMed

Floyd, Liz; Bryce, Fiona; Ramaswamy, Rohit; Olufolabi, Adeyemi; Srofenyoh, Emmanuel; Goodman, David; Pearson, Nancy; Morgan, Kerry; Tetteh, Cecilia; Ahwireng, Victoria; Owen, Medge

2018-06-01

to introduce and embed a midwife-led obstetric triage system in a busy labour ward in Accra, Ghana to improve the quality of care and to reduce delay. the study utilized a participatory action research design. Local staff participated in baseline data collection, the triage training course design and delivery, and post-training monitoring and evaluation. a regional referral hospital in Accra, Ghana undertaking 11,032 deliveries in 2012. all midwives and medical staff. measurements included maternal health outcomes, observations of labour ward activity, structured assessments of midwife actions during admission, waiting times, focus group discussions, and learning needs assessments which informed the course content. During training, two quality improvement tools were developed; coloured risk acuity wristbands and a one page triage assessment form. Participants measured compliance and accuracy in the use of these tools following course completion. initially, no formal triage system was in place. The environment was chaotic with poor compliance to existing protocols. Sixty-two midwives received triage training between 2013 and 2014. Two Triage Champions became responsible for triage implementation, monitoring and further training. Following training, the 'in-charge' midwives recorded a cumulative average of 83.4% of women wearing coloured wristbands. A separate audit by the Triage Champions found that 495/535 (93%) of the wristbands were correctly applied based on the diagnosis. Quarterly monitoring of the triage assessment forms by Kybele trainers, showed that 92% recorded the risk acuity colour, 85% a 'working diagnosis' and 82% a 'plan.' Median (interquartile range) waiting times were reduced from 40 (15-100) to 29 (11-60) minutes (p = 007). Twenty of 25 of the staff reported that the wristbands were helpful. an interactive triage training course led to the development of a triage assessment form and the use of coloured patient wristbands which resulted in delay

Nursing Perceptions of the Emergency Severity Index as a Triage Tool in the United Arab Emirates: A Qualitative Analysis.

PubMed

Mistry, Binoy; Balhara, Kamna S; Hinson, Jeremiah S; Anton, Xavier; Othman, Iman Yassin; E'nouz, Maysoon Abdel Latif; Avila, Norman Agustin; Henry, Sophia; Levin, Scott; De Ramirez, Sarah Stewart

2017-11-19

With emergency department crowding becoming an increasing problem across the globe, nursing triage to prioritize patients receiving care is ever more important. ESI is the most common triage system used in the United States and is increasingly used worldwide. This qualitative study that explores emergency nursing perceptions of the ESI identifies strengths, weaknesses, and barriers to implementation of the ESI internationally. We conducted a cross-sectional qualitative analysis using semistructured interviews of 27 emergency triage nurses. Content analysis was performed by 2 independent coders, using NVivo software to identify and analyze important themes. Interview coding revealed 7 core themes related to use of the ESI (frequencies indicated in parentheses): ease of use (90), speed and efficiency (135), patient safety (12), accuracy and reliability (30), challenging patient characteristics (123), subjectivity and variability (173), and effect of triage system on team dynamics (100). Intercoder agreement was excellent (Cohen's unweighted kappa = 0.84). Subjectivity and variability in ESI score assignment consistently emerged in all interviews and included variability in number and use of resources, definition of "high risk," nursing experience, and subjectivity in pain assessment. Although emergency nurses perceive the ESI as easy to use, there are concerns about the subjectivity and variability inherent in the ESI that can lead to a functional lack of triage and a burden of undifferentiated ESI level 3 patients. These limitations in separating critically ill patients and in stratifying patients based on anticipated required resources points to the need for improvement in the ESI algorithm or a more objective triage system that can predict patient outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Pressure Injuries in Critical Care: A Survey of Critical Care Nurses.

PubMed

Cox, Jill; Schallom, Marilyn

2017-10-01

Critical care nurses must be able to skillfully balance the prevention of adverse events such as pressure injuries in an environment with multiple competing and lifesaving technologies that often take precedent. Despite strategies to prevent them, pressure injuries do occur in intensive care unit patients, and consensus is building that some pressure injuries are unavoidable. To determine critical care nurses' attitudes toward prevention of pressure injury and the perceptions of frontline critical care nurses of specific risk factors associated with unavoidable pressure injuries. A descriptive cross-sectional survey design was used. An online survey was posted on the newsletter website of the American Association of Critical-Care Nurses in January 2016. An invitation to participate in the study was emailed to more than 3000 members of the association; 333 nurses responded, for a response rate of approximately 11%. Among the responders, 73% were employed as bedside critical care nurses. More than half (67%) thought that pressure injuries are avoidable, and 66% disagreed that pressure injury prevention was of less interest than other aspects of critical care. The top 2 risk factors for unavoidable pressure injuries were impaired tissue perfusion and impaired tissue oxygenation. Critical care nurses are steadfast stewards of safe patient care and think that pressure injury prevention is a crucial aspect of the care they deliver every day. The findings on risk factors for unavoidable pressure injuries mirrored those of experts and provide a layer of support for these factors. ©2017 American Association of Critical-Care Nurses.

Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear agents

PubMed Central

Ramesh, Aruna C.; Kumar, S.

2010-01-01

In a mass casualty situation due to chemical, biological, radiological, or nuclear (CBRN) event, triage is absolutely required for categorizing the casualties in accordance with medical care priorities. Dealing with a CBRN event always starts at the local level. Even before the detection and analysis of agents can be undertaken, zoning, triage, decontamination, and treatment should be initiated promptly. While applying the triage system, the available medical resources and maximal utilization of medical assets should be taken into consideration by experienced triage officers who are most familiar with the natural course of the injury presented and have detailed information on medical assets. There are several triage systems that can be applied to CBRN casualties. With no one standardized system globally or nationally available, it is important for deploying a triage and decontamination system which is easy to follow and flexible to the available medical resources, casualty number, and severity of injury. PMID:21829319

Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study

PubMed Central

Eastwood, Kathryn; Smith, Karen; Morgans, Amee; Stoelwinder, Johannes

2017-01-01

Objective To investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary telephone triage. Design A pragmatic retrospective cohort analysis of all the planned and unplanned ED presentations within 48 hours of a secondary telephone triage. Setting The secondary telephone triage service, called the Referral Service, and the hospitals were located in metropolitan Melbourne, Australia and operated 24 hours a day, servicing 4.25 million people. The Referral Service provides an in-depth secondary triage of cases classified as low acuity when calling the Australian emergency telephone number. Population Cases triaged by the Referral Service between September 2009 and June 2012 were linked to ED and hospital admission records (N=44,523). Planned ED presentations were cases referred to the ED following the secondary triage, unplanned ED presentations were cases that presented despite being referred to alternative care pathways. Main outcome measures Appropriateness was measured using an ED suitability definition and hospital admission rates. These were compared with mean population data which consisted of all of the ED presentations for the state (termed the ‘average Victorian ED presentation’). Results Planned ED presentations were more likely to be ED suitable than unplanned ED presentations (OR 1.62; 95% CI 1.5 to 1.7; p<0.001) and the average Victorian ED presentation (OR 1.85; 95% CI 1.01 to 3.4; p=0.046). They were also more likely to be admitted to the hospital than the unplanned ED presentation (OR 1.5; 95% CI 1.4 to 1.6; p<0.001) and the average Victorian ED presentation (OR 2.3, 95% CI 2.24 to 2.33; p<0.001). Just under 15% of cases diverted away from the emergency care pathways presented in the ED (unplanned ED attendances), and 9.5% of all the alternative care pathway cases were classified as ED suitable and 6.5% were admitted to hospital. Conclusions Secondary telephone triage was able to

An Integrated Computerized Triage System in the Emergency Department

PubMed Central

Aronsky, Dominik; Jones, Ian; Raines, Bill; Hemphill, Robin; Mayberry, Scott R; Luther, Melissa A; Slusser, Ted

2008-01-01

Emergency department (ED) triage is a fast-paced process that prioritizes the allocation of limited health care resources to patients in greatest need. This paper describes the experiences with an integrated, computerized triage application. The system exchanges information with other information systems, including the ED patient tracking board, the longitudinal electronic medical record, the computerized provider order entry, and the medication reconciliation application. The application includes decision support capabilities such as assessing the patient’s acuity level, age-dependent alerts for vital signs, and clinical reminders. The browser-based system utilizes the institution’s controlled vocabulary, improves data completeness and quality, such as compliance with capturing required data elements and screening questions, initiates clinical processes, such as pneumococcal vaccination ordering, and reminders to start clinical pathways, issues alerts for clinical trial eligibility, and facilitates various reporting needs. The system has supported the triage documentation of >290,000 pediatric and adult patients. PMID:18999190

Decreasing triage time: effects of implementing a step-wise ESI algorithm in an EHR.

PubMed

Villa, Stephen; Weber, Ellen J; Polevoi, Steven; Fee, Christopher; Maruoka, Andrew; Quon, Tina

2018-06-01

To determine if adapting a widely-used triage scale into a computerized algorithm in an electronic health record (EHR) shortens emergency department (ED) triage time. Before-and-after quasi-experimental study. Urban, tertiary care hospital ED. Consecutive adult patient visits between July 2011 and June 2013. A step-wise algorithm, based on the Emergency Severity Index (ESI-5) was programmed into the triage module of a commercial EHR. Duration of triage (triage interval) for all patients and change in percentage of high acuity patients (ESI 1 and 2) completing triage within 15 min, 12 months before-and-after implementation of the algorithm. Multivariable analysis adjusted for confounders; interrupted time series demonstrated effects over time. Secondary outcomes examined quality metrics and patient flow. About 32 546 patient visits before and 33 032 after the intervention were included. Post-intervention patients were slightly older, census was higher and admission rate slightly increased. Median triage interval was 5.92 min (interquartile ranges, IQR 4.2-8.73) before and 2.8 min (IQR 1.88-4.23) after the intervention (P < 0.001). Adjusted mean triage interval decreased 3.4 min (95% CI: -3.6, -3.2). The proportion of high acuity patients completing triage within 15 min increased from 63.9% (95% CI 62.5, 65.2%) to 75.0% (95% CI 73.8, 76.1). Monthly time series demonstrated immediate and sustained improvement following the intervention. Return visits within 72 h and door-to-balloon time were unchanged. Total length of stay was similar. The computerized triage scale improved speed of triage, allowing more high acuity patients to be seen within recommended timeframes, without notable impact on quality.

Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT).

PubMed

Vassallo, James; Beavis, John; Smith, Jason E; Wallis, Lee A

2017-05-01

Triage is a key principle in the effective management at a major incident. There are at least three different triage systems in use worldwide and previous attempts to validate them, have revealed limited sensitivity. Within a civilian adult population, there has been no work to develop an improved system. A retrospective database review of the UK Joint Theatre Trauma Registry was performed for all adult patients (>18years) presenting to a deployed Military Treatment Facility between 2006 and 2013. Patients were defined as Priority One if they had received one or more life-saving interventions from a previously defined list. Using first recorded hospital physiological data (HR/RR/GCS), binary logistic regression models were used to derive optimum physiological ranges to predict need for life-saving intervention. This allowed for the derivation of the Modified Physiological Triage Tool-MPTT (GCS≥14, HR≥100, 12triage tools was then performed using sensitivities and specificities with 95% confidence intervals. Differences in performance were assessed for statistical significance using a McNemar test with Bonferroni correction. Of 6095 patients, 3654 (60.0%) had complete data and were included in the study, with 1738 (47.6%) identified as priority one. Existing triage tools had a maximum sensitivity of 50.9% (Modified Military Sieve) and specificity of 98.4% (Careflight). The MPTT (sensitivity 69.9%, 95% CI 0.677-0.720, specificity 65.3%, 95% CI 0.632-0.675) showed an absolute increase in sensitivity over existing tools ranging from 19.0% (Modified Military Sieve) to 45.1% (Triage Sieve). There was a statistically significant difference between the performance (p<0.001) between the MPTT and the Modified Military Sieve. The performance characteristics of the MPTT exceed existing major incident triage systems, whilst maintaining an appropriate rate of over-triage and minimising under-triage within the context of

Factors that affect the flow of patients through triage.

PubMed

Lyons, Melinda; Brown, Ruth; Wears, Robert

2007-02-01

To use observational methods to objectively evaluate the organisation of triage and what issues may affect the effectiveness of the process. A two-phase study comprising observation of 16 h of triage in a London hospital emergency department and interviews with the triage staff to build a qualitative task analysis and study protocol for phase 2; observation and timing in triage for 1870 min including 257 patients and for 16 different members of the triage staff. No significant difference was found between grades of staff for the average triage time or the fraction of time absent from triage. In all, 67% of the time spent absent from triage was due to escorting patients into the department. The average time a patient waited in the reception before triage was 13 min 34 s; the average length of time to triage for a patient was 4 min 17 s. A significant increase in triage time was found when patients were triaged to a specialty, expected by a specialty, or were actively "seen and treated" in triage. Protocols to prioritise patients with potentially serious conditions to the front of the queue had a significantly positive effect on their waiting time. Supplementary tasks and distractions had varying effects on the timely assessment and triage of patients. The human factors method is applicable to the triage process and can identify key factors that affect the throughput at triage. Referring a patient to a specialty at triage affects significantly the triage workload; hence, alternative methods or management should be suggested. The decision to offer active treatment at triage increases the time taken, and should be based on clinical criteria and the workload determined by staffing levels. The proportion of time absent from triage could be markedly improved by support from porters or other non-qualified staff, as well as by proceduralised handovers from triage to the main clinical area. Triage productivity could be improved by all staff by becoming aware of the effect of

Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.

PubMed

Christian, Michael D; Devereaux, Asha V; Dichter, Jeffrey R; Rubinson, Lewis; Kissoon, Niranjan

2014-10-01

Natural disasters, industrial accidents, terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government officials. The current Task Force included a total of 100 participants from nine countries, comprised of clinicians and experts from a wide variety of disciplines. Comprehensive literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert-opinion-based suggestions that are presented in this supplement using a modified Delphi process. The ultimate aim of the supplement is to expand the focus beyond the walls of ICUs to provide recommendations for the management of all critically ill or injured adults and children resulting from a pandemic or disaster wherever that care may be provided. Considerations for the management of critically ill patients include clinical priorities and logistics (supplies, evacuation, and triage) as well as the key enablers (systems planning, business continuity, legal framework, and ethical considerations) that facilitate the provision of this care. The supplement also aims to illustrate how the concepts of mass critical care are integrated across the spectrum of surge events from conventional through contingency to crisis standards of care.

Investigating the validity and usability of an interactive computer programme for assessing competence in telephone-based mental health triage.

PubMed

Sands, Natisha; Elsom, Stephen; Keppich-Arnold, Sandra; Henderson, Kathryn; King, Peter; Bourke-Finn, Karen; Brunning, Debra

2016-02-01

Telephone-based mental health triage services are frontline health-care providers that operate 24/7 to facilitate access to psychiatric assessment and intervention for people requiring assistance with a mental health problem. The mental health triage clinical role is complex, and the populations triage serves are typically high risk; yet to date, no evidence-based methods have been available to assess clinician competence to practice telephone-based mental health triage. The present study reports the findings of a study that investigated the validity and usability of the Mental Health Triage Competency Assessment Tool, an evidence-based, interactive computer programme designed to assist clinicians in developing and assessing competence to practice telephone-based mental health triage. © 2015 Australian College of Mental Health Nurses Inc.

Telemedicine in Critical Care

PubMed Central

Murias, Gastón; Sales, Bernat; Garcia-Esquirol, Oscar; Blanch, Lluis

2009-01-01

Critical care medicine is the specialty that cares for patients with acute life-threatening illnesses where intensivists look after all aspects of patient care. Nevertheless, shortage of physicians and nurses, the relationship between high costs and economic restrictions, and the fact that critical care knowledge is only available at big hospitals puts the system on the edge. In this scenario, telemedicine might provide solutions to improve availability of critical care knowledge where the patient is located, improve relationship between attendants in different institutions and education material for future specialist training. Current information technologies and networking capabilities should be exploited to improve intensivist coverage, advanced alarm systems and to have large critical care databases of critical care signals. PMID:19452034

[Emergency and disaster response in critical care unit in the Mexican Social Security Institute: triage and evacuation].

PubMed

Echevarría-Zuno, Santiago; Cruz-Vega, Felipe; Elizondo-Argueta, Sandra; Martínez Valdés, Everardo; Franco-Bey, Rubén; Méndez-Sánchez, Luis Miguel

2013-01-01

Providing medical assistance in emergencies and disaster in advance makes the need to maintain Medical Units functional despite the disturbing phenomenon that confronts the community, but conflict occurs when the Medical Unit needs support and needs to be evacuated, especially when the evacuation of patients in a Critical Care Unit is required. In world literature there is little on this topic, and what is there usually focuses on the conversion of areas and increased ability to care for mass casualties, but not about how to evacuate if necessary, and when a wrong decision can have fatal consequences. That is why the Mexican Social Security Institute gave the task of examining these problems to a working group composed of specialists of the Institute. The purpose was to evaluate and establish a method for performing a protocol in the removal of patients and considering always to safeguard both staff and patients and maintain the quality of care.

The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial).

PubMed

Campbell, John L; Fletcher, Emily; Britten, Nicky; Green, Colin; Holt, Tim; Lattimer, Valerie; Richards, David A; Richards, Suzanne H; Salisbury, Chris; Taylor, Rod S; Calitri, Raff; Bowyer, Vicky; Chaplin, Katherine; Kandiyali, Rebecca; Murdoch, Jamie; Price, Linnie; Roscoe, Julia; Varley, Anna; Warren, Fiona C

2015-02-01

Telephone triage is proposed as a method of managing increasing demand for primary care. Previous studies have involved small samples in limited settings, and focused on nurse roles. Evidence is limited regarding the impact on primary care workload, costs, and patient safety and experience when triage is used to manage patients requesting same-day consultations in general practice. In comparison with usual care (UC), to assess the impact of GP-led telephone triage (GPT) and nurse-led computer-supported telephone triage (NT) on primary care workload and cost, patient experience of care, and patient safety and health status for patients requesting same-day consultations in general practice. Pragmatic cluster randomised controlled trial, incorporating economic evaluation and qualitative process evaluation. General practices (n = 42) in four regions of England, UK (Devon, Bristol/Somerset, Warwickshire/Coventry, Norfolk/Suffolk). Patients requesting same-day consultations. Practices were randomised to GPT, NT or UC. Data collection was not blinded; however, analysis was conducted by a statistician blinded to practice allocation. Primary - primary care contacts [general practice, out-of-hours primary care, accident and emergency (A&E) and walk-in centre attendances] in the 28 days following the index consultation request. Secondary - resource use and costs, patient safety (deaths and emergency hospital admissions within 7 days of index request, and A&E attendance within 28 days), health status and experience of care. Of 20,990 eligible randomised patients (UC n = 7283; GPT n = 6695; NT n = 7012), primary outcome data were analysed for 16,211 patients (UC n = 5572; GPT n = 5171; NT n = 5468). Compared with UC, GPT and NT increased primary outcome contacts (over 28-day follow-up) by 33% [rate ratio (RR) 1.33, 95% confidence interval (CI) 1.30 to 1.36] and 48% (RR 1.48, 95% CI 1.44 to 1.52), respectively. Compared with GPT, NT was associated

Design and development of a mobile system for supporting emergency triage.

PubMed

Michalowski, W; Slowinski, R; Wilk, S; Farion, K J; Pike, J; Rubin, S

2005-01-01

Our objective was to design and develop a mobile clinical decision support system for emergency triage of different acute pain presentations. The system should interact with existing hospital information systems, run on mobile computing devices (handheld computers) and be suitable for operation in weak-connectivity conditions (with unstable connections between mobile clients and a server). The MET (Mobile Emergency Triage) system was designed following an extended client-server architecture. The client component, responsible for triage decision support, is built as a knowledge-based system, with domain ontology separated from generic problem solving methods and used for the automatic creation of a user interface. The MET system is well suited for operation in the Emergency Department of a hospital. The system's external interactions are managed by the server, while the MET clients, running on handheld computers are used by clinicians for collecting clinical data and supporting triage at the bedside. The functionality of the MET client is distributed into specialized modules, responsible for triaging specific types of acute pain presentations. The modules are stored on the server, and on request they can be transferred and executed on the mobile clients. The modular design provides for easy extension of the system's functionality. A clinical trial of the MET system validated the appropriateness of the system's design, and proved the usefulness and acceptance of the system in clinical practice. The MET system captures the necessary hospital data, allows for entry of patient information, and provides triage support. By operating on handheld computers, it fits into the regular emergency department workflow without introducing any hindrances or disruptions. It supports triage anytime and anywhere, directly at the point of care, and also can be used as an electronic patient chart, facilitating structured data collection.

Impact of an ABCDE team triage process combined with public guidance on the division of work in an emergency department.

PubMed

Kantonen, Jarmo; Lloyd, Robert; Mattila, Juho; Kauppila, Timo; Menezes, Ricardo

2015-06-01

To study the effects of applying an emergency department (ED) triage system, combined with extensive publicity in local media about the "right" use of emergency services, on the division of work between ED nurses and general practitioners (GPs). An observational and quasi-experimental study based on before-after comparisons. Implementation of the ABCDE triage system in a Finnish combined ED where secondary care is adjacent, and in a traditional primary care ED where secondary care is located elsewhere. GPs and nurses from two different primary care EDs. Numbers of monthly visits to different professional groups before and after intervention in the studied primary care EDs and numbers of monthly visits to doctors in the local secondary care ED. The beginning of the triage process increased temporarily the number of independent consultations and patient record entries by ED nurses in both types of studied primary care EDs and reduced the number of patient visits to a doctor compared with previous years but had no effect on doctor visits in the adjacent secondary care ED. No further decrease in the number of nurse or GP visits was observed by inhibiting the entrance of non-urgent patients. The ABCDE triage system combined with public guidance may reduce non-urgent patient visits to doctors in different kinds of primary care EDs without increasing visits in the secondary care ED. However, the additional work to implement the ABCDE system is mainly directed to nurses, which may pose a challenge for staffing.

Triage: a literature review 1985-1993.

PubMed

McDonald, L; Butterworth, T; Yates, D W

1995-10-01

Following an extensive literature review of Accident and Emergency (A & E) nursing from 1985-1993, the authors focused upon triage. A wide range of issues related to triage and its use in A & E departments are examined. An appendix is included to clarify major research finds in this area. Many of the claims made regarding triage require further investigation.

Patient compliance with telephone triage recommendations: a meta-analytic review.

PubMed

Purc-Stephenson, Rebecca J; Thrasher, Christine

2012-05-01

To systematically investigate the extent to which patients comply with triage advice from telenurses and to identify factors that potentially influence compliance. Findings from 13 studies identified through interdisciplinary research databases (1990-2010) were meta-analyzed. Separate pooled analyses compared patients' compliance rates for emergency services and office care (13 outcomes), emergency services and self care (13 outcomes), and self care and office care (12 outcomes). Overall patient compliance was 62%, but varied by intensity of care recommended with low compliance rates for advice to see a general practitioner. Reasons for noncompliance include patients reporting to have heard a different disposition, patients' intentions and health beliefs. Patient compliance to triage recommendations was influenced by the interactive role of patient perceptions and the quality of provider communication, both of which were mediated by access to health services. Further research is needed to clarify whether noncompliance is attributable to poor communication by the nurse or patient misinterpretation. We highlight the need for communication-skills training in a telephone-consultation context that is patient centered, and specifically addresses building active listening and active advising skills and advantages to structuring the call. Crown Copyright © 2011. Published by Elsevier Ireland Ltd. All rights reserved.

An Intervention to Improve the Comfort And Satisfaction of Nurses in the Telephone Triage of Child Maltreatment Calls.

PubMed

Hunter, Julie

2015-01-01

Nurses are mandated reporters of actual or suspected child maltreatment or the threat thereof. The purpose of this quality improvement project was to determine the knowledge and comfort of nurses in telephone triage in pediatric clinics when dealing with suspected or actual child abuse calls. Nurses (N = 17) from three pediatric primary care clinics and one specialty care orthopedic clinic were surveyed. Based on results of the survey showing a lack of knowledge and adequate referral resources perceived by the nursing staff, resources and staff education were developed, along with a script for guiding maltreatment calls toward standardization of care. Following the intervention, nurses reported an increased comfort level when doing telephone triage for child maltreatment calls, an increase in knowledge of risk factors for county resources. Further, they reported a substantial shift in opinion about the need for a standardized script when responding to child maltreatment telephone calls. Nurses undertaking telephone triage of high-risk child maltreatment calls can improve their comfort and knowledge through a survey of their needs and directed education and resource development for the management of child maltreatment telephone triage.

2 Major incident triage and the implementation of a new triage tool, the MPTT-24.

PubMed

Vassallo, James; Smith, Jason

2017-12-01

Over the last decade, a number of European cities including London, have witnessed high profile terrorist attacks resulting in major incidents with large numbers of casualties. Triage, the process of categorising casualties on the basis of their clinical acuity, is a key principle in the effective management of major incidents.The Modified Physiological Triage Tool (MPTT) is a recently developed primary triage tool which in comparison to existing triage tools, including the 2013 UK NARU Sieve, demonstrates the greatest sensitivity at predicting need for life-saving intervention (LSI) within both military and civilian populations.To improve the applicability and usability of the MPTT we increased the upper respiratory rate threshold to 24 breaths per minute (MPTT-24), to make it divisible by four, and included an assessment of external catastrophic haemorrhage. The aim of this study was to conduct a feasibility analysis of the proposed MPTT-24 (figure 1).emermed;34/12/A860-b/F1F1F1Figure 1MPTT-24 METHODS: A retrospective review of the Joint Theatre Trauma Registry (JTTR) and Trauma Audit Research Network (TARN) databases was performed for all adult ( > 18 years) patients presenting between 2006-2013 (JTTR) and 2014 (TARN). Patients were defined as priority one (P1) if they had received one or more life-saving interventions.Using first recorded hospital physiology, patients were categorised as P1 or not-P1 by existing triage tools and both MPTT and MPTT-24. Performance characteristics were evaluated using sensitivity, specificity, under and over-triage with a McNemar test to determine statistical significance. Basic study characteristics are shown in Table 1. Both the MPTT and MPTT-24 outperformed all existing triage methods with a statistically significant (p<0.001) absolute reduction of between 25.5%-29.5% in under-triage when compared to existing UK civilian methods (NARU Sieve). In both populations the MPTT-24 demonstrated an absolute reduction in sensitivity

Decision support system for triage management: A hybrid approach using rule-based reasoning and fuzzy logic.

PubMed

Dehghani Soufi, Mahsa; Samad-Soltani, Taha; Shams Vahdati, Samad; Rezaei-Hachesu, Peyman

2018-06-01

Fast and accurate patient triage for the response process is a critical first step in emergency situations. This process is often performed using a paper-based mode, which intensifies workload and difficulty, wastes time, and is at risk of human errors. This study aims to design and evaluate a decision support system (DSS) to determine the triage level. A combination of the Rule-Based Reasoning (RBR) and Fuzzy Logic Classifier (FLC) approaches were used to predict the triage level of patients according to the triage specialist's opinions and Emergency Severity Index (ESI) guidelines. RBR was applied for modeling the first to fourth decision points of the ESI algorithm. The data relating to vital signs were used as input variables and modeled using fuzzy logic. Narrative knowledge was converted to If-Then rules using XML. The extracted rules were then used to create the rule-based engine and predict the triage levels. Fourteen RBR and 27 fuzzy rules were extracted and used in the rule-based engine. The performance of the system was evaluated using three methods with real triage data. The accuracy of the clinical decision support systems (CDSSs; in the test data) was 99.44%. The evaluation of the error rate revealed that, when using the traditional method, 13.4% of the patients were miss-triaged, which is statically significant. The completeness of the documentation also improved from 76.72% to 98.5%. Designed system was effective in determining the triage level of patients and it proved helpful for nurses as they made decisions, generated nursing diagnoses based on triage guidelines. The hybrid approach can reduce triage misdiagnosis in a highly accurate manner and improve the triage outcomes. Copyright © 2018 Elsevier B.V. All rights reserved.

Sensitivity and specificity of the Manchester Triage System in risk prioritization of patients with acute myocardial infarction who present with chest pain.

PubMed

Nishi, Fernanda A; Polak, Catarina; Cruz, Diná de Almeida Lopes Monteiro da

2018-05-01

The purpose of the Manchester Triage System is to clinically prioritize each patient seeking care in an emergency department. Patients with suspected acute myocardial infarction who have typical symptoms including chest pain should be classified in the highest priority groups, requiring immediate medical assistance or care within 10 min. As such, the Manchester Triage System should present adequate sensitivity and specificity. This study estimated the sensitivity and specificity of the Manchester Triage System in the triage of patients with chest pain related to the diagnosis of acute myocardial infarction, and the associations between the performance of the Manchester Triage System and selected variables. This was an observational, analytical, cross-sectional, retrospective study. The sensitivity and specificity of the Manchester Triage System were estimated by verifying the triage classification received by these patients and their established medical diagnoses. The sample was composed of 10,087 triage episodes, in which 139 (1.38%) patients had a diagnosis of acute myocardial infarction. In 49 episodes, confirmation of medical diagnosis was not possible. The estimated sensitivity of the Manchester Triage System was 44.60% (36.18-53.27%) and the estimated specificity was 91.30% (90.73-91.85%). Of the 10,038 episodes in which the diagnosis of acute myocardial infarction was confirmed or excluded, 938 patients (9.34%) received an incorrect classification - undertriage or overtriage. This study showed that the specificity of the Manchester Triage System was very good. However, the low sensitivity based on the Manchester Triage System indicated that patients in high priority categories were undertriaged, leading to longer wait times and associated increased risks of adverse events.

Dermoscopy improves accuracy of primary care physicians to triage lesions suggestive of skin cancer.

PubMed

Argenziano, Giuseppe; Puig, Susana; Zalaudek, Iris; Sera, Francesco; Corona, Rosamaria; Alsina, Mercè; Barbato, Filomena; Carrera, Cristina; Ferrara, Gerardo; Guilabert, Antonio; Massi, Daniela; Moreno-Romero, Juan A; Muñoz-Santos, Carlos; Petrillo, Gianluca; Segura, Sonia; Soyer, H Peter; Zanchini, Renato; Malvehy, Josep

2006-04-20

Primary care physicians (PCPs) constitute an appropriate target for new interventions and educational campaigns designed to increase skin cancer screening and prevention. The aim of this randomized study was to determine whether the adjunct of dermoscopy to the standard clinical examination improves the accuracy of PCPs to triage lesions suggestive of skin cancer. PCPs in Barcelona, Spain, and Naples, Italy, were given a 1-day training course in skin cancer detection and dermoscopic evaluation, and were randomly assigned to the dermoscopy evaluation arm or naked-eye evaluation arm. During a 16-month period, 73 physicians evaluated 2,522 patients with skin lesions who attended their clinics and scored individual lesions as benign or suggestive of skin cancer. All patients were re-evaluated by expert dermatologists at clinics for pigmented lesions. Referral accuracy of both PCP groups was calculated by their scores, which were compared to those tabulated for dermatologists. Referral sensitivity, specificity, and positive and negative predictive values were 54.1%, 71.3%, 11.3%, and 95.8%, respectively, in the naked-eye arm, and 79.2%, 71.8%, 16.1%, and 98.1%, respectively, in the dermoscopy arm. Significant differences were found in terms of sensitivity and negative predictive value (P = .002 and P = .004, respectively). Histopathologic examination of equivocal lesions revealed 23 malignant skin tumors missed by PCPs performing naked-eye observation and only six by PCPs using dermoscopy (P = .002). The use of dermoscopy improves the ability of PCPs to triage lesions suggestive of skin cancer without increasing the number of unnecessary expert consultations.

A machine learning approach to triaging patients with chronic obstructive pulmonary disease

PubMed Central

Qirko, Klajdi; Smith, Ted; Corcoran, Ethan; Wysham, Nicholas G.; Bazaz, Gaurav; Kappel, George; Gerber, Anthony N.

2017-01-01

COPD patients are burdened with a daily risk of acute exacerbation and loss of control, which could be mitigated by effective, on-demand decision support tools. In this study, we present a machine learning-based strategy for early detection of exacerbations and subsequent triage. Our application uses physician opinion in a statistically and clinically comprehensive set of patient cases to train a supervised prediction algorithm. The accuracy of the model is assessed against a panel of physicians each triaging identical cases in a representative patient validation set. Our results show that algorithm accuracy and safety indicators surpass all individual pulmonologists in both identifying exacerbations and predicting the consensus triage in a 101 case validation set. The algorithm is also the top performer in sensitivity, specificity, and ppv when predicting a patient’s need for emergency care. PMID:29166411

Implementing street triage: a qualitative study of collaboration between police and mental health services.

PubMed

Horspool, Kimberley; Drabble, Sarah J; O'Cathain, Alicia

2016-09-07

Street Triage is a collaborative service between mental health workers and police which aims to improve the emergency response to individuals experiencing crisis, but peer reviewed evidence of the effectiveness of these services is limited. We examined the design and potential impact of two services, along with factors that hindered and facilitated the implementation of the services. We conducted 14 semi-structured interviews with mental health and police stakeholders with experience of a Street Triage service in two locations of the UK. Framework analysis identified themes related to key aspects of the Street Triage service, perceived benefits of Street Triage, and ways in which the service could be developed in the future. Stakeholders endorsed the Street Triage services which utilised different operating models. These models had several components including a joint response vehicle or a mental health worker in a police control room. Operating models were developed with consideration of the local geographical and population density. The ability to make referrals to the existing mental health service was perceived as key to the success of the service yet there was evidence to suggest Street Triage had the potential to increase pressure on already stretched mental health and police services. Identifying staff with skills and experience for Street Triage work was important, and their joint response resulted in shared decision making which was less risk averse for the police and regarded as in the interest of patient care by mental health professionals. Collaboration during Street Triage improved the understanding of roles and responsibilities in the 'other' agency and led to the development of local information sharing agreements. Views about the future direction of the service focused on expansion of Street Triage to address other shared priorities such as frequent users of police and mental health services, and a reduction in the police involvement in crisis

Multilocation teleradiology system for emergency triage consultation

NASA Astrophysics Data System (ADS)

Herron, John M.; Yonas, Howard

1996-05-01

A remote consultation system is available at the University of Pittsburgh Medical Center (UPMC) which links four outlying hospitals in Western Pennsylvania and Eastern Ohio. This system has the potential to improve short and long term clinical outcomes and to reduce overall medical care cost by establishing improved emergency triage capability. An EMED, Inc. teleradiology system permits rapid, high-quality transfer of digitized film and CT images from the remote sites to the tertiary care center (UPMC). The images are sent over dial-on- demand ISDN and SW56 lines from the remote hospitals to a central server where they are transmitted to a dual 2K monitor workstation in the Emergency Department, thirteen Eastman Kodak PDS workstations within UPMC, and to three physician homes. Transmission to a workstation at each of the physician homes over ISDN lines enables `after hours' consultation. The radiographic images along with voice and fax communications provide a technique where physicians in outlying hospitals will be able to consult with specialists at any time. A study is in progress to evaluate the effectiveness of this system in terms of perception of utility and its potential to improve emergency triage capability, as well as selection of the appropriate transportation mode (helicopter versus ambulance).

ED Triage Process Improvement: Timely Vital Signs for Less Acute Patients.

PubMed

Falconer, Stella S; Karuppan, Corinne M; Kiehne, Emily; Rama, Shravan

2018-06-13

Vital signs can result in an upgrade of patients' Emergency Severity Index (ESI) levels. It is therefore preferable to obtain vital signs early in the triage process, particularly for ESI level 3 patients. Emergency departments have an opportunity to redesign triage processes to meet required protocols while enhancing the quality and experience of care. We performed process analyses to redesign the door-to-vital signs process. We also developed spaghetti diagrams to reconfigure the patient arrival area. The door-to-vital signs time was reduced from 43.1 minutes to 6.44 minutes. Both patients and triage staff seemed more satisfied with the new process. The patient arrival area was less congested and more welcoming. Performing activities in parallel reduces flow time with no additional resources. Staff involvement in process planning, redesign, and control ensures engagement and early buy-in. One should anticipate how changes to one process might affect other processes. Copyright © 2018. Published by Elsevier Inc.

Field triage and patient maldistribution in a mass-casualty incident.

PubMed

Zoraster, Richard M; Chidester, Cathy; Koenig, William

2007-01-01

Management of mass-casualty incidents should optimize outcomes by appropriate prehospital care, and patient triage to the most capably facilities. The number of patients, the nature of injuries, transportation needs, distances, and hospital capabilities and availabilities are all factors to be considered. Patient maldistributions such as overwhelming individual facilities, or transport to facilities incapable of providing appropriate care should be avoided. This report is a critical view of the application of the START triage nomenclature in the prehospital arena following a train crash in Los Angeles County on 26 January 2005. A scheduled debriefing was held with the major fire and emergency medical services responders, Medical Alert Center staff, and hospitals to assess and review the response to the incident. Site visits were made to all of the hospitals involved. Follow-up questions were directed to emergency department staff that were on duty during the day of the incident. The five Level-I Trauma Centers responded to the poll with the capacity to receive a total of 12 "Immediate" patients, 2.4 patients per center, the eight Level-II Trauma Centers responded with capacity to receive 17 "Immediate" patients, two patients per center, while the 25 closest community hospitals offered to accept 75 "Immediate" patients, three patients per hospital. These community hospitals were typically about one-half of the size of the trauma centers (average 287 beds versus 548, average 8.7 operating rooms versus 16.6). Twenty-six patients were transported to a community hospital >15 miles from the scene, while eight closer community hospitals did not receive any patients. The debriefing summary of this incident concluded that there were no consistently used criteria to decide ultimate destination for "Immediates", and that they were distributed about equally between community hospitals and trauma centers.

Using Triage Figuratively to Describe Effective Teaching in Physical Education

ERIC Educational Resources Information Center

Henkel, Steven A.

2016-01-01

This article presents critical outcomes for physical education in a "triage" framework by comparing the process of determining the severity of injuries at the scene of an accident to the process of prioritizing decisions in the classroom. The intent is to reduce all possible outcomes of effective teaching to six nonnegotiable outcomes…

A Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health-care Professionals. A Call for Action.

PubMed

Moss, Marc; Good, Vicki S; Gozal, David; Kleinpell, Ruth; Sessler, Curtis N

2016-07-01

Burnout syndrome (BOS) occurs in all types of health-care professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other health-care professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care health-care professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care health-care professionals and diminish the harmful consequences of BOS, both for critical care health-care professionals and for patients.

Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing.

PubMed

Ward, Nicholas S; Afessa, Bekele; Kleinpell, Ruth; Tisherman, Samuel; Ries, Michael; Howell, Michael; Halpern, Neil; Kahn, Jeremy

2013-02-01

Increases in the number, size, and occupancy rates of ICUs have not been accompanied by a commensurate growth in the number of critical care physicians leading to a workforce shortage. Due to concern that understaffing may exist, the Society of Critical Care Medicine created a taskforce to generate guidelines on maximum intensivists/patient ratios. A multidisciplinary taskforce conducted a review of published literature on intensivist staffing and related topics, a survey of pulmonary/Critical Care physicians, and held an expert roundtable conference. A statement was generated and revised by the taskforce members using an iterative consensus process and submitted for review to the leadership council of the Society of Critical Care Medicine. For the purposes of this statement, the taskforce limited its recommendations to ICUs that use a "closed" model where the intensivists control triage and patient care. The taskforce concluded that while advocating a specific maximum number of patients cared for is unrealistic, an approach that uses the following principles is essential: 1) proper staffing impacts patient care; 2) large caseloads should not preclude rounding in a timely fashion; 3) staffing decisions should factor surge capacity and nondirect patient care activities; 4) institutions should regularly reassess their staffing; 5) high staff turnover or decreases in quality-of-care indicators in an ICU may be markers of overload; 6) telemedicine, advanced practice professionals, or nonintensivist medical staff may be useful to alleviate overburdening the intensivist, but should be evaluated using rigorous methods; 7) in teaching institutions, feedback from faculty and trainees should be sought to understand the implications of potential understaffing on medical education; and 8) in academic medical ICUs, there is evidence that intensivist/patient ratios less favorable than 1:14 negatively impact education, staff well-being, and patient care.

An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health Care Professionals: A Call for Action.

PubMed

Moss, Marc; Good, Vicki S; Gozal, David; Kleinpell, Ruth; Sessler, Curtis N

2016-07-01

Burnout syndrome (BOS) occurs in all types of health care professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other health care professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care health care professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care health care professionals and diminish the harmful consequences of BOS, both for critical care health care professionals and for patients. ©2016 American Association of Critical-Care Nurses.

Initial resuscitation for Australasian Triage Scale 2 patients in a Nepalese emergency department.

PubMed

Basnet, Bibhusan; Bhandari, Rabin; Moore, Malcolm

2012-08-01

Triage is recognized as important in providing timely care to emergency patients. However, systematic triage is only practised in two EDs in Nepal. The first objective of this study was to assess the performance of one of these departments in seeing triaged patients in a timely fashion. Second, an epidemiological survey of patients presenting to the ED was performed to describe the conditions seen and initial resuscitation undertaken. We performed a descriptive cross-sectional study in the ED of B.P. Koirala Institute of Health Sciences, eastern Nepal where the Australasian Triage Scale (ATS) is used. One hundred and sixty patients triaged as ATS 2 were recruited. The time taken for the duty doctor to see the patient was noted. The presenting problems, vital signs and level of consciousness were measured at presentation. The resuscitation measures were recorded. The mean waiting time was 2.1 ± 1.7 min with a range of 1-10 min, which meets the benchmark for ATS 2. At triage, the most common presenting problems were circulatory shock (23.1%), altered consciousness (21%), respiratory difficulty (16.9%) and poisoning (15%). Oxygen, i.v. fluids and antibiotics were the most common therapies used in the initial resuscitation of patients. Patients triaged as ATS 2 were seen in a timely fashion. Seriously ill patients requiring resuscitation present commonly to this ED. This is a big challenge for junior doctors. Improved training, treatment protocols and equipment are needed to help manage this burden. © 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Building effective critical care teams

PubMed Central

2011-01-01

Critical care is formulated and delivered by a team. Accordingly, behavioral scientific principles relevant to teams, namely psychological safety, transactive memory and leadership, apply to critical care teams. Two experts in behavioral sciences review the impact of psychological safety, transactive memory and leadership on medical team outcomes. A clinician then applies those principles to two routine critical care paradigms: daily rounds and resuscitations. Since critical care is a team endeavor, methods to maximize teamwork should be learned and mastered by critical care team members, and especially leaders. PMID:21884639

Partiality, impartiality and the ethics of triage.

PubMed

Okorie, Ndukaku

2018-06-22

In this paper, I discuss the question of partiality and impartiality in the application of triage. Triage is a process in medical research which recommends that patients should be sorted for treatment according to the degree or severity of their injury. In employing the triage protocol, however, the question of partiality arises because socially vulnerable groups will be neglected since there is the likelihood that the social determinants of a patient's health may diminish her chance of survival. As a process that is based on the severity of a patient's injury, triage will be unfair, and hence negatively partial, to socially vulnerable people. Thus, I aim in this paper to show that the triage protocol fails as an impartial evaluative process because its only aim is to maximize survivability. I contend that: (i) triage would lead to the neglect of the social condition of patients or victims, and (ii) it will only serve the utilitarian purpose of maximization of outcomes which may not be justified in some cases. © 2018 John Wiley & Sons Ltd.

Development and evaluation of an influenza pandemic intensive care unit triage protocol.

PubMed

Cheung, Winston; Myburgh, John; Seppelt, Ian M; Parr, Michael J; Blackwell, Nikki; Demonte, Shannon; Gandhi, Kalpesh; Hoyling, Larissa; Nair, Priya; Passer, Melissa; Reynolds, Claire; Saunders, Nicholas M; Saxena, Manoj K; Thanakrishnan, Govindasamy

2012-09-01

To develop an influenza pandemic ICU triage (iPIT) protocol that excludes patients with the highest and lowest predicted mortality rates, and to determine the increase in ICU bed availability that would result. Post-hoc analysis of a study evaluating two triage protocols, designed to determine which patients should be excluded from access to ICU resources during an influenza pandemic. ICU mortality rates were determined for the individual triage criteria in the protocols and included criteria based on the Sequential Organ Failure Assessment (SOFA) score. Criteria resulting in mortality rates outside the 25th and 75th percentiles were used as exclusion criteria in a new iPIT-1 protocol. The SOFA threshold component was modified further and reported as iPIT-2 and iPIT-3. Increase in ICU bed availability. The 25th and 75th percentiles for ICU mortality were 8.3% and 35.2%, respectively. Applying the iPIT-1 protocol resulted in an increase in ICU bed availability at admission of 71.7% ± 0.6%. Decreasing the lower SOFA score exclusion criteria to ≤6 (iPIT-2) and ≤4 (iPIT-3) resulted in an increase in ICU bed availability at admission of 66.9% ± 0.6% and 59.4 ± 0.7%, respectively (P < 0.001). The iPIT protocol excludes patients with the lowest and highest ICU mortality, and provides increases in ICU bed availability. Adjusting the lower SOFA score exclusion limit provides a method of escalation or de- escalation to cope with demand.

Automated Cervical Screening and Triage, Based on HPV Testing and Computer-Interpreted Cytology.

PubMed

Yu, Kai; Hyun, Noorie; Fetterman, Barbara; Lorey, Thomas; Raine-Bennett, Tina R; Zhang, Han; Stamps, Robin E; Poitras, Nancy E; Wheeler, William; Befano, Brian; Gage, Julia C; Castle, Philip E; Wentzensen, Nicolas; Schiffman, Mark

2018-04-11

State-of-the-art cervical cancer prevention includes human papillomavirus (HPV) vaccination among adolescents and screening/treatment of cervical precancer (CIN3/AIS and, less strictly, CIN2) among adults. HPV testing provides sensitive detection of precancer but, to reduce overtreatment, secondary "triage" is needed to predict women at highest risk. Those with the highest-risk HPV types or abnormal cytology are commonly referred to colposcopy; however, expert cytology services are critically lacking in many regions. To permit completely automatable cervical screening/triage, we designed and validated a novel triage method, a cytologic risk score algorithm based on computer-scanned liquid-based slide features (FocalPoint, BD, Burlington, NC). We compared it with abnormal cytology in predicting precancer among 1839 women testing HPV positive (HC2, Qiagen, Germantown, MD) in 2010 at Kaiser Permanente Northern California (KPNC). Precancer outcomes were ascertained by record linkage. As additional validation, we compared the algorithm prospectively with cytology results among 243 807 women screened at KPNC (2016-2017). All statistical tests were two-sided. Among HPV-positive women, the algorithm matched the triage performance of abnormal cytology. Combined with HPV16/18/45 typing (Onclarity, BD, Sparks, MD), the automatable strategy referred 91.7% of HPV-positive CIN3/AIS cases to immediate colposcopy while deferring 38.4% of all HPV-positive women to one-year retesting (compared with 89.1% and 37.4%, respectively, for typing and cytology triage). In the 2016-2017 validation, the predicted risk scores strongly correlated with cytology (P < .001). High-quality cervical screening and triage performance is achievable using this completely automated approach. Automated technology could permit extension of high-quality cervical screening/triage coverage to currently underserved regions.

Critical Care Pharmacist Market Perceptions: Comparison of Critical Care Program Directors and Directors of Pharmacy

PubMed Central

Hager, David R.; Persaud, Rosemary A.; Naseman, Ryan W.; Choudhary, Kavish; Carter, Kristen E.; Hansen, Amanda

2017-01-01

Background: While hospital beds continue to decline as patients previously treated as inpatients are stabilized in ambulatory settings, the number of critical care beds available in the United States continues to rise. Growth in pharmacy student graduation, postgraduate year 2 critical care (PGY2 CC) residency programs, and positions has also increased. There is a perception that the critical care trained pharmacist market is saturated, yet this has not been evaluated since the rise in pharmacy graduates and residency programs. Purpose: To describe the current perception of critical care residency program directors (CC RPDs) and directors of pharmacy (DOPs) on the critical care pharmacist job market and to evaluate critical care postresidency placement and anticipated changes in PGY2 CC programs. Methods: Two electronic surveys were distributed from October 2015 to November 2015 through Vizient/University HealthSystem Consortium, American Society of Health-System Pharmacists (ASHP), Society of Critical Care Medicine, and American College of Clinical Pharmacy listservs to target 2 groups of respondents: CC RPDs and DOPs. Questions were based on the ASHP Pharmacy Forecast and the Pharmacy Workforce Center’s Aggregate Demand Index and were intended to identify perceptions of the critical care market of the 2 groups. Results: Of 116 CC RPDs, there were 66 respondents (56.9% response rate). Respondents have observed an increase in applicants; however, they do not anticipate increasing the number of positions in the next 5 years. The overall perception is that there is a balance in supply and demand in the critical care trained pharmacist market. A total of 82 DOPs responded to the survey. Turnover of critical care pharmacists within respondent organizations is expected to be low. Although a majority of DOPs plan to expand residency training positions, only 9% expect to increase positions in critical care PGY2 training. Overall, DOP respondents indicated a balance of

Critical Care Pharmacist Market Perceptions: Comparison of Critical Care Program Directors and Directors of Pharmacy.

PubMed

Hager, David R; Persaud, Rosemary A; Naseman, Ryan W; Choudhary, Kavish; Carter, Kristen E; Hansen, Amanda

2017-05-01

Background: While hospital beds continue to decline as patients previously treated as inpatients are stabilized in ambulatory settings, the number of critical care beds available in the United States continues to rise. Growth in pharmacy student graduation, postgraduate year 2 critical care (PGY2 CC) residency programs, and positions has also increased. There is a perception that the critical care trained pharmacist market is saturated, yet this has not been evaluated since the rise in pharmacy graduates and residency programs. Purpose: To describe the current perception of critical care residency program directors (CC RPDs) and directors of pharmacy (DOPs) on the critical care pharmacist job market and to evaluate critical care postresidency placement and anticipated changes in PGY2 CC programs. Methods: Two electronic surveys were distributed from October 2015 to November 2015 through Vizient/University HealthSystem Consortium, American Society of Health-System Pharmacists (ASHP), Society of Critical Care Medicine, and American College of Clinical Pharmacy listservs to target 2 groups of respondents: CC RPDs and DOPs. Questions were based on the ASHP Pharmacy Forecast and the Pharmacy Workforce Center's Aggregate Demand Index and were intended to identify perceptions of the critical care market of the 2 groups. Results: Of 116 CC RPDs, there were 66 respondents (56.9% response rate). Respondents have observed an increase in applicants; however, they do not anticipate increasing the number of positions in the next 5 years. The overall perception is that there is a balance in supply and demand in the critical care trained pharmacist market. A total of 82 DOPs responded to the survey. Turnover of critical care pharmacists within respondent organizations is expected to be low. Although a majority of DOPs plan to expand residency training positions, only 9% expect to increase positions in critical care PGY2 training. Overall, DOP respondents indicated a balance of

Exploring the characteristics of high-performing hospitals that influence trauma triage and transfer.

PubMed

Gagliardi, Anna R; Nathens, Avery B

2015-02-01

Many trauma patients might be first cared for at nondesignated centers before transfer to a trauma center. Limited research has investigated determinants of timely triage and transfer to identify those amenable to quality improvement. This study explored factors influencing timely triage and transfer in a regional trauma system. Centers (n = 15) with both long and short transfer times (emergency department length of stay before transfer) in Ontario were identified using a regional trauma registry. Physicians and nurses in these centers were interviewed with a view to determining factors that either impeded or enabled rapid decisions regarding the need for transfer to a trauma center. A grounded theory approach and constant comparative technique were used to collect and analyze data. Nineteen physicians and eight nurses participated. Clinician level (experience, training, personality, fear of judgment, nursing role), institutional level (guidelines, continuing education, trauma infrastructure, human resources) and system-level (bed availability, referral center, air transport, communication with trauma centers) factors influenced timely decision making. Participants offered several recommendations to improve care. These included guidelines for transfer, a "no refusal" policy at trauma centers, improved air transport and referral center services, as well as further regionalization. Additional features of hospitals with shorter transfer times included coaching of new staff, team meetings, leadership engagement, sharing of performance data, and minimum work hours for physicians. Numerous interacting factors that may influence trauma triage and transfer were identified. These findings can be used by policy makers, health care managers, and clinicians in emergency departments or trauma centers to evaluate and improve trauma triage and transfer, or plan new services. The findings can also be used by researchers to examine the relevance of these factors in other settings

Evidence-based Effective Triage Operation During Disaster: Application of Human-trajectory Data to Triage Drill Sessions.

PubMed

Ohta, Shoichi; Yoda, Ikushi; Takeda, Munekazu; Kuroshima, Satomi; Uchida, Kotaro; Kawai, Kentaro; Yukioka, Tetsuo

2015-02-01

Though many governmental and nongovernmental efforts for disaster prevention have been sought throughout Japan since the Great East Japan Earthquake on March 11, 2011, most of the preparation efforts for disasters have been based more on structural and conventionalized regulations than on scientific and objective grounds. Problem There has been a lack of scientific knowledge for space utilization for triage posts in disaster drill sessions. This report addresses how participants occupy and make use of the space within a triage post in terms of areas of use and occupied time. The trajectories of human movement by using Ubiquitous Stereo Vision (USV) cameras during two emergency drill sessions held in 2012 in a large commercial building have been measured. The USV cameras collect each participant's travel distance and the wait time before, during, and after undergoing triage. The correlation between the wait time and the space utilization of patients at a triage post has been analyzed. In the first session, there were some spaces not entirely used. This was caused largely by a patient who arrived earlier than others and lingered in the middle area, which caused the later arrivals to crowd the entrance area. On the other hand, in the second session, the area was used in a more evenly-distributed manner. This is mainly because the earlier arrivals were guided to the back space of the triage post (ie, the opposite side of the entrance), and the late arrivals were also guided to the front half, which was not occupied by anyone. As a result, the entire space was effectively utilized without crowding the entrance. This study has shown that this system could measure people's arrival times and the speed of their movements at the triage post, as well as where they are placed until they receive triage. Space utilization can be improved by efficiently planning and controlling the positioning of arriving patients. Based on the results, it has been suggested that for triage

Thinking strategies used by Registered Nurses during emergency department triage.

PubMed

Göransson, Katarina E; Ehnfors, Margareta; Fonteyn, Marsha E; Ehrenberg, Anna

2008-01-01

This paper is a report of a study to describe and compare thinking strategies and cognitive processing in the emergency department triage process by Registered Nurses with high and low triage accuracy. Sound clinical reasoning and accurate decision-making are integral parts of modern nursing practice and are of vital importance during triage in emergency departments. Although studies have shown that individual and contextual factors influence the decisions of Registered Nurses in the triage process, others have failed to explain the relationship between triage accuracy and clinical experience. Furthermore, no study has shown the relationship between Registered Nurses' thinking strategies and their triage accuracy. Using the 'think aloud' method, data were collected in 2004-2005 from 16 RNs working in Swedish emergency departments who had previously participated in a study examining triage accuracy. Content analysis of the data was performed. The Registered Nurses used a variety of thinking strategies, ranging from searching for information, generating hypotheses to stating propositions. They structured the triage process in several ways, beginning by gathering data, generating hypotheses or allocating acuity ratings. Comparison of participants' use of thinking strategies and the structure of the triage process based on their previous triage accuracy revealed only slight differences. The wide range of thinking strategies used by Registered Nurses when performing triage indicates that triage decision-making is complex. Further research is needed to ascertain which skills are most important in triage decision-making.

911 Emergency Medical Services and Re-Triage to Level I Trauma Centers.

PubMed

Kuncir, Eric; Spencer, Dean; Feldman, Kelly; Barrios, Cristobal; Miller, Kenneth; Lush, Stephanie; Dolich, Matthew; Lekawa, Michael

2018-01-01

Interfacility transfer of undertriaged patients to higher-level trauma centers has been found to result in a delay of appropriate care and an increase in mortality. To address this, for the last 10 years our region has used 911 emergency medical services (EMS) paramedics for rapid re-triage of undertriaged patients to our institution's Level I trauma center. We sought to determine whether using 911 EMS for re-triage to our institution was associated with worse outcomes-with mortality as the primary end point-compared with direct EMS transport from point of injury. We retrospectively reviewed all trauma activations to our institution during a 16-month period; 3,394 active traumas were analyzed. Two hundred and seventy patients (8%) arrived via 911 EMS re-triage and 3,124 (92%) arrived via direct EMS transport. Total EMS transport time was significantly longer (122.5 minutes vs 33.7 minutes; p < 0.001) between the 2 groups, but there was no significant difference in mortality rates (4.1% vs 3.6%; p = 0.67). These data show that although using 911 EMS for re-triage is associated with an increase in total transport time, it does not result in an increase in mortality compared with direct EMS transport. We conclude that the use of 911 EMS can be considered a safe method to re-triage patients to higher-level trauma centers. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible?

PubMed

van Rein, Eveline A J; van der Sluijs, Rogier; Houwert, R Marijn; Gunning, Amy C; Lichtveld, Rob A; Leenen, Luke P H; van Heijl, Mark

2018-01-27

In an optimal trauma system, prehospital trauma triage ensures transport of the right patient to the right hospital. Incorrect triage results in undertriage and overtriage. The aim of this systematic review is to evaluate and compare prehospital trauma triage system quality worldwide and determine effectiveness in terms of undertriage and overtriage for trauma patients. A systematic search of Pubmed/MEDLINE, Embase, and Cochrane Library databases was performed, using "trauma", "trauma center," or "trauma system", combined with "triage", "undertriage," or "overtriage", as search terms. All studies describing ground transport and actual destination hospital of patients with and without severe injuries, using prehospital triage, published before November 2017, were eligible for inclusion. To assess the quality of these studies, a critical appraisal tool was developed. A total of 33 articles were included. The percentage of undertriage ranged from 1% to 68%; overtriage from 5% to 99%. Older age and increased geographical distance were associated with undertriage. Mortality was lower for severely injured patients transferred to a higher-level trauma center. The majority of the included studies were of poor methodological quality. The studies of good quality showed poor performance of the triage protocol, but additional value of EMS provider judgment in the identification of severely injured patients. In most of the evaluated trauma systems, a substantial part of the severely injured patients is not transported to the appropriate level trauma center. Future research should come up with new innovative ways to improve the quality of prehospital triage in trauma patients. Copyright © 2018. Published by Elsevier Inc.

The 9-11 Commission's invitation to imagine: a pathophysiology-based approach to critical care of nuclear explosion victims.

PubMed

Manthous, Constantine A; Jackson, William L

2007-03-01

The successful management of mass casualties arising from detonation of a nuclear device (NDD) would require significant preparation at all levels of the healthcare system. This article briefly outlines previously published models of destruction and casualties, details approaches to on-site triage and medical evacuation, and offers pathophysiology-based suggestions for treatment of the critically injured. Documentation from previous bomb blasts and nuclear accidents is reviewed to assist in forecasting needs of both systems and patients in the event of an NDD in a major metropolitan area. This review extracts data from previously published models of destruction and casualties projected from an NDD, the primary literature detailing observations of patients' pathophysiology following NDDs in Japan and relevant nuclear accidents, and available contemporary resources for first responders and healthcare providers. The blast and radiation exposures that accompany an NDD will significantly affect local and regional public resources. Morbidity and mortality likely to arise in the setting of dose-dependent organ dysfunction may be minimized by rigorous a priori planning/training for field triage decisions, coordination of medical and civil responses to effect rapid responses and medical evacuation routes, radiation-specific interventions, and modern intensive care. Although the responses of emergency and healthcare systems following NDD will vary depending on the exact mechanism, magnitude, and location of the event, dose exposures and individual pathophysiology evolution are reasonably predictable. Triage decisions, resource requirements, and bedside therapeutic plans can be evidence-based and can be developed rapidly with appropriate preparation and planning.

Advanced Critical Care Practitioners - Practical experience of implementing the Advanced Critical Care Practitioner Faculty of Intensive Care Medicine Curriculum in a London Critical Care Unit.

PubMed

Lee, Geraldine; Gilroy, Jo-Anne; Ritchie, Alistair; Grover, Vimal; Gull, Keetje; Gruber, Pascale

2018-05-01

With a chronic shortage of doctors in intensive care, alternative roles are being explored. One of these is the role of the Advanced Critical Care Practitioner. The Advanced Critical Care Practitioner Curriculum was developed by the Faculty of Intensive Care Medicine and is used to provide a structured programme of training. The Advanced Critical Care Practitioner programme consists of an academic and clinical component. This article outlines a practical approach of how the programme was developed and is currently being delivered at a single institution. This new advanced practice role offers opportunities to fill gaps in the medical workforce, improve continuity of patient care, provide mentoring and training for less experienced staff as well as offering a rewarding clinical role.

Factors influencing consistency of triage using the Australasian Triage Scale: implications for guideline development.

PubMed

Gerdtz, Marie F; Chu, Matthew; Collins, Marnie; Considine, Julie; Crellin, Dianne; Sands, Natisha; Stewart, Carmel; Pollock, Wendy E

2009-08-01

To examine the influence of the nurse, the type of patient presentation and the level of hospital service on consistency of triage using the Australasian Triage Scale. A secondary analysis of survey data was conducted. The main study was undertaken to measure the reliability of 237 scenarios for inclusion in a national training programme. Nurses were recruited from a quota sample of Australian ED according to peer group. Analysis was performed to determine concordance: the percentage of responses in the modal triage category. Analysis of variance (anova) and Pearson correlations were used to investigate associations between the explanatory variables and concordance. A total of 42/50 (84%) participants returned questionnaires, providing 9946 scenario responses for analysis. Significant differences in concordance were observed by variables describing the type of patient presentation and level of urgency. Mean scores for the comparison group (adult pain; 70.7%) were higher than the groups involving a mental health or pregnancy presentations (61.4%; Ptriage for mental health and pregnancy presentations. Further research is needed to improve the guidelines on the implementation of the Australasian Triage Scale for these populations.

A concept for major incident triage: full-scaled simulation feasibility study.

PubMed

Rehn, Marius; Andersen, Jan E; Vigerust, Trond; Krüger, Andreas J; Lossius, Hans M

2010-08-11

Efficient management of major incidents involves triage, treatment and transport. In the absence of a standardised interdisciplinary major incident management approach, the Norwegian Air Ambulance Foundation developed Interdisciplinary Emergency Service Cooperation Course (TAS). The TAS-program was established in 1998 and by 2009, approximately 15 500 emergency service professionals have participated in one of more than 500 no-cost courses. The TAS-triage concept is based on the established triage Sieve and Paediatric Triage Tape models but modified with slap-wrap reflective triage tags and paediatric triage stretchers. We evaluated the feasibility and accuracy of the TAS-triage concept in full-scale simulated major incidents. The learners participated in two standardised bus crash simulations: without and with competence of TAS-triage and access to TAS-triage equipment. The instructors calculated triage accuracy and measured time consumption while the learners participated in a self-reported before-after study. Each question was scored on a 7-point Likert scale with points labelled "Did not work" (1) through "Worked excellent" (7). Among the 93 (85%) participating emergency service professionals, 48% confirmed the existence of a major incident triage system in their service, whereas 27% had access to triage tags. The simulations without TAS-triage resulted in a mean over- and undertriage of 12%. When TAS-Triage was used, no mistriage was found. The average time from "scene secured to all patients triaged" was 22 minutes (range 15-32) without TAS-triage vs. 10 minutes (range 5-21) with TAS-triage. The participants replied to "How did interdisciplinary cooperation of triage work?" with mean 4,9 (95% CI 4,7-5,2) before the course vs. mean 5,8 (95% CI 5,6-6,0) after the course, p < 0,001. Our modified triage Sieve tool is feasible, time-efficient and accurate in allocating priority during simulated bus accidents and may serve as a candidate for a future national

Physician Reimbursement for Critical Care Services Integrating Palliative Care for Patients Who Are Critically Ill

PubMed Central

Nelson, Judith E.; Weissman, David E.; Hays, Ross M.; Mosenthal, Anne C.; Mulkerin, Colleen; Puntillo, Kathleen A.; Ray, Daniel E.; Bassett, Rick; Boss, Renee D.; Brasel, Karen J.; Campbell, Margaret L.; Cortez, Therese B.; Curtis, J. Randall

2012-01-01

Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes. PMID:22396564

An Official Critical Care Societies Collaborative Statement-Burnout Syndrome in Critical Care Health-care Professionals: A Call for Action.

PubMed

Moss, Marc; Good, Vicki S; Gozal, David; Kleinpell, Ruth; Sessler, Curtis N

2016-07-01

Burnout syndrome (BOS) occurs in all types of health-care professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other health-care professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care health-care professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care health-care professionals and diminish the harmful consequences of BOS, both for critical care health-care professionals and for patients. Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

An evaluation of the critical care assistant role within an acute NHS Trust Critical Care Unit.

PubMed

McGloin, Sarah; Knowles, Judie

2005-01-01

This study provides an evaluation of a training programme designed for developing six critical care assistants to work alongside registered nurses to care for patients within the critical care environment. The programme was run as a pilot funded from the Department of Health's 'critical care bid'. At 18 months long, the programme incorporated a foundation programme, and National Vocational Qualification (NVQ) level 3 in care and adapted Operating Department Practitioner (ODP) NVQ units. Six critical care assistants successfully completed the programme; however, they all then left the unit to undertake further study for pre-registration nursing qualifications. Upon evaluation, a number of key issues were identified. Clear definition of the critical care assistants's role is essential as are dedicated practice development staff, who focus purely on developing the critical care assistant role. More importantly, however, with such key changes in the staffing structure within critical care units, appropriate change management techniques should be employed, ensuring that all staff contributing to the training and development are fully involved from the start.

Reconfiguring diagnostic work in Danish general practice; regulation, triage and the secretaries as diagnostician.

PubMed

Andersen, Rikke Sand; Aarhus, Rikke

2017-07-31

Health care systems as well as bodies of medical knowledge are dynamic and change as the result of political and social transformations. In recent decades, health care systems have been subjected to a whole assemblage of regulatory practices. The local changes undertaken in Denmark that are being explored here are indicative of a long-term shift that has occurred in many welfare states intended to make public services in the Global North more efficient and transparent. Departing in prolonged field work in Danish general practice and the anthropological literature on audit culture, this paper suggests that the introduction of regulatory practices has enhanced the need for triage as a key organising principle. The term triage literally means separating out and refers to the process of sorting and placing patients in time and space. The paper suggests that an increasing introduction of triage feeds into a reconfiguration of diagnostic work, where the clinical setting is gradually becoming more intertwined with the governing domains of policy, and the work of the secretary is gradually becoming more intertwined with that of the doctor. Finally, the paper argues that an increasing regulation of general practice poses an ethically charged challenge to existing welfare politics of responsibility between the state and the public, as it makes it increasingly difficult to negotiate access to care.

The critical care air transport program.

PubMed

Beninati, William; Meyer, Michael T; Carter, Todd E

2008-07-01

The critical care air transport team program is a component of the U.S. Air Force Aeromedical Evacuation system. A critical care air transport team consists of a critical care physician, critical care nurse, and respiratory therapist along with the supplies and equipment to operate a portable intensive care unit within a cargo aircraft. This capability was developed to support rapidly mobile surgical teams with high capability for damage control resuscitation and limited capacity for postresuscitation care. The critical care air transport team permits rapid evacuation of stabilizing casualties to a higher level of care. The aeromedical environment presents important challenges for the delivery of critical care. All equipment must be tested for safety and effectiveness in this environment before use in flight. The team members must integrate the current standards of care with the limitation imposed by stresses of flight on their patient. The critical care air transport team capability has been used successfully in a range of settings from transport within the United States, to disaster response, to support of casualties in combat.

[Emergency department triage: independent nursing intervention?].

PubMed

Corujo Fontes, Sergio José

2014-03-01

The branch hospital triage aimed at, as well as exercised by nurses, has evolved to meet their needs to organize and make visible the nurses' duties. However, it is still not properly considered as independent nursing intervention. Evidencing practice triage nurse in hospital as experienced by their protagonists disclosed the possible causes of this paradoxical competence. In a sample of 41 nurses, of the 52 possible with previous experience in hospital triage in the Emergency Department of the Hospital General Dr. José Molina Orosa in Lanzarote, the nurses themselves carried out an opinion survey that group together statements about different aspects of the triaje nurse. In its results, 65.8% of those polled thought the triaje nursing training to be deficient and even though nearly half 48.7%, was considered competent to decide the level of emergency, 46.3% disagreed to take this task part of their duty. It is conclusive that the training received in hospital triage, regulated and sustained, is deficient, that is the main reason why professionals have their doubts to take on an activity they are not familiar with. Triage systems do not record the entire outcome of the nursing work and nursing methodology does not seem to be quite indicative for this task.

Strengthening Emergency Care Systems to Mitigate Public Health Challenges Arising from Influxes of Individuals with Different Socio-Cultural Backgrounds to a Level One Emergency Center in South East Europe.

PubMed

Twomey, Michèle; Šijački, Ana; Krummrey, Gert; Welzel, Tyson; Exadaktylos, Aristomenis K; Ercegovac, Marko

2018-03-12

Emergency center visits are mostly unscheduled, undifferentiated, and unpredictable. A standardized triage process is an opportunity to obtain real-time data that paints a picture of the variation in acuity found in emergency centers. This is particularly pertinent as the influx of people seeking asylum or in transit mostly present with emergency care needs or first seek help at an emergency center. Triage not only reduces the risk of missing or losing a patient that may be deteriorating in the waiting room but also enables a time-critical response in the emergency care service provision. As part of a joint emergency care system strengthening and patient safety initiative, the Serbian Ministry of Health in collaboration with the Centre of Excellence in Emergency Medicine (CEEM) introduced a standardized triage process at the Clinical Centre of Serbia (CCS). This paper describes four crucial stages that were considered for the integration of a standardized triage process into acute care pathways.

Validation of different pediatric triage systems in the emergency department

PubMed Central

Aeimchanbanjong, Kanokwan; Pandee, Uthen

2017-01-01

BACKGROUND: Triage system in children seems to be more challenging compared to adults because of their different response to physiological and psychosocial stressors. This study aimed to determine the best triage system in the pediatric emergency department. METHODS: This was a prospective observational study. This study was divided into two phases. The first phase determined the inter-rater reliability of five triage systems: Manchester Triage System (MTS), Emergency Severity Index (ESI) version 4, Pediatric Canadian Triage and Acuity Scale (CTAS), Australasian Triage Scale (ATS), and Ramathibodi Triage System (RTS) by triage nurses and pediatric residents. In the second phase, to analyze the validity of each triage system, patients were categorized as two groups, i.e., high acuity patients (triage level 1, 2) and low acuity patients (triage level 3, 4, and 5). Then we compared the triage acuity with actual admission. RESULTS: In phase I, RTS illustrated almost perfect inter-rater reliability with kappa of 1.0 (P<0.01). ESI and CTAS illustrated good inter-rater reliability with kappa of 0.8–0.9 (P<0.01). Meanwhile, ATS and MTS illustrated moderate to good inter-rater reliability with kappa of 0.5–0.7 (P<0.01). In phase II, we included 1 041 participants with average age of 4.7±4.2 years, of which 55% were male and 45% were female. In addition 32% of the participants had underlying diseases, and 123 (11.8%) patients were admitted. We found that ESI illustrated the most appropriate predicting ability for admission with sensitivity of 52%, specificity of 81%, and AUC 0.78 (95%CI 0.74–0.81). CONCLUSION: RTS illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system. PMID:28680520

Paramedic Application of a Triage Sieve: A Paper-Based Exercise.

PubMed

Cuttance, Glen; Dansie, Kathryn; Rayner, Tim

2017-02-01

Introduction Triage is the systematic prioritization of casualties when there is an imbalance between the needs of these casualties and resource availability. The triage sieve is a recognized process for prioritizing casualties for treatment during mass-casualty incidents (MCIs). While the application of a triage sieve generally is well-accepted, the measurement of its accuracy has been somewhat limited. Obtaining reliable measures for triage sieve accuracy rates is viewed as a necessity for future development in this area. The goal of this study was to investigate how theoretical knowledge acquisition and the practical application of an aide-memoir impacted triage sieve accuracy rates. Two hundred and ninety-two paramedics were allocated randomly to one of four separate sub-groups, a non-intervention control group, and three intervention groups, which involved them receiving either an educational review session and/or an aide-memoir. Participants were asked to triage sieve 20 casualties using a previously trialed questionnaire. The study showed the non-intervention control group had a correct accuracy rate of 47%, a similar proportion of casualties found to be under-triaged (37%), but a significantly lower number of casualties were over-triaged (16%). The provision of either an educational review or aide-memoir significantly increased the correct triage sieve accuracy rate to 77% and 90%, respectively. Participants who received both the educational review and aide-memoir had an overall accuracy rate of 89%. Over-triaged rates were found not to differ significantly across any of the study groups. This study supports the use of an aide-memoir for maximizing MCI triage accuracy rates. A "just-in-time" educational refresher provided comparable benefits, however its practical application to the MCI setting has significant operational limitations. In addition, this study provides some guidance on triage sieve accuracy rate measures that can be applied to define

Pre-hospital National Early Warning Score (NEWS) is associated with in-hospital mortality and critical care unit admission: A cohort study.

PubMed

Abbott, Tom E F; Cron, Nicholas; Vaid, Nidhi; Ip, Dorothy; Torrance, Hew D T; Emmanuel, Julian

2018-03-01

National Early Warning Score (NEWS) is increasingly used in UK hospitals. However, there is only limited evidence to support the use of pre-hospital early warning scores. We hypothesised that pre-hospital NEWS was associated with death or critical care escalation within the first 48 h of hospital stay. Planned secondary analysis of a prospective cohort study at a single UK teaching hospital. Consecutive medical ward admissions over a 20-day period were included in the study. Data were collected from ambulance report forms, medical notes and electronic patient records. Pre-hospital NEWS was calculated retrospectively. The primary outcome was a composite of death or critical care unit escalation within 48 h of hospital admission. The secondary outcome was length of hospital stay. 189 patients were included in the analysis. The median pre-hospital NEWS was 3 (IQR 1-5). 13 patients (6.9%) died or were escalated to the critical care unit within 48 h of hospital admission. Pre-hospital NEWS was associated with death or critical care unit escalation (OR, 1.25; 95% CI, 1.04-1.51; p = 0.02), but NEWS on admission to hospital was more strongly associated with this outcome (OR, 1.52; 95% CI, 1.18-1.97, p < 0.01). Neither was associated with hospital length of stay. Pre-hospital NEWS was associated with death or critical care unit escalation within 48 h of hospital admission. NEWS could be used by ambulance crews to assist in the early triage of patients requiring hospital treatment or rapid transport. Further cohort studies or trials in large samples are required before implementation.

Call-duration and triage decisions in out of hours cooperatives with and without the use of an expert system.

PubMed

Ong, Rob S G; Post, Johan; van Rooij, Harry; de Haan, Jan

2008-02-13

Cooperatives delivering out of hours care in the Netherlands are hesitant about the use of expert systems during triage. Apart from the extra costs, cooperatives are not sure that quality of triage is sufficiently enhanced by these systems and believe that call duration will be prolonged drastically. No figures about the influence of the use of an expert system during triage on call duration and triage decisions in out of hours care in the Netherlands are available. Electronically registered data concerning call duration and triage decisions were collected in two cooperatives. One in Tilburg, a cooperative in a Southern city of the Netherlands using an expert system, and one in Groningen, a cooperative in a Northern city not using an expert system. Some other relevant information about the care process was collected additionally. Data about call duration was compared using an independent sample t-test. Data about call decisions was compared using Chi Square. The mean call time in the cooperative using the TAS expert system is 4.6 minutes, in the cooperative not using the expert system 3.9 minutes. A significant difference of 0.7 minutes (0.4 - 1.0, 95% CI) minutes. In the cooperative with an expert system a larger percentage of patients is handled by the assistant, patients are less often referred to a telephone consultation with the GP and are less likely to be offered a visit by the GP.A quick interpretation of the impact of the difference in triage decisions, show that these may be large enough to support the hypothesis that longer call duration is compensated for by less contacts with the GP (by telephone or face-to-face). There is no proof, however, that these differences are caused by the use of the triage system. The larger amount of calls handled by the assistant may be partly caused by the fact that the assistants in the cooperative with an expert system more often consult the GP during triage. And it is not likely that the larger amount of home visits in

Call-duration and triage decisions in out of hours cooperatives with and without the use of an expert system

PubMed Central

Ong, Rob SG; Post, Johan; van Rooij, Harry; de Haan, Jan

2008-01-01

Background Cooperatives delivering out of hours care in the Netherlands are hesitant about the use of expert systems during triage. Apart from the extra costs, cooperatives are not sure that quality of triage is sufficiently enhanced by these systems and believe that call duration will be prolonged drastically. No figures about the influence of the use of an expert system during triage on call duration and triage decisions in out of hours care in the Netherlands are available. Methods Electronically registered data concerning call duration and triage decisions were collected in two cooperatives. One in Tilburg, a cooperative in a Southern city of the Netherlands using an expert system, and one in Groningen, a cooperative in a Northern city not using an expert system. Some other relevant information about the care process was collected additionally. Data about call duration was compared using an independent sample t-test. Data about call decisions was compared using Chi Square. Results The mean call time in the cooperative using the TAS expert system is 4.6 minutes, in the cooperative not using the expert system 3.9 minutes. A significant difference of 0.7 minutes (0.4 – 1.0, 95% CI) minutes. In the cooperative with an expert system a larger percentage of patients is handled by the assistant, patients are less often referred to a telephone consultation with the GP and are less likely to be offered a visit by the GP. A quick interpretation of the impact of the difference in triage decisions, show that these may be large enough to support the hypothesis that longer call duration is compensated for by less contacts with the GP (by telephone or face-to-face). There is no proof, however, that these differences are caused by the use of the triage system. The larger amount of calls handled by the assistant may be partly caused by the fact that the assistants in the cooperative with an expert system more often consult the GP during triage. And it is not likely that the

Trauma triage in the emergency departments of nontrauma centers: an analysis of individual physician caseload on triage patterns.

PubMed

Mohan, Deepika; Barnato, Amber E; Rosengart, Matthew R; Farris, Coreen; Yealy, Donald M; Switzer, Galen E; Fischhoff, Baruch; Saul, Melissa; Angus, Derek C

2013-06-01

Treatment at Level I/II trauma centers improves outcomes for patients with severe injuries. Little is known about the role of physicians' clinical judgment in triage at outlying hospitals. We assessed the association between physician caseload, case mix, and the triage of trauma patients presenting to nontrauma centers. A retrospective cohort analysis of patients evaluated between January 1, 2007, and December 31, 2010, by emergency physicians working in eight community hospitals in western Pennsylvania. We linked billing records to hospital charts, summarized physicians' caseloads, and calculated rates of undertriage (proportion of patients with moderate-to-severe injuries not transferred to a trauma center), and overtriage (proportion of patients transferred with a minor injury). We measured the correlation between physician characteristics, caseload, and rates of triage. Of 50 eligible physicians, 29 (58%) participated in the study. Physicians had a mean (SD) of 16.8 (10.1) years of postresidency clinical experience; 21 (72%) were board certified in emergency medicine. They evaluated a median of 2,423 patients per year, of whom 148 (6%) were trauma patients and 3 (0.1%) had moderate-to-severe injuries. The median undertriage rate was 80%; the median overtriage rate was 91%. Physicians' caseload of patients with moderate-to-severe injuries was inversely associated with rates of undertriage (correlation coefficient, -0.42; p = 0.03). Compared with physicians in the lowest quartile, those in the highest quartile undertriaged 31% fewer patients. Emergency physicians working in nontrauma centers rarely encounter patients with moderate-to-severe injuries. Caseload was strongly associated with compliance with American College of Surgeons' Committee on Trauma guidelines. Therapeutic/care management, level IV.

Evaluation of a novel algorithm for primary mass casualty triage by paramedics in a physician manned EMS system: a dummy based trial

PubMed Central

2014-01-01

staffing of mobile intensive care units, patient transport ambulances, or disaster response volunteers. Up to now, there is no clinical validation of either triage concept. Therefore, reality based evaluation studies are needed. PMID:25214310

Triage of patients with acute gastrointestinal bleeding for intensive care unit admission based on risk factors for poor outcome.

PubMed

Afessa, B

2000-04-01

This study's aim was to determine the prognostic factors and to develop a triage system for intensive care unit (ICU) admission of patients with gastrointestinal bleeding (GIB). This prospective, observational study included 411 adults consecutively hospitalized for GIB. Each patient's selected clinical findings and laboratory values at presentation were obtained. The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were calculated from the initial findings in the emergency department. Poor outcome was defined as recurrent GIB, emergency surgery, or death. The role of hepatic cirrhosis, APACHE II score, active GIB, end-organ dysfunction, and hypotension in predicting outcome was evaluated. Chi-square, Student's t, Mann-Whitney U, and logistic regression analysis tests were used for statistical comparisons. Poor outcome developed in 81 (20%) patients; 39 died, 23 underwent emergency surgery, and 47 rebled. End-organ dysfunction, active bleeding, hepatic cirrhosis, and high APACHE II scores were independent predictors of poor outcome with odds ratios of 3:1, 3:1, 2:3, and 1:1, respectively. The ICU admission rate was 37%. High APACHE II score, active bleeding, end-organ dysfunction, and hepatic cirrhosis are independent predictors of poor outcome in patients with GIB and can be used in the triage of these patients for ICU admission.

Examining triage patterns of inhalation injury and toxic epidermal necrolysis-Stevens Johnson syndrome.

PubMed

Davis, James S; Pandya, Reeni K; Pizano, Louis R; Namias, Nicholas; Dearwater, Stephen; Schulman, Carl I

2013-01-01

The American Burn Association recommends that patients with toxic epidermal necrolysis-Stevens Johnson syndrome (TEN-SJS) or burn inhalation injuries would benefit from admission or transfer to a burn center (BC). This study examines to what extent those criteria are observed within a regional burn network. Hospital discharge data from 2000 to 2010 was obtained for all hospitals within the South Florida regional burn network. Patients with International Classification of Disease-9th revision discharge diagnoses for TEN-SJS or burn inhalation injury and their triage destination were compared using burn triage referral criteria to determine whether the patients were triaged differently from American Burn Association recommendations. Two hundred ninety-nine TEN-SJS and 131 inhalation injuries were admitted to all South Florida hospitals. Only 25 (8.4%) of TEN-SJS and 27 (21%) of inhalation injuries were admitted to the BC. BC patients had greater length of stay (TEN-SJS 22 vs 10 days; inhalation 13 vs 7) and were more likely to be funded by charity or be self-paid (TEN-SJS 24 vs 9.5%, P = .025; inhalation 44 vs 14%, P < .001), but less likely to hold some form of private or government insurance (TEN-SJS 72 vs 88%, P = .02; inhalation 48 vs 81%, P = .006). TEN-SJS BC patients were more frequently discharged home for self-care (76 vs 50%, P = .006). Non-BC patients were more often discharged to other healthcare facilities (28 vs 0% TEN-SJS, 20 vs 7.4% inhalation). Inappropriate triage may occur in more than 3 out of 4 of the TEN-SJS and inhalation injury patients within our burn network. Unfamiliarity with triage criteria, patient insurance status, and overcoding may play a role. Further studies should fully characterize the problem and implement education or incentives to encourage more appropriate triage.

Translating change: the development of a person-centred triage training programme for emergency nurses.

PubMed

McBrien, Barry

2009-01-01

Within health care, there has been a change in practice from an illness-orientated service to one that is more health-focused and person-centred. The concept of person-centredness is frequently espoused by practitioners as being not only a desirable, but a necessary element of health care provision. Indeed, nationally and internationally, person-centred care has underpinned many healthcare documents and policies. Person-centred practice focuses on providing care, utilising a variety of processes that operationalise person-centred nursing and include working with patients' beliefs and values, engagement, presence, sharing decision-making and providing for physical needs. In the field of emergency nursing, the incorporation of person-centred care and its holistic foundation may require a significant shift in practice. There is evidence to suggest that emergency nurses view their role as one, which is predominantly concerned with providing urgent physical care, rather than one, which espouses the theories of holistic healthcare. To this extent, being person-centred in the context of emergency care, requires the nurse to move beyond the traditional notions of his/her role and to embrace the more holistic aspects of patient care. The aim of this article is to critically analyse how a change in nurse-led triage training in one Irish Emergency Department facilitated an improved person-centred approach in practice.

Working with Manchester triage -- job satisfaction in nursing.

PubMed

Forsgren, Susanne; Forsman, Berit; Carlström, Eric D

2009-10-01

This article covers nurses' job satisfaction during triage at emergency departments in Western Sweden. Data was collected from 74 triage nurses using a questionnaire containing 37 short form open questions. The answers were analyzed descriptively and by measuring the covariance. The open questions were analyzed by content analysis. The results showed a high degree of job satisfaction (88%). Triage as a method, the interesting nature of the work, and a certain freedom in connection with the triage tasks contributed to job satisfaction (R(2) = 0.40). The nurses found their work interesting and stimulating, although some reported job dissatisfaction due to a heavy workload and lack of competence. Most of the nurses thought that Manchester triage (MTS) was a clear and straightforward method but in need of development. The rational modelling structure by which the triage method is constructed is unable to distinguish all the parameters that an experienced nurse takes into account. When the model is allowed to take precedence over experience, it can be of hindrance and contribute to certain estimates not corresponding with the patient's needs. The participants requested regular exercises solving and discussing patient scenarios. They also wanted to participate on a regular basis in the development of the instrument.

Web-based resources for critical care education.

PubMed

Kleinpell, Ruth; Ely, E Wesley; Williams, Ged; Liolios, Antonios; Ward, Nicholas; Tisherman, Samuel A

2011-03-01

To identify, catalog, and critically evaluate Web-based resources for critical care education. A multilevel search strategy was utilized. Literature searches were conducted (from 1996 to September 30, 2010) using OVID-MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature with the terms "Web-based learning," "computer-assisted instruction," "e-learning," "critical care," "tutorials," "continuing education," "virtual learning," and "Web-based education." The Web sites of relevant critical care organizations (American College of Chest Physicians, American Society of Anesthesiologists, American Thoracic Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine, World Federation of Societies of Intensive and Critical Care Medicine, American Association of Critical Care Nurses, and World Federation of Critical Care Nurses) were reviewed for the availability of e-learning resources. Finally, Internet searches and e-mail queries to critical care medicine fellowship program directors and members of national and international acute/critical care listserves were conducted to 1) identify the use of and 2) review and critique Web-based resources for critical care education. To ensure credibility of Web site information, Web sites were reviewed by three independent reviewers on the basis of the criteria of authority, objectivity, authenticity, accuracy, timeliness, relevance, and efficiency in conjunction with suggested formats for evaluating Web sites in the medical literature. Literature searches using OVID-MEDLINE, PubMed, and the Cumulative Index to Nursing and Allied Health Literature resulted in >250 citations. Those pertinent to critical care provide examples of the integration of e-learning techniques, the development of specific resources, reports of the use of types of e-learning, including interactive tutorials, case studies, and simulation, and reports of student or learner satisfaction, among other general

Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital.

PubMed

Jones, Courtney Marie Cora; Cushman, Jeremy T; Lerner, E Brooke; Fisher, Susan G; Seplaki, Christopher L; Veazie, Peter J; Wasserman, Erin B; Dozier, Ann; Shah, Manish N

2016-01-01

We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.

Prehospital telemedicine electrocardiogram triage for a regional public emergency medical service: is it worth it? A preliminary cost analysis.

PubMed

Brunetti, Natale Daniele; Dellegrottaglie, Giulia; Lopriore, Claudio; Di Giuseppe, Giuseppe; De Gennaro, Luisa; Lanzone, Saverio; Di Biase, Matteo

2014-03-01

Telemedicine has been shown to improve quality of health-care delivery in several fields of medicine; its cost-effectiveness, however, is still a matter of debate. Pre-hospital telemedicine electrocardiogram triage for regional public emergency medical service may reduce costs. An economic evaluation (cost analysis) was performed from the perspective of regional health-care system. Patients enrolled in the study and considered for cost analysis were those who called the local emergency medical service (EMS; dialing 1-1-8) during 2012 and underwent prehospital field triage with a telemedicine electrocardiogram (ECG) in the case of suspected acute cardiac disease (acute coronary syndrome, arrhythmia). The prehospital ECGs were read by a remote cardiologist, available 24/7. Cost savings associated with this method were calculated by subtracting the cost of prehospital triage with telemedicine support from the cost of conventional emergency department triage (ECG and consultation by a cardiologist). During 2012, the regional EMS performed 109 750 ECGs by telemedicine support. The associated total cost for the regional health-care system was €1 833 333, with a €16.70 cost per single ECG/consultation. Given the cost of similar conventional emergency department treatment from a regional rate list of €24.80 to €55.20, the savings was €8.10 to €38.40 per ECG/consultation (total savings, €891 759.50 to €4 219 379.50). The cost for ruling out an acute cardiac disease was €25.30; for a prehospital diagnosis of cardiovascular disease, €49.20. With 629 prehospital diagnoses of ST-elevation myocardial infarction and reported reductions in mortality thanks to prehospital diagnosis deduced from prior studies, 69 lives per year presumably could be saved, with a cost per quality-adjusted life year gained of €1927, €990/€ - 2508 after correction for potential savings. Prehospital EMS triage with telemedicine ECG in patients with suspected

Implementation of critical care response team.

PubMed

Al Shimemeri, Abdullah

2014-04-01

Analyses of hospital deaths have indicated that a significant proportion of the reported deaths might have been prevented had the patients received intensive level care early enough. Over the past few decades the critical care response team has become an important means of preventing these deaths. As the proactive arm of intensive care delivery, the critical care response team places emphasis on early identification of signs of clinical deterioration, which then prompts the mobilization of intensive care brought right to the patient's bedside. However, the setting up of a critical care response team is a difficult undertaking involving different levels of cooperation between all service stakeholders, and a bringing together of professional expertise and experience in its operations. The implementation of a critical care response team often involves a high-level restructuring of a hospital's service orientation. In the present work, the various factors and different models to be considered in implementing a critical care response team are addressed.

Critical care in the surgical global period.

PubMed

Painter, Julie R

2013-03-01

This article explores the rules and regulations from Current Procedural Terminology (CPT) code set and US Medicare and Medicaid Services (Medicare) regarding multiple physicians reporting critical care services during the global period. The article takes into account the critical care definitions, regulations, documentation requirements, and services each provider can report to Medicare. A clinical scenario based on literature supporting the types of complications and care that might typically be included in the post-operative period for a patient who is surgically treated for a type A aortic dissection was analyzed. It was determined that multiple physicians may provide critical care services to a single patient during the global period. The physician who performed the primary procedure cannot report critical care separately unless documentation supporting use of modifier 25 (significant, separately identifiable services) or 24 (unrelated services) supports that critical care is unrelated to the global period. Other physicians may report critical care services separately if specific criteria are met. To report critical care services to Medicare, the patient's condition must meet the Medicare definition of critical care and the physicians should generally represent different specialties providing different aspects of care to the critically ill or injured patient as defined by Medicare. There should be no overlap in time of services provided by each physician. Each physician's documentation should clearly support medical necessity with the diagnosis demonstrating the critical nature of the patients' illness, the total time spent providing critical care, the critical care service provided, and other contributing factors.

ReSTART: A Novel Framework for Resource-Based Triage in Mass-Casualty Events.

PubMed

Mills, Alex F; Argon, Nilay T; Ziya, Serhan; Hiestand, Brian; Winslow, James

2014-01-01

Current guidelines for mass-casualty triage do not explicitly use information about resource availability. Even though this limitation has been widely recognized, how it should be addressed remains largely unexplored. The authors present a novel framework developed using operations research methods to account for resource limitations when determining priorities for transportation of critically injured patients. To illustrate how this framework can be used, they also develop two specific example methods, named ReSTART and Simple-ReSTART, both of which extend the widely adopted triage protocol Simple Triage and Rapid Treatment (START) by using a simple calculation to determine priorities based on the relative scarcity of transportation resources. The framework is supported by three techniques from operations research: mathematical analysis, optimization, and discrete-event simulation. The authors? algorithms were developed using mathematical analysis and optimization and then extensively tested using 9,000 discrete-event simulations on three distributions of patient severity (representing low, random, and high acuity). For each incident, the expected number of survivors was calculated under START, ReSTART, and Simple-ReSTART. A web-based decision support tool was constructed to help providers make prioritization decisions in the aftermath of mass-casualty incidents based on ReSTART. In simulations, ReSTART resulted in significantly lower mortality than START regardless of which severity distribution was used (paired t test, p<.01). Mean decrease in critical mortality, the percentage of immediate and delayed patients who die, was 8.5% for low-acuity distribution (range ?2.2% to 21.1%), 9.3% for random distribution (range ?0.2% to 21.2%), and 9.1% for high-acuity distribution (range ?0.7% to 21.1%). Although the critical mortality improvement due to ReSTART was different for each of the three severity distributions, the variation was less than 1 percentage point

[Clinical evaluation of triage as drug-of-abuse test kit].

PubMed

Yoshioka, Toshiharu; Kohriyama, Kazuaki; Kondo, Rumiko; Goto, Kyoko; Yashiki, Mikio

2003-01-01

There are about 60,000 chemical substances which may cause poisoning. Identifying the cause substances is, therefore, very important for patient at emergency department. Triage is an immunoassay kit for the qualitative test for the metabolites of 8 major abuse drugs in urine. We assessed the usefullness of Triage on two patient groups. The first Group consists of the patients considered having not taken substances at initial diagnosis; the second Group consists of the patients considered having taken substances. The result are as follows. 1) The rate of Triage positive patients in the first Group were: attempt-suicide 23%, coma 24%, shock 10%, trauma 7%, respectively. Except for the habitually used medicine, narcotic and stimulant drugs were detected. In the first Group, negative result of Triage was effective in diagnosing the patients as not poisoned, excluding the possitivity of 8 major drugs usage. 2) The rate of Triage positive patients in the second Group were very high: attempt-suicide 77%, coma 51%, shock 57%, trauma 30%, respectively, showing mostly any of 8 major drugs were the cause of poisoning. In the second Group, positive result of Triage was effective in diagnosing the patient as poisoning or as coexisting poisoning with other diseases. 3) The specificity of Triage diagnosis in the first Group was 80% (113/142). The specificity and the sensitivity in the second Group were 64% (50/78) and 97% (74/76), respectively. These results means that Triage is very useful for diagnosis on 8 major drugs poisoning. 4) Triage is efficient for identifying the cause substances in drug poisoning and, therefore, can save medical expense. Triage is a very useful test kit at emergency department.

Perceptions of doctors and nurses at a Ugandan hospital regarding the introduction and use of the South African Triage Scale.

PubMed

Mulindwa, Francis; Blitz, Julia

2016-03-29

International Hospital Kampala (IHK) experienced a challenge with how to standardise the triaging and sorting of patients. There was no triage tool to help to prioritise which patients to attend to first, with very sick patient often being missed. To explore whether the introduction of the South African Triage Scale (SATS) was seen as valuable and sustainable by the IHK's outpatient department and emergency unit (OPD and EU) staff. The study used qualitative methods to introduce SATS in the OPD and EU at IHK and to obtain the perceptions of doctors and nurses who had used it for 3-6 months on its applicability and sustainability. Specific questions about challenges faced prior to its introduction, strengths and weaknesses of the triage tool, the impact it had on staff practices, and their recommendations on the continued use of the tool were asked. In-depth interviews were conducted with 4 doctors and 12 nurses. SATS was found to be necessary, applicable and recommended for use in the IHK setting. It improved the sorting of patients, as well as nurse-patient and nurse-doctor communication.The IHK OPD & EU staff attained new skills, with nurses becoming more involved in-patient care. It is possibly also useful in telephone triaging and planning of hospital staffing. Adequate nurse staffing, a computer application for automated coding of patients, and regular training would encourage consistent use and sustainability of SATS. Setting up a hospital committee to review signs and symptoms would increase acceptability and sustainability. SATS is valuable in the IHK setting because it improved overall efficiency of triaging and care, with significantly more strengths than weaknesses.

Do poison center triage guidelines affect healthcare facility referrals?

PubMed

Benson, B E; Smith, C A; McKinney, P E; Litovitz, T L; Tandberg, W D

2001-01-01

The purpose of this study was to determine the extent to which poison center triage guidelines influence healthcare facility referral rates for acute, unintentional acetaminophen-only poisoning and acute, unintentional adult formulation iron poisoning. Managers of US poison centers were interviewed by telephone to determine their center's triage threshold value (mg/kg) for acute iron and acute acetaminophen poisoning in 1997. Triage threshold values and healthcare facility referral rates were fit to a univariate logistic regression model for acetaminophen and iron using maximum likelihood estimation. Triage threshold values ranged from 120-201 mg/kg (acetaminophen) and 16-61 mg/kg (iron). Referral rates ranged from 3.1% to 24% (acetaminophen) and 3.7% to 46.7% (iron). There was a statistically significant inverse relationship between the triage value and the referral rate for acetaminophen (p < 0.001) and iron (p = 0.0013). The model explained 31.7% of the referral variation for acetaminophen but only 4.1% of the variation for iron. There is great variability in poison center triage values and referral rates for iron and acetaminophen poisoning. Guidelines can account for a meaningful proportion of referral variation. Their influence appears to be substance dependent. These data suggest that efforts to determine and utilize the highest, safe, triage threshold value could substantially decrease healthcare costs for poisonings as long as patient medical outcomes are not compromised.

Five-level emergency triage systems: variation in assessment of validity.

PubMed

Kuriyama, Akira; Urushidani, Seigo; Nakayama, Takeo

2017-11-01

Triage systems are scales developed to rate the degree of urgency among patients who arrive at EDs. A number of different scales are in use; however, the way in which they have been validated is inconsistent. Also, it is difficult to define a surrogate that accurately predicts urgency. This systematic review described reference standards and measures used in previous validation studies of five-level triage systems. We searched PubMed, EMBASE and CINAHL to identify studies that had assessed the validity of five-level triage systems and described the reference standards and measures applied in these studies. Studies were divided into those using criterion validity (reference standards developed by expert panels or triage systems already in use) and those using construct validity (prognosis, costs and resource use). A total of 57 studies examined criterion and construct validity of 14 five-level triage systems. Criterion validity was examined by evaluating (1) agreement between the assigned degree of urgency with objective standard criteria (12 studies), (2) overtriage and undertriage (9 studies) and (3) sensitivity and specificity of triage systems (7 studies). Construct validity was examined by looking at (4) the associations between the assigned degree of urgency and measures gauged in EDs (48 studies) and (5) the associations between the assigned degree of urgency and measures gauged after hospitalisation (13 studies). Particularly, among 46 validation studies of the most commonly used triages (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System), 13 and 39 studies examined criterion and construct validity, respectively. Previous studies applied various reference standards and measures to validate five-level triage systems. They either created their own reference standard or used a combination of severity/resource measures. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All

Level I center triage and mass casualties.

PubMed

Hoey, Brian A; Schwab, C William

2004-05-01

The world has been marked by a recent series of high-profile terrorist attacks, including the attack of September 11, 2001, in New York City. Similar to natural disasters, these attacks often result in a large number of casualties necessitating triage strategies. The end of the twentieth century was marked by the development of trauma systems in the United States and abroad. By their very nature, trauma centers are best equipped to handle mass casualties resulting from natural and manmade disasters. Triage assessment tools and scoring systems have evolved to facilitate this triage process and to potentially reduce the morbidity and mortality associated with these events.

Respiratory assessment in critical care units.

PubMed

Cox, C L; McGrath, A

1999-08-01

As healthcare delivery changes in critical care, nursing continues to extend its practice base. Nursing practice is expanding to incorporate skills once seen as the remit of the medical profession. Critical care nurses are equipping themselves with evidence-based knowledge and skills that can enhance the care they provide to their patients. Assessment of patients is a major role in nursing and, by expanding assessment techniques, nurses can ensure patients receive the care most appropriate to their needs. Nurses in critical care are well placed to perform a more detailed assessment which can help to focus nursing care. This article describes the step-by-step process of undertaking a full and comprehensive respiratory assessment in critical care settings. It identifies many of the problems that patients may have and the signs and symptoms that a nurse may not whilst undertaking the assessment and preparing to prescribe care.

Critical care nursing: Embedded complex systems.

PubMed

Trinier, Ruth; Liske, Lori; Nenadovic, Vera

2016-01-01

Variability in parameters such as heart rate, respiratory rate and blood pressure defines healthy physiology and the ability of the person to adequately respond to stressors. Critically ill patients have lost this variability and require highly specialized nursing care to support life and monitor changes in condition. The critical care environment is a dynamic system through which information flows. The critical care unit is typically designed as a tree structure with generally one attending physician and multiple nurses and allied health care professionals. Information flow through the system allows for identification of deteriorating patient status and timely interventionfor rescue from further deleterious effects. Nurses provide the majority of direct patient care in the critical care setting in 2:1, 1:1 or 1:2 nurse-to-patient ratios. The bedside nurse-critically ill patient relationship represents the primary, real-time feedback loop of information exchange, monitoring and treatment. Variables that enhance information flow through this loop and support timely nursing intervention can improve patient outcomes, while barriers can lead to errors and adverse events. Examining patient information flow in the critical care environment from a dynamic systems perspective provides insights into how nurses deliver effective patient care and prevent adverse events.

The design and implementation of an obstetric triage system for unscheduled pregnancy related attendances: a mixed methods evaluation.

PubMed

Kenyon, Sara; Hewison, Alistair; Dann, Sophie-Anna; Easterbrook, Jolene; Hamilton-Giachritsis, Catherine; Beckmann, April; Johns, Nina

2017-09-18

No standardised system of triage exists in Maternity Care and local audit identified this to be problematic. We designed, implemented and evaluated an Obstetric Triage System in a large UK maternity unit. This includes a standard clinical triage assessment by a midwife, within 15 min of attendance, leading to assignment to a category of clinical urgency (on a 4-category scale). This guides timing of subsequent standardised immediate care for the eight most common reasons for attendance. A training programme was integral to the introduction. A mixed methods evaluation was conducted. A structured audit of 994 sets of maternity notes before and after implementation identified the number of women seen within 15 min of attendance. Secondary measures reviewed included time to subsequent care and attendance. An inter-operator reliability study using scenarios was completed by midwives. A focus group and two questionnaire studies were undertaken to explore midwives' views of the system and to evaluate the training. In addition a national postal survey of practice in UK maternity units was undertaken in 2015. The structured audit of 974/992 (98%) of notes demonstrated an increase in the number of women seen within 15 min of attendance from 39% before implementation to 54% afterwards (RR (95% CI) 1.4 (1.2, 1.7) p = <0.0001). Excellent inter-operator reliability (ICC 0.961 (95% CI 0.91-0.99)) was demonstrated with breakdown showing consistently good rates. Thematic analysis of focus group data (n = 12) informed the development of the questionnaire which was sent to all appropriate midwives. The response rate was 53/79 (67%) and the midwives reported that the new system helped them manage the department and improved safety. The National Survey (response rate 85/135 [63%]) demonstrated wide variation in where women are seen and staffing models in place. The majority of units 69/85 (81%) did not use a triage system based on clinical assessment to prioritise care. This

The factors influencing burnout and job satisfaction among critical care nurses: a study of Saudi critical care nurses.

PubMed

Alharbi, Jalal; Wilson, Rhonda; Woods, Cindy; Usher, Kim

2016-09-01

The aim of the study was to explore the prevalence of burnout and job satisfaction among Saudi national critical care nurses. Burnout is caused by a number of factors, including personal, organisational and professional issues. Previous literature reports a strong relationship between burnout and job satisfaction among critical care nurses. Little is known about this phenomenon among Saudi national critical care nurses. A convenience sample of 150 Saudi national critical care nurses from three hospitals in Hail, Saudi Arabia were included in a cross-sectional survey. Saudi national critical care registered nurses reported moderate to high levels of burnout in the areas of emotional exhaustion and depersonalisation. Participants also reported a feeling of ambivalence and dissatisfaction with their jobs but were satisfied with the nature of their work. Saudi national critical care nurses experience moderate to high levels of burnout and low levels of job satisfaction. Burnout is a predictor of job satisfaction for Saudi national critical care nurses. These results provide clear evidence of the need for nurse managers and policy makers to devise strategies to help nurses better cope with a stressful work environment, thereby also improving job satisfaction among Saudi national critical care nurses. © 2016 John Wiley & Sons Ltd.

Orthopaedic podiatry triage: process outcomes of a skill mix initiative.

PubMed

Homeming, Lyndon J; Kuipers, Pim; Nihal, Aneel

2012-11-01

The Orthopaedic Podiatry Triage Clinic (OPodTC) is a 'skill mix' model of care developed in Queensland Health to address the problem of lengthy waiting times for orthopaedic surgery on foot and ankle pathologies. It is based on the recognition that many orthopaedic surgery referrals can be identified early and treated conservatively with podiatry, averting the need for more costly and invasive surgical interventions. The model is collaborative and relies on screening and triage by the podiatrist, rather than delegation by the orthopaedic surgeon. Screening and triage through OPodTC was trialled at three Queensland Health hospital facilities during 2009 and 2010 to improve service timeliness. Patients identified by the OPodTC podiatrist as suitable for conservative management were provided with non-surgical podiatry interventions and discharged if appropriate. Those identified as still requiring surgical intervention after the benefit of interim conservative treatment provided by the podiatrist (or who chose to remain on the list) were returned to their previous place on the orthopaedic waiting list. This paper presents a summary and description of waiting list changes in association with this trial. The OPodTC intervention resulted in a reduction in the non-urgent category of the waiting list across the three hospitals of between 23.3% and 49.7%. Indications from wait-list service data demonstrated increased timeliness and improved patient flow, which are core goals of these skill mix initiatives. This study highlights the potential of screening and triage functions in the skill mix debate. In this example, conservative treatment options were considered first, suitable patients did not have to wait long periods to receive timely and appropriate interventions, and those for whom surgery was indicated, were provided with a more targeted service.

Prevalence of neuropathic features of back pain in clinical populations: implications for the diagnostic triage paradigm.

PubMed

Hush, Julia M; Marcuzzi, Anna

2012-07-01

SUMMARY Contemporary clinical assessment of back pain is based on the diagnostic triage paradigm. The most common diagnostic classification is nonspecific back pain, considered to be of nociceptive etiology. A small proportion are diagnosed with radicular pain, of neuropathic origin. In this study we review the body of literature on the prevalence of neuropathic features of back pain, revealing that the point prevalence is 17% in primary care, 34% in mixed clinical settings and 53% in tertiary care. There is evidence that neuropathic features of back pain are not restricted to typical clinical radicular pain phenotypes and may be under-recognized, particularly in primary care. The consequence of this is that in the clinic, diagnostic triage may erroneously classify patients with nonspecific back pain or radicular pain. A promising alternative is the development of mechanism-based pain phenotyping in patients with back pain. Timely identification of contributory pain mechanisms may enable greater opportunity to select appropriate therapeutic targets and improve patient outcomes.

Multisociety Task Force for Critical Care Research

PubMed Central

Deutschman, Clifford S.; Ahrens, Tom; Cairns, Charles B.; Sessler, Curtis N.

2012-01-01

Background: Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. Objective: To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. Methods: The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the US Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. Results: The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: 1) the traditional “silo-ed” approach to critical care research is counterproductive and should be modified; 2) an approach that more effectively links areas of research (ie, basic and translational research, or clinical research and implementation) should be embraced; 3) future approaches to human research should account for disease complexity and patient heterogeneity; and 4) an enhanced infrastructure for critical care research is essential for future success. Conclusions: This document contains the themes/recommendations developed by a large

Bombings specific triage (Bost Tool) tool and its application by healthcare professionals.

PubMed

Sanjay, Jaiswal; Ankur, Verma; Tamorish, Kole

2015-01-01

Bombing is a unique incident which produces unique patterns, multiple and occult injuries. Death often is a result of combined blast, ballistic and thermal effect injuries. Various natures of injury, self referrals and arrival by private transportation may lead to "wrong triage" in the emergency department. In India there has been an increase in incidence of bombing in the last 15 years. There is no documented triage tool from the National Disaster Management Authority of India for Bombings. We have tried to develop an ideal bombing specific triage tool which will guide the right patients to the right place at the right time and save more lives. There are three methods of studying the triage tool: 1) real disaster; 2) mock drill; 3) table top exercise. In this study, a table top exercise method was selected. There are two groups, each consisting of an emergency physician, a nurse and a paramedic. By using the proportion test, we found that correct triaging was significantly different (P=0.005) in proportion between the two groups: group B (80%) with triage tool performed better in triaging the bomb blast victims than group A (50%) without the bombing specific triage tool performed. Development of bombing specific triage tool can reduce under triaging.

Critical Care Organizations: Building and Integrating Academic Programs.

PubMed

Moore, Jason E; Oropello, John M; Stoltzfus, Daniel; Masur, Henry; Coopersmith, Craig M; Nates, Joseph; Doig, Christopher; Christman, John; Hite, R Duncan; Angus, Derek C; Pastores, Stephen M; Kvetan, Vladimir

2018-04-01

Academic medical centers in North America are expanding their missions from the traditional triad of patient care, research, and education to include the broader issue of healthcare delivery improvement. In recent years, integrated Critical Care Organizations have developed within academic centers to better meet the challenges of this broadening mission. The goal of this article was to provide interested administrators and intensivists with the proper resources, lines of communication, and organizational approach to accomplish integration and Critical Care Organization formation effectively. The Academic Critical Care Organization Building section workgroup of the taskforce established regular monthly conference calls to reach consensus on the development of a toolkit utilizing methods proven to advance the development of their own academic Critical Care Organizations. Relevant medical literature was reviewed by literature search. Materials from federal agencies and other national organizations were accessed through the Internet. The Society of Critical Care Medicine convened a taskforce entitled "Academic Leaders in Critical Care Medicine" on February 22, 2016 at the 45th Critical Care Congress using the expertise of successful leaders of advanced governance Critical Care Organizations in North America to develop a toolkit for advancing Critical Care Organizations. Key elements of an academic Critical Care Organization are outlined. The vital missions of multidisciplinary patient care, safety, and quality are linked to the research, education, and professional development missions that enhance the value of such organizations. Core features, benefits, barriers, and recommendations for integration of academic programs within Critical Care Organizations are described. Selected readings and resources to successfully implement the recommendations are provided. Communication with medical school and hospital leadership is discussed. We present the rationale for critical

Impact of the introduction of a specialist critical care pharmacist on the level of pharmaceutical care provided to the critical care unit.

PubMed

Richter, Anja; Bates, Ian; Thacker, Meera; Jani, Yogini; O'Farrell, Bryan; Edwards, Caroline; Taylor, Helen; Shulman, Rob

2016-08-01

To evaluate the impact of a dedicated specialist critical care pharmacist service on patient care at a UK critical care unit (CCU). Pharmacist intervention data was collected in two phases. Phase 1 was with the provision of a non-specialist pharmacist chart review service and Phase 2 was after the introduction of a specialist dedicated pharmacy service. Two CCUs with established critical care pharmacist services were used as controls. The impact of pharmacist interventions on optimising drug therapy or preventing harm from medication errors was rated on a 4-point scale. There was an increase in the mean daily rate of pharmacist interventions after the introduction of the specialist critical care pharmacist (5.45 versus 2.69 per day, P < 0.0005). The critical care pharmacist intervened on more medication errors preventing potential harm and optimised more medications. There was no significant change to intervention rates at the control sites. Across all study sites the majority of pharmacist interventions were graded to have at least moderate impact on patient care. The introduction of a specialist critical care pharmacist resulted in an increased rate of pharmacist interventions compared to a non-specialist pharmacist service thus improving the quality of patient care. © 2016 The Authors. IJPP © 2016 Royal Pharmaceutical Society.

Confidence in critical care nursing.

PubMed

Evans, Jeanne; Bell, Jennifer L; Sweeney, Annemarie E; Morgan, Jennifer I; Kelly, Helen M

2010-10-01

The purpose of the study was to gain an understanding of the nursing phenomenon, confidence, from the experience of nurses in the nursing subculture of critical care. Leininger's theory of cultural care diversity and universality guided this qualitative descriptive study. Questions derived from the sunrise model were used to elicit nurses' perspectives about cultural and social structures that exist within the critical care nursing subculture and the influence that these factors have on confidence. Twenty-eight critical care nurses from a large Canadian healthcare organization participated in semistructured interviews about confidence. Five themes arose from the descriptions provided by the participants. The three themes, tenuously navigating initiation rituals, deliberately developing holistic supportive relationships, and assimilating clinical decision-making rules were identified as social and cultural factors related to confidence. The remaining two themes, preserving a sense of security despite barriers and accommodating to diverse challenges, were identified as environmental factors related to confidence. Practice and research implications within the culture of critical care nursing are discussed in relation to each of the themes.

Faecal immunochemical tests to triage patients with lower abdominal symptoms for suspected colorectal cancer referrals in primary care: a systematic review and cost-effectiveness analysis.

PubMed

Westwood, Marie; Corro Ramos, Isaac; Lang, Shona; Luyendijk, Marianne; Zaim, Remziye; Stirk, Lisa; Al, Maiwenn; Armstrong, Nigel; Kleijnen, Jos

2017-05-01

Colorectal cancer (CRC) is the third most common cancer in the UK. Presenting symptoms that can be associated with CRC usually have another explanation. Faecal immunochemical tests (FITs) detect blood that is not visible to the naked eye and may help to select patients who are likely to benefit from further investigation. To assess the effectiveness of FITs [OC-Sensor (Eiken Chemical Co./MAST Diagnostics, Tokyo, Japan), HM-JACKarc (Kyowa Medex/Alpha Laboratories Ltd, Tokyo, Japan), FOB Gold (Sentinel/Sysmex, Sentinel Diagnostics, Milan, Italy), RIDASCREEN Hb or RIDASCREEN Hb/Hp complex (R-Biopharm, Darmstadt, Germany)] for primary care triage of people with low-risk symptoms. Twenty-four resources were searched to March 2016. Review methods followed published guidelines. Summary estimates were calculated using a bivariate model or a random-effects logistic regression model. The cost-effectiveness analysis considered long-term costs and quality-adjusted life-years (QALYs) that were associated with different faecal occult blood tests and direct colonoscopy referral. Modelling comprised a diagnostic decision model, a Markov model for long-term costs and QALYs that were associated with CRC treatment and progression, and a Markov model for QALYs that were associated with no CRC. We included 10 studies. Using a single sample and 10 µg Hb/g faeces threshold, sensitivity estimates for OC-Sensor [92.1%, 95% confidence interval (CI) 86.9% to 95.3%] and HM-JACKarc (100%, 95% CI 71.5% to 100%) indicated that both may be useful to rule out CRC. Specificity estimates were 85.8% (95% CI 78.3% to 91.0%) and 76.6% (95% CI 72.6% to 80.3%). Triage using FITs could rule out CRC and avoid colonoscopy in approximately 75% of symptomatic patients. Data from our systematic review suggest that 22.5-93% of patients with a positive FIT and no CRC have other significant bowel pathologies. The results of the base-case analysis suggested minimal difference in QALYs between all of the

An exploration of clinical decision making in mental health triage.

PubMed

Sands, Natisha

2009-08-01

Mental health (MH) triage is a specialist area of clinical nursing practice that involves complex decision making. The discussion in this article draws on the findings of a Ph.D. study that involved a statewide investigation of the scope of MH triage nursing practice in Victoria, Australia. Although the original Ph.D. study investigated a number of core practices in MH triage, the focus of the discussion in this article is specifically on the findings related to clinical decision making in MH triage, which have not previously been published. The study employed an exploratory descriptive research design that used mixed data collection methods including a survey questionnaire (n = 139) and semistructured interviews (n = 21). The study findings related to decision making revealed a lack of empirically tested evidence-based decision-making frameworks currently in use to support MH triage nursing practice. MH triage clinicians in Australia rely heavily on clinical experience to underpin decision making and have little of knowledge of theoretical models for practice, such as methodologies for rating urgency. A key recommendation arising from the study is the need to develop evidence-based decision-making frameworks such as clinical guidelines to inform and support MH triage clinical decision making.

Training dedicated emergency physicians in surgical critical care: knowledge acquisition and workforce collaboration for the care of critically ill trauma/surgical patients.

PubMed

Chiu, William C; Marcolini, Evie G; Simmons, Dell E; Yeatts, Dale J; Scalea, Thomas M

2011-07-01

The Leapfrog Group initiative has led to an increasing public demand for dedicated intensivists providing critical care services. The Acute Care Surgery training initiative promotes an expansion of trauma/surgical care and operative domain, redirecting some of our focus from critical care. Will we be able to train and enforce enough intensivists to care for critically ill surgical patients? We have been training emergency physicians (EPs) alongside surgeons in our country's largest Trauma/Surgical Critical Care Fellowship Program annually for more than a decade. We reviewed our Society of Critical Care Medicine Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP, critical care in-training examination) scores from 2006 to 2009 (4 years). The MCCKAP, administered during the ninth month of a Critical Care Fellowship, is the only known standardized objective examination available in this country to compare critical care knowledge acquisition across different specialties. Subsequent workforce outcome for these Emergency Medicine Critical Care Fellowship graduates was analyzed. Over the 4-year period, we trained 42 Fellows in our Program who qualified for this study (30 surgeons and 12 EPs). Surgeons and EP performance scores on the MCCKAP examination were not different. The mean National Board Equivalent score was 419 ± 61 (mean ± standard deviation) for surgeons and 489 ± 87 for EPs. The highest score was achieved by an EP. The lowest score was not achieved by an EP. Ten of 12 (83%) EP Critical Care Fellowship graduates are practicing inpatient critical care in intensive care units with attending physician level responsibilities. EPs training in a Surgical Critical Care Fellowship can acquire critical care knowledge equivalent to that of surgeons. EPs trained in a Surgical Critical Care paradigm can potentially expand the intensive care unit workforce for Surgical Critical Care patients.

Critical thinking in patient centered care.

PubMed

Mitchell, Shannon H; Overman, Pamela; Forrest, Jane L

2014-06-01

Health care providers can enhance their critical thinking skills, essential to providing patient centered care, by use of motivational interviewing and evidence-based decision making techniques. The need for critical thinking skills to foster optimal patient centered care is being emphasized in educational curricula for health care professions. The theme of this paper is that evidence-based decision making (EBDM) and motivational interviewing (MI) are tools that when taught in health professions educational programs can aid in the development of critical thinking skills. This paper reviews the MI and EBDM literature for evidence regarding these patient-centered care techniques as they relate to improved oral health outcomes. Comparisons between critical thinking and EBDM skills are presented and the EBDM model and the MI technique are briefly described followed by a discussion of the research to date. The evidence suggests that EBDM and MI are valuable tools; however, further studies are needed regarding the effectiveness of EBDM and MI and the ways that health care providers can best develop critical thinking skills to facilitate improved patient care outcomes. Copyright © 2014 Elsevier Inc. All rights reserved.

Optimal Sector Sampling for Drive Triage

DTIC Science & Technology

2013-06-01

known files, which we call target data, that could help identify a drive holding evidence such as child pornography or malware. Triage is needed to sift...we call target data, that could help identify a drive holding evidence such as child pornography or malware. Triage is needed to sift through drives...situations where the user is looking for known data.1 One example is a law enforcement officer searching for evidence of child pornography from a large num

[Severe infection in critical emergency care].

PubMed

Matsuda, Naoyuki; Takatani, Yudai; Higashi, Tomoko; Inaba, Masato; Ejima, Tadashi

2016-02-01

In the emergency and critical care medicine, infection is easy to merge to various basic conditions and diseases. In the social structure aging in critical care, the immune weakness was revealed as the result of severe infection and septic shock in the reduced function of neutrophils and lymphocytes. In the life-saving emergency care, cardiovascular diseases, diabetes, chronic renal failure and lever dysfunction are often observed, and the underlying diseases have the foundation of biological invasion after a first inflammatory attack of surgery, trauma, burn, and systemic injury. It will be placed into a susceptible situation such as artificial respiratory management. In this review, we discussed severe infection in emergency and critical care. It is necessary to pay attention to the drug resistance bacterias in own critical care setting by trends.

Triage management, survival, and the law in the age of Ebola.

PubMed

Burkle, Frederick M; Burkle, Christopher M

2015-02-01

Liberia, Sierra Leone, and Guinea lack the public health infrastructure, economic stability, and overall governance to stem the spread of Ebola. Even with robust outside assistance, the epidemiological data have not improved. Vital resource management is haphazard and left to the discretion of individual Ebola treatment units. Only recently has the International Health Regulations (IHR) and World Health Organization (WHO) declared Ebola a Public Health Emergency of International Concern, making this crisis their fifth ongoing level 3 emergency. In particular, the WHO has been severely compromised by post-2003 severe acute respiratory syndrome (SARS) staffing, budget cuts, a weakened IHR treaty, and no unambiguous legal mandate. Population-based triage management under a central authority is indicated to control the transmission and ensure fair and decisive resource allocation across all triage categories. The shared responsibilities critical to global health solutions must be realized and the rightful attention, sustained resources, and properly placed legal authority be assured within the WHO, the IHR, and the vulnerable nations.

Healthcare reform: the role of coordinated critical care.

PubMed

Cerra, F B

1993-03-01

To evaluate and editorialize the evolving role of the discipline of critical care as a healthcare delivery system in the process of healthcare reform. The sources included material from the Federal Office of Management and Budget, Health Care Financing Review, President Bush's Office, Association of American Medical Colleges, and publications of the Society of Critical Care Medicine. Data were selected that the author felt was relevant to the healthcare reform process and its implications for the discipline of critical care. The data were extracted by the author to illustrate the forces behind healthcare reform, the implications for the practice of critical care, and role of critical care as a coordinated (managed) care system in the process of healthcare reform. Healthcare reform has been initiated because of a number of considerations that arise in evaluating the current healthcare delivery system: access, financing, cost, dissatisfactions with the mechanisms of delivery, and political issues. The reform process will occur with or without the involvement of critical care practitioners. Reforms may greatly alter the delivery of critical care services, education, training, and research in critical care. Critical care has evolved into a healthcare delivery system that provides services to patients who need and request them and provides these services in a coordinated (managed) care model. Critical care practitioners must become involved in the healthcare reform process, and critical care services that are effective must be preserved, as must the education, training, and research programs. Critical care as a healthcare delivery system utilizing a coordinated (managed) care model has the potential to provide services to all patients who need them and to deliver them in a manner that is cost effective and recognized as providing added value.

Trauma Quality Improvement: Reducing Triage Errors by Automating the Level Assignment Process.

PubMed

Stonko, David P; O Neill, Dillon C; Dennis, Bradley M; Smith, Melissa; Gray, Jeffrey; Guillamondegui, Oscar D

2018-04-12

Trauma patients are triaged by the severity of their injury or need for intervention while en route to the trauma center according to trauma activation protocols that are institution specific. Significant research has been aimed at improving these protocols in order to optimize patient outcomes while striving for efficiency in care. However, it is known that patients are often undertriaged or overtriaged because protocol adherence remains imperfect. The goal of this quality improvement (QI) project was to improve this adherence, and thereby reduce the triage error. It was conducted as part of the formal undergraduate medical education curriculum at this institution. A QI team was assembled and baseline data were collected, then 2 Plan-Do-Study-Act (PDSA) cycles were implemented sequentially. During the first cycle, a novel web tool was developed and implemented in order to automate the level assignment process (it takes EMS-provided data and automatically determines the level); the tool was based on the existing trauma activation protocol. The second PDSA cycle focused on improving triage accuracy in isolated, less than 10% total body surface area burns, which we identified to be a point of common error. Traumas were reviewed and tabulated at the end of each PDSA cycle, and triage accuracy was followed with a run chart. This study was performed at Vanderbilt University Medical Center and Medical School, which has a large level 1 trauma center covering over 75,000 square miles, and which sees urban, suburban, and rural trauma. The baseline assessment period and each PDSA cycle lasted 2 weeks. During this time, all activated, adult, direct traumas were reviewed. There were 180 patients during the baseline period, 189 after the first test of change, and 150 after the second test of change. All were included in analysis. Of 180 patients, 30 were inappropriately triaged during baseline analysis (3 undertriaged and 27 overtriaged) versus 16 of 189 (3 undertriaged and 13

Bombings specific triage (Bost Tool) tool and its application by healthcare professionals

PubMed Central

Sanjay, Jaiswal; Ankur, Verma; Tamorish, Kole

2015-01-01

BACKGROUND: Bombing is a unique incident which produces unique patterns, multiple and occult injuries. Death often is a result of combined blast, ballistic and thermal effect injuries. Various natures of injury, self referrals and arrival by private transportation may lead to “wrong triage” in the emergency department. In India there has been an increase in incidence of bombing in the last 15 years. There is no documented triage tool from the National Disaster Management Authority of India for Bombings. We have tried to develop an ideal bombing specific triage tool which will guide the right patients to the right place at the right time and save more lives. METHODS: There are three methods of studying the triage tool: 1) real disaster; 2) mock drill; 3) table top exercise. In this study, a table top exercise method was selected. There are two groups, each consisting of an emergency physician, a nurse and a paramedic. RESULTS: By using the proportion test, we found that correct triaging was significantly different (P=0.005) in proportion between the two groups: group B (80%) with triage tool performed better in triaging the bomb blast victims than group A (50%) without the bombing specific triage tool performed. CONCLUSION: Development of bombing specific triage tool can reduce under triaging. PMID:26693264

Evaluating the fundamental critical care support course in critical care education in Japan: a survey of Japanese fundamental critical care support course experience.

PubMed

Atagi, Kazuaki; Nishi, Shinichi; Fujitani, Shigeki; Kodama, Takamitsu; Ishikawa, Junya; Shimaoka, Hideki

2013-01-01

The Fundamental Critical Care Support (FCCS) course has been introduced after minimal adaptation according to Japanese clinical settings. The original course in the USA is often used to prepare residents for rotations in the intensive care unit (ICU). Therefore, the FCCS program can be appropriate for the basic training of critical care in Japan to standardize critical care management. The purpose of this study is to evaluate whether Japanese FCCS course is useful and has a possibility to deserve a basis of critical care management in Japan. The course program was provided with the form of lecture and skills stations. Pre- and post-training knowledge was assessed. After completion of the 2-day course, a questionnaire survey was administered to all course participants. Participants were asked to fill out the questions regarding socio-demographic characteristics. Participants were also asked to identify which lectures or skill stations they thought to be useful for clinical practice. Then, they were asked to rate their performance of each field: 'Assessment,' 'Diagnosis,' 'Recognition,' 'Response,' and 'Transfer'. The number of participants increased year after year and reached 1,804 during the past 4 years. Nearly 70% of the participants were physicians. Most of the others were nurses. In the established year, the percentage of physicians who had clinical experience more than 5 years exceeded 50%, however, this percentage gradually decreased. On the contrary, the percentages of residents and nurses increased. Regarding useful sessions, nearly half of the participants thought that mechanical ventilation was the most useful. With regard to the results of pre- and post-tests, the participants had already shown a high average mark (78.8 ± 14.1) at the pre-test. Furthermore, the score at the post-test was significantly improved (82.0 ± 6.6, p < 0.01). The participants' confidence in any field regarding critical care management was almost 4 points (5-point

Reverse triage: more than just another method.

PubMed

Pollaris, Gwen; Sabbe, Marc

2016-08-01

Reverse triage is a way to rapidly create inpatient surge capacity by identifying hospitalized patients who do not require major medical assistance for at least 96 h and who only have a small risk for serious complications resulting from early discharge. Electronic searches were conducted in the MEDLINE, TRIP, Cochrane Library, CINAHL, EMBASE, Web of Science, and SCOPUS databases to identify relevant publications published from 2004 to 2014. The reference lists of all relevant articles were screened for additional relevant studies that might have been missed in the primary searches. There will always be small individual differences in the reverse triage decision process, influencing the potential effect on surge capacity, but at most, 10-20% of hospital total bed capacity can be made available within a few hours. Reverse triage could be a response to Emergency Department (ED) crowding, as it gives priority to ED patients with urgent needs over inpatients who can be discharged with little to no health risks. The early discharge of inpatients entails negative consequences. They often return to the ED for further assessment, treatment, and even readmission. When time to a medical referral or bed is less than 4-6 h, 100 additional lives per annum are predicted to be potentially saved. The results of our systematic review identified only a small number of publications addressing reverse triage, indicating that reverse triage and surge capacity are relatively new subjects of research within the medical field. Not all research questions could be fully answered.

Critical Care Delivery: The Importance of Process of Care and ICU Structure to Improved Outcomes: An Update From the American College of Critical Care Medicine Task Force on Models of Critical Care.

PubMed

Weled, Barry J; Adzhigirey, Lana A; Hodgman, Tudy M; Brilli, Richard J; Spevetz, Antoinette; Kline, Andrea M; Montgomery, Vicki L; Puri, Nitin; Tisherman, Samuel A; Vespa, Paul M; Pronovost, Peter J; Rainey, Thomas G; Patterson, Andrew J; Wheeler, Derek S

2015-07-01

In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.

Thirty years of critical care medicine

PubMed Central

2010-01-01

Critical care medicine is a relatively young but rapidly evolving specialty. On the occasion of the 30th International Symposium on Intensive Care and Emergency Medicine, we put together some thoughts from a few of the leaders in critical care who have been actively involved in this field over the years. Looking back over the last 30 years, we reflect on areas in which, despite large amounts of research and technological and scientific advances, no major therapeutic breakthroughs have been made. We then look at the process of care and realize that, here, huge progress has been made. Lastly, we suggest how critical care medicine will continue to evolve for the better over the next 30 years. PMID:20550727

[Triage evaluation making in a pediatric emergency department of a tertiary hospital].

PubMed

Pascual-Fernández, Ma Cristina; Ignacio-Cerro, Ma Carmen; Jiménez-Carrascosa, Ma Amalia

2014-03-01

Evaluation triage level assignments depending level of the professionals' education and experience in the unit. This was a retrospective and observational study to triages making from January to March 2012 in Pediatric Emergency Department of tertiary hospital in Madrid. The collection data included variables from Pediatric Canadian Triage with five levels, triage tool using in the unit. 6443 triages were evaluated. The most common mistakes was: not to register pain level, 1445 (22.4%); not to register hydration level, 377 (5.9%); principal symptoms inappropriate, 232 (3.6%). Didn't indicate pain level 140 (5.6%) nurses with 12 hour formal training on triage; 492 (14.5%) with training in the unit, and 92 (16.3%) without training in the last year (p < 0.001). Among the nurses working in the unit more than 7 years did not register pain level 472 (12.3%), identified inappropriate principal symptoms 197 (5%) and did not register hydration level 296 (7.7%). The triage education favors better adaptation in the triage assignment. The most common errors are: not to register level pain and hydration when it's needed for the principal symptoms.

Automated imaging technologies for the diagnosis of glaucoma: a comparative diagnostic study for the evaluation of the diagnostic accuracy, performance as triage tests and cost-effectiveness (GATE study).

PubMed

Azuara-Blanco, Augusto; Banister, Katie; Boachie, Charles; McMeekin, Peter; Gray, Joanne; Burr, Jennifer; Bourne, Rupert; Garway-Heath, David; Batterbury, Mark; Hernández, Rodolfo; McPherson, Gladys; Ramsay, Craig; Cook, Jonathan

2016-01-01

Many glaucoma referrals from the community to hospital eye services are unnecessary. Imaging technologies can potentially be useful to triage this population. To assess the diagnostic performance and cost-effectiveness of imaging technologies as triage tests for identifying people with glaucoma. Within-patient comparative diagnostic accuracy study. Markov economic model comparing the cost-effectiveness of a triage test with usual care. Secondary care. Adults referred from the community to hospital eye services for possible glaucoma. Heidelberg Retinal Tomography (HRT), including two diagnostic algorithms, glaucoma probability score (HRT-GPS) and Moorfields regression analysis (HRT-MRA); scanning laser polarimetry [glaucoma diagnostics (GDx)]; and optical coherence tomography (OCT). The reference standard was clinical examination by a consultant ophthalmologist with glaucoma expertise including visual field testing and intraocular pressure (IOP) measurement. (1) Diagnostic performance of imaging, using data from the eye with most severe disease. (2) Composite triage test performance (imaging test, IOP measurement and visual acuity measurement), using data from both eyes, in correctly identifying clinical management decisions, that is 'discharge' or 'do not discharge'. Outcome measures were sensitivity, specificity and incremental cost per quality-adjusted life-year (QALY). Data from 943 of 955 participants were included in the analysis. The average age was 60.5 years (standard deviation 13.8 years) and 51.1% were females. Glaucoma was diagnosed by the clinician in at least one eye in 16.8% of participants; 37.9% of participants were discharged after the first visit. Regarding diagnosing glaucoma, HRT-MRA had the highest sensitivity [87.0%, 95% confidence interval (CI) 80.2% to 92.1%] but the lowest specificity (63.9%, 95% CI 60.2% to 67.4%) and GDx had the lowest sensitivity (35.1%, 95% CI 27.0% to 43.8%) but the highest specificity (97.2%, 95% CI 95.6% to 98

Comparison of the 1999 and 2006 Trauma Triage Guidelines: Where do Patients Go?

PubMed Central

Lerner, E. Brooke; Shah, Manish N.; Swor, Robert; Cushman, Jeremy T.; Guse, Clare E.; Brasel, Karen; Blatt, Alan; Jurkovich, Gregory J.

2010-01-01

In 2006, the CDC released a revised Field Triage Decision Scheme. It is unknown how this modified scheme will affect the number of patients identified by EMS for transport to a trauma center. Objective To determine the change in the number of patients transported by EMS who meet the 2006 scheme, compared to the 1999 scheme, and to determine how the scheme change would affect under- and over-triage rates. Methods EMS providers in charge of care for injured adult patients transported to a regional trauma center in three mid-sized cities were interviewed immediately after completing transport. All injured patients were included, regardless of severity. The interview included patient demographics, vital signs, apparent anatomic injury, and the mechanism of injury. Included patients were then followed through hospital discharge. The 1999 and 2006 scheme criteria were each retrospectively applied to the collected data. The number of patients identified by the two schemes was determined. Patients were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. Data were analyzed using descriptive statistics including 95% confidence intervals. Results EMS interviews were conducted for 11,892 patients and outcome data was unavailable for one patient. Average patient age was 48 years; 51% were men. Providers reported bringing 54% of the enrolled patients to the trauma center based on their local trauma protocol. 12% of enrolled patients were identified as needing a trauma center based on medical record review. Use of the 2006 scheme would have resulted in 1,423 fewer patients (12%; 95% CI:11-13%) being identified as needing a trauma center by EMS providers (40%; 95%CI:39-41% versus 28%; 95%CI:27-29%). 1,344 of those patients did not actually need the resources of a trauma center (94%). 78 (6%) of those patients actually needed the resources of a trauma center and would have been under-triaged. Conclusion Use of the

An examination of ESI triage scoring accuracy in relationship to ED nursing attitudes and experience.

PubMed

Martin, Andrew; Davidson, Carolyn L; Panik, Anne; Buckenmyer, Charlotte; Delpais, Paul; Ortiz, Michele

2014-09-01

This research was designed to examine if there is a difference in nurse attitudes and experience for those who assign Emergency Severity Index (ESI) scores accurately and those who do not assign ESI scores accurately. Studies that have used ESI scoring discussed the role of experience, but have not specifically addressed how the amount of experience and attitude towards patients in triage affect the triage nurse's decision-making capabilities. A descriptive, exploratory study design was used. Data from 64 nurses and 1,644 triage events at 3 emergency departments was collected. Participants completed demographic data, attitude (Caring Nurse Patient Interaction, CNPI-23) survey, and triage data collection tools during the continuous 8-hour triage shift. Clinical nurse expert raters retrospectively reviewed the charts and assigned an ESI score to be compared with the nurse. Descriptive statistics were used to describe the nurse and Pearson's correlation was used to examine the relationship between experience and attitude. In this study of 64 nurse participants, the ESI score assigned by nurse participants did not differ significantly based on years of experience or CNPI mean score. The Kappa statistic ranged from a high of 0.63 in the nurse participant with 1.00 to 1.99 years of experience to a low of 0.51 in the nurse participant with 15 to 19 years of experience. The nurse participants with an overall mean CNPI-23 score of 106 to 115 achieved the highest agreement compared with a single participant with a CNPI-23 overall mean score of less than 77 who had a Kappa agreement of 0.50. The nurse participants with a CNPI-23 overall mean score between 81 and 92 demonstrated agreement of 0.54 to 0.60. Based on the high level of liability the triage area presents, special consideration needs to be made when deciding which nurse should be assigned to that area. The evidence produced from this study should provide some reassurance to ED managers and nurses alike that nurses

Factors Influencing Active Family Engagement in Care Among Critical Care Nurses.

PubMed

Hetland, Breanna; Hickman, Ronald; McAndrew, Natalie; Daly, Barbara

2017-01-01

Critical care nurses are vital to promoting family engagement in the intensive care unit. However, nurses have varying perceptions about how much family members should be involved. The Questionnaire on Factors That Influence Family Engagement was given to a national sample of 433 critical care nurses. This correlational study explored the impact of nurse and organizational characteristics on barriers and facilitators to family engagement. Study results indicate that (1) nurses were most likely to invite family caregivers to provide simple daily care; (2) age, degree earned, critical care experience, hospital location, unit type, and staffing ratios influenced the scores; and (3) nursing work-flow partially mediated the relationships between the intensive care unit environment and nurses' attitudes and between patient acuity and nurses' attitudes. These results help inform nursing leaders on ways to promote nurse support of active family engagement in the intensive care unit. ©2017 American Association of Critical-Care Nurses.

Using robotic telecommunications to triage pediatric disaster victims.

PubMed

Burke, Rita V; Berg, Bridget M; Vee, Paul; Morton, Inge; Nager, Alan; Neches, Robert; Wetzel, Randall; Upperman, Jeffrey S

2012-01-01

During a disaster, hospitals may be overwhelmed and have an insufficient number of pediatric specialists available to care for injured children. The aim of this study was to determine the feasibility of remotely providing pediatric expertise via a robot to treat pediatric victims. In 2008, Los Angeles County held 2 drills involving telemedicine. The first was the Tri-Hospital drill in which 3 Los Angeles County hospitals, one being a pediatric hospital, participated. The disaster scenario involved a Metrolink train crash, resulting in a large surge of traumatic injuries. The second drill involved multiple agencies and was called the Great California Shakeout, a simulated earthquake exercise. The telemedicine equipment installed is an InTouch Health, Inc, Santa Barbara, CA robotic telecommunications system. We used mixed-methods to evaluate the use of telemedicine during these drills. Pediatric specialists successfully provided remote triage and treatment consults of victims via the robot. The robot proved to be a useful means to extend resources and provide expert consult if pediatric specialists were unable to physically be at the site. Telemedicine can be used in the delayed treatment areas as well as for training first receivers to collaborate with specialists in remote locations to triage and treat seriously injured pediatric victims. Copyright © 2012 Elsevier Inc. All rights reserved.

Diversity in the Emerging Critical Care Workforce: Analysis of Demographic Trends in Critical Care Fellows From 2004 to 2014.

PubMed

Lane-Fall, Meghan B; Miano, Todd A; Aysola, Jaya; Augoustides, John G T

2017-05-01

Diversity in the physician workforce is essential to providing culturally effective care. In critical care, despite the high stakes and frequency with which cultural concerns arise, it is unknown whether physician diversity reflects that of critically ill patients. We sought to characterize demographic trends in critical care fellows, who represent the emerging intensivist workforce. We used published data to create logistic regression models comparing annual trends in the representation of women and racial/ethnic groups across critical care fellowship types. United States Accreditation Council on Graduate Medical Education-approved residency and fellowship training programs. Residents and fellows employed by Accreditation Council on Graduate Medical Education-accredited training programs from 2004 to 2014. None. From 2004 to 2014, the number of critical care fellows increased annually, up 54.1% from 1,606 in 2004-2005 to 2,475 in 2013-2014. The proportion of female critical care fellows increased from 29.5% (2004-2005) to 38.3% (2013-2014) (p < 0.001). The absolute number of black fellows increased each year but the percentage change was not statistically significantly different (5.1% in 2004-2005 vs 3.9% in 2013-2014; p = 0.92). Hispanic fellows increased in number from 124 (7.7%) in 2004-2005 to 216 (8.4%) in 2013-2014 (p = 0.015). The number of American Indian/Alaskan Native/Native Hawaiian/Pacific Islander fellows decreased from 15 (1.0%) to seven (0.3%) (p < 0.001). When compared with population estimates, female critical care fellows and those from racial/ethnic minorities were underrepresented in all years. The demographics of the emerging critical care physician workforce reflect underrepresentation of women and racial/ethnic minorities. Trends highlight increases in women and Hispanics and stable or decreasing representation of non-Hispanic underrepresented minority critical care fellows. Further research is needed to elucidate the reasons underlying

Walk-In Triage Systems in University Counseling Centers

ERIC Educational Resources Information Center

Shaffer, Katharine S.; Love, Michael M.; Chapman, Kelsey M.; Horn, Angela J.; Haak, Patricia P.; Shen, Claire Y. W.

2017-01-01

To meet the complex mental health needs of students, some university counseling centers (UCCs) have implemented walk-in triage intake systems, which have not yet been empirically investigated. This study compared client and clinician differences (N = 5564) between a traditional scheduled intake system (Year 1) and a walk-in triage system (Year 2)…

Point-of-Care Ultrasonography in Emergency and Critical Care Medicine.

PubMed

Chen, Leon; Malek, Tony

To stabilize critically ill patients, emergency and critical care medicine providers often require rapid diagnosis and intervention. The demand for a safe, timely diagnostic device, alongside technological innovation, led to the advent of point-of-care ultrasonography (POCUS). POCUS allows the provider to gain invaluable clinical information with a high level of accuracy, leading to better clinical decision-making and improvements in patient safety. We have outlined the history of POCUS adaptation in emergency and critical care medicine and various clinical applications of POCUS described in literature.

Critical care cardiology.

PubMed

Fox, P R

1989-11-01

Management of the critical care cardiology patient often requires a rapid, accurate diagnostic and therapeutic strategy. A wide range of cardiovascular drugs is available for treatment of shock, congestive heart failure, and arrhythmias.

Virtual reality triage training provides a viable solution for disaster-preparedness.

PubMed

Andreatta, Pamela B; Maslowski, Eric; Petty, Sean; Shim, Woojin; Marsh, Michael; Hall, Theodore; Stern, Susan; Frankel, Jen

2010-08-01

The objective of this study was to compare the relative impact of two simulation-based methods for training emergency medicine (EM) residents in disaster triage using the Simple Triage and Rapid Treatment (START) algorithm, full-immersion virtual reality (VR), and standardized patient (SP) drill. Specifically, are there differences between the triage performances and posttest results of the two groups, and do both methods differentiate between learners of variable experience levels? Fifteen Postgraduate Year 1 (PGY1) to PGY4 EM residents were randomly assigned to two groups: VR or SP. In the VR group, the learners were effectively surrounded by a virtual mass disaster environment projected on four walls, ceiling, and floor and performed triage by interacting with virtual patients in avatar form. The second group performed likewise in a live disaster drill using SP victims. Setting and patient presentations were identical between the two modalities. Resident performance of triage during the drills and knowledge of the START triage algorithm pre/post drill completion were assessed. Analyses included descriptive statistics and measures of association (effect size). The mean pretest scores were similar between the SP and VR groups. There were no significant differences between the triage performances of the VR and SP groups, but the data showed an effect in favor of the SP group performance on the posttest. Virtual reality can provide a feasible alternative for training EM personnel in mass disaster triage, comparing favorably to SP drills. Virtual reality provides flexible, consistent, on-demand training options, using a stable, repeatable platform essential for the development of assessment protocols and performance standards.

Year in review 2009: Critical Care--cardiac arrest, trauma and disasters.

PubMed

Metzger, Jeffery C; Eastman, Alexander L; Pepe, Paul E

2010-01-01

During 2009, Critical Care published nine papers on various aspects of resuscitation, prehospital medicine, trauma care and disaster response. One article demonstrated that children as young as 9 years of age can learn cardiopulmonary resuscitation (CPR) effectively, although, depending on their size, some may have difficulty performing it. Another paper showed that while there was a trend toward mild therapeutic hypothermia reducing S-100 levels, there was no statistically significant change. Another predictor study also showed a strong link between acute kidney injury and neurologic outcome while another article described a program in which kidneys were harvested from cardiac arrest patients and showed an 89% graft survival rate. One experimental investigation indicated that when a pump-less interventional lung assist device is present, leaving the device open (unclamped) while performing CPR has no harmful effects on mean arterial pressures and it may have positive effects on blood oxygenation and CO2 clearance. One other study, conducted in the prehospital environment, found that end-tidal CO2 could be useful in diagnosing pulmonary embolism. Three articles addressed disaster medicine, the first of which described a triage system for use during pandemic influenza that demonstrated high reliability in delineating patients with a good chance of survival from those likely to die. The other two studies, both drawn from the 2008 Sichuan earthquake experience, showed success in treating crush injured patients in an on-site tent ICU and, in the second case, how the epidemiology of earthquake injuries and related factors predicted mortality.

Compliance with telephone triage advice among adults aged 45 years and older: an Australian data linkage study.

PubMed

Tran, Duong Thuy; Gibson, Amy; Randall, Deborah; Havard, Alys; Byrne, Mary; Robinson, Maureen; Lawler, Anthony; Jorm, Louisa R

2017-08-01

Middle-aged and older patients are prominent users of telephone triage services for timely access to health information and appropriate referrals. Non-compliance with advice to seek appropriate care could potentially lead to poorer health outcomes among those patients. It is imperative to assess the extent to which middle-aged and older patients follow triage advice and how this varies according to their socio-demographic, lifestyle and health characteristics as well as features of the call. Records of calls to the Australian healthdirect helpline (July 2008-December 2011) were linked to baseline questionnaire data from the 45 and Up Study (participants age ≥ 45 years), records of emergency department (ED) presentations, hospital admissions, and medical consultation claims. Outcomes of the call included compliance with the advice "Attend ED immediately"; "See a doctor (immediately, within 4 hours, or within 24 hours)"; "Self-care"; and self-referral to ED or hospital within 24 h when given a self-care or low-urgency care advice. Multivariable logistic regression was used to investigate associations between call outcomes and patient and call characteristics. This study included 8406 adults (age ≥ 45 years) who were subjects of 11,088 calls to the healthdirect helpline. Rates of compliance with the advices "Attend ED immediately", "See a doctor" and "Self-care" were 68.6%, 64.6% and 77.5% respectively, while self-referral to ED within 24 h followed 7.0% of calls. Compliance with the advice "Attend ED immediately" was higher among patients who had three or more positive lifestyle behaviours, called after-hours, or stated that their original intention was to attend ED, while it was lower among those who lived in rural and remote areas or reported high or very high levels of psychological distress. Compliance with the advice "See a doctor" was higher in patients who were aged ≥65 years, worked full-time, or lived in socio-economically advantaged areas

Critical care providers refer to information tools less during communication tasks after a critical care clinical information system introduction.

PubMed

Ballermann, Mark; Shaw, Nicola T; Mayes, Damon C; Gibney, R T Noel

2011-01-01

Electronic documentation methods may assist critical care providers with information management tasks in Intensive Care Units (ICUs). We conducted a quasi-experimental observational study to investigate patterns of information tool use by ICU physicians, nurses, and respiratory therapists during verbal communication tasks. Critical care providers used tools less at 3 months after the CCIS introduction. At 12 months, care providers referred to paper and permanent records, especially during shift changes. The results suggest potential areas of improvement for clinical information systems in assisting critical care providers in ensuring informational continuity around their patients.

Critical care nurses' experiences when technology malfunctions.

PubMed

Haghenbeck, Karen Toby

2005-01-01

When caring for critically ill patients, critical care nurses work with technology every day. Technology and equipment malfunctions can have a profound effect on nurses' practice and self-image. In this article, a descriptive phenomenological methodology was chosen to explicate the experience of seven critical care nurses. While participants realized that machines might malfunction, they experienced surprise, shock, and feelings of being "let down" and inadequate when malfunctions occurred. They questioned their competence and felt malfunctioning technology jeopardized their credibility and professional image. These findings are useful when structuring educational sessions on technology and in facilitating a supportive environment for critical care nurses when technology malfunctions.

What critical care nurses need to know about health care access when caring for elders in acute care settings.

PubMed

Jennings, Bonnie Mowinski; Lamb, Gerri

2007-09-01

Health care system issues, in general, and access to care, in particular, are not problems typically studied by critical care nurses. Rather, initial and continuing education focuses on clinical aspects of care. This focus is necessary to assure that critical care nurses have the expertise to care for patients who need astute surveillance for complicated physical problems and their emotional sequelae, as well as in-depth knowledge and skills related to care coordination for patient stabilization and transfer. However, evidence is growing that patients benefit when critical care nurses expand their knowledge about access to care. This article provides insights regarding access to health care and how it relates to many of the admission and readmission patterns that critical care nurses observe.

Gender Parity in Critical Care Medicine.

PubMed

Mehta, Sangeeta; Burns, Karen E A; Machado, Flavia R; Fox-Robichaud, Alison E; Cook, Deborah J; Calfee, Carolyn S; Ware, Lorraine B; Burnham, Ellen L; Kissoon, Niranjan; Marshall, John C; Mancebo, Jordi; Finfer, Simon; Hartog, Christiane; Reinhart, Konrad; Maitland, Kathryn; Stapleton, Renee D; Kwizera, Arthur; Amin, Pravin; Abroug, Fekri; Smith, Orla; Laake, Jon H; Shrestha, Gentle S; Herridge, Margaret S

2017-08-15

Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. These documents inform and shape patient care around the world. In this Perspective we discuss the importance of diversity on guideline panels, the disproportionately low representation of women on critical care guideline panels, and existing initiatives to increase the representation of women in corporations, universities, and government. We propose five strategies to ensure gender parity within critical care medicine.

Support to triage and public risk perception considering long-term response to a Cs-137 radiological dispersive device scenario.

PubMed

Andrade, Cristiane Ps; Souza, Cláudio J; Camerini, Eduardo Sn; Alves, Isabela S; Vital, Hélio C; Healy, Matthew Jf; Ramos De Andrade, Edson

2018-06-01

A radiological dispersive device (RDD) spreads radioactive material, complicates the treatment of physical injuries, raises cancer risk, and induces disproportionate fear. Simulating such an event enables more effective and efficient utilization of the triage and treatment resources of staff, facilities, and space. Fast simulation can give detail on events in progress or future events. The resources for triage and treatment of contaminated trauma victims can differ for pure exposure individuals, while discouraging the "worried well" from presenting in the crisis phase by media announcement would relieve pressure on hospital facilities. The proposed methodology integrates capabilities from different platforms in a convergent way composed of three phases: (a) scenario simulation, (b) data generation, and (c) risk assessment for triage focused on follow-up epidemiological assessment. Simulations typically indicate that most of the affected population does not require immediate medical assistance. Medical triage for the few severely injured and the radiological triage to diminish the contamination with radioactivity will always be the priority. For this study, however, higher priorities should be given to individuals from radiological "warm" and "hot" zones as required by risk criteria. The proposed methodology could thus help to (a) filter and reduce the number of individuals to be attended, (b) optimize the prioritization of medical care, (c) reduce or prepare for future costs, (d) effectively locate the operational triage site to avoid possible contamination on the main facility, and (e) provide the scientific data needed to develop an adequate approach to risk and its proper communication.

Do you see what I see? Insights from using google glass for disaster telemedicine triage.

PubMed

Cicero, Mark X; Walsh, Barbara; Solad, Yauheni; Whitfill, Travis; Paesano, Geno; Kim, Kristin; Baum, Carl R; Cone, David C

2015-02-01

Disasters are high-stakes, low-frequency events. Telemedicine may offer a useful adjunct for paramedics performing disaster triage. The objective of this study was to determine the feasibility of telemedicine in disaster triage, and to determine whether telemedicine has an effect on the accuracy of triage or the time needed to perform triage. This is a feasibility study in which an intervention team of two paramedics used the mobile device Google Glass (Google Inc; Mountain View, California USA) to communicate with an off-site physician disaster expert. The paramedic team triaged simulated disaster victims at the triennial drill of a commercial airport. The simulated victims had preassigned expected triage levels. The physician had an audio-video interface with the paramedic team and was able to observe the victims remotely. A control team of two paramedics performed disaster triage in the usual fashion. Both teams used the SMART Triage System (TSG Associates LLP; Halifax, England), which assigns patients into Red, Yellow, Green, and Black triage categories. The paramedics were video recorded, and their time required to triage was logged. It was determined whether the intervention team and the control team varied regarding accuracy of triage. Finally, the amount of time the intervention team needed to triage patients when telemedicine was used was compared to when that team did not use telemedicine. The two teams triaged the same 20 patients. There was no significant difference between the two groups in overall triage accuracy (85.7% for the intervention group vs 75.9% for the control group; P = .39). Two patients were triaged with telemedicine. For the intervention group, there was a significant difference in time to triage patients with telemedicine versus those without telemedicine (35.5 seconds; 95% CI, 72.5-143.5 vs 18.5 seconds; 95% CI, 13.4-23.6; P = .041). There was no increase in triage accuracy when paramedics evaluating disaster victims used telemedicine

Critical care medicine training and certification for emergency physicians.

PubMed

Huang, David T; Osborn, Tiffany M; Gunnerson, Kyle J; Gunn, Scott R; Trzeciak, Stephen; Kimball, Edward; Fink, Mitchell P; Angus, Derek C; Dellinger, R Phillip; Rivers, Emanuel P

2005-09-01

Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine and critical care medicine. Demand for critical care services is increasing. Unless the supply of intensivists increases, critically ill patients will not have access to intensivists. Recent critical care society recommendations include increased graduate medical education support and expansion of the J-1 visa waiver program for foreign medical graduates. This article proposes additional recommendations, based on strengthening the relationship between emergency medicine (EM) and critical care medicine (CCM). Critical care is a continuum that includes prehospital, emergency department (ED), and intensive care unit (ICU) care teams. Both EM and CCM require expertise in treating life-threatening acute illness, with many critically ill patients often presenting first to the ED. Increased patient volumes and acuity have resulted in longer ED lengths of stay and more critical care delivery in the ED. However, the majority of CCM fellowships do not accept EM residents, and those who successfully complete a fellowship do not have access to a U.S. certification exam in CCM. Despite these barriers, interest in CCM training among EM physicians is increasing. Dual EM/CCM-trained physicians not only will help alleviate the intensivist shortage but also will strengthen critical care delivery in the ED and facilitate coordination at the ED-ICU interface. We therefore propose that all accreditation bodies work cooperatively to create a route to CCM certification for emergency physicians who complete a critical care fellowship.

The variability of critical care bed numbers in Europe.

PubMed

Rhodes, A; Ferdinande, P; Flaatten, H; Guidet, B; Metnitz, P G; Moreno, R P

2012-10-01

To quantify the numbers of critical care beds in Europe and to understand the differences in these numbers between countries when corrected for population size and gross domestic product. Prospective data collection of critical care bed numbers for each country in Europe from July 2010 to July 2011. Sources were identified in each country that could provide data on numbers of critical care beds (intensive care and intermediate care). These data were then cross-referenced with data from international databases describing population size and age, gross domestic product (GDP), expenditure on healthcare and numbers of acute care beds. We identified 2,068,892 acute care beds and 73,585 (2.8 %) critical care beds. Due to the heterogeneous descriptions of these beds in the individual countries it was not possible to discriminate between intensive care and intermediate care in most cases. On average there were 11.5 critical care beds per 100,000 head of population, with marked differences between countries (Germany 29.2, Portugal 4.2). The numbers of critical care beds per country corrected for population size were positively correlated with GDP (r(2) = 0.16, p = 0.05), numbers of acute care beds corrected for population (r(2) = 0.12, p = 0.05) and the percentage of acute care beds designated as critical care (r(2) = 0.59, p < 0.0001). They were not correlated with the proportion of GDP expended on healthcare. Critical care bed numbers vary considerably between countries in Europe. Better understanding of these numbers should facilitate improved planning for critical care capacity and utilization in the future.

No Child Overlooked: Mental Health Triage in the Schools

ERIC Educational Resources Information Center

Wilson, F. Robert; Tang, Mei; Schiller, Kelly; Sebera, Kerry

2009-01-01

Mental health problems among children in schools are on the increase. To exercise due diligence in their responsibility to monitor and promote mental health among our nation's children, school counselors may learn from triage systems employed in hospitals, clinics, and mental health centers. The School Counselor's Triage Model provides school…

The Speaker Gender Gap at Critical Care Conferences.

PubMed

Mehta, Sangeeta; Rose, Louise; Cook, Deborah; Herridge, Margaret; Owais, Sawayra; Metaxa, Victoria

2018-06-01

To review women's participation as faculty at five critical care conferences over 7 years. Retrospective analysis of five scientific programs to identify the proportion of females and each speaker's profession based on conference conveners, program documents, or internet research. Three international (European Society of Intensive Care Medicine, International Symposium on Intensive Care and Emergency Medicine, Society of Critical Care Medicine) and two national (Critical Care Canada Forum, U.K. Intensive Care Society State of the Art Meeting) annual critical care conferences held between 2010 and 2016. Female faculty speakers. None. Male speakers outnumbered female speakers at all five conferences, in all 7 years. Overall, women represented 5-31% of speakers, and female physicians represented 5-26% of speakers. Nursing and allied health professional faculty represented 0-25% of speakers; in general, more than 50% of allied health professionals were women. Over the 7 years, Society of Critical Care Medicine had the highest representation of female (27% overall) and nursing/allied health professional (16-25%) speakers; notably, male physicians substantially outnumbered female physicians in all years (62-70% vs 10-19%, respectively). Women's representation on conference program committees ranged from 0% to 40%, with Society of Critical Care Medicine having the highest representation of women (26-40%). The female proportions of speakers, physician speakers, and program committee members increased significantly over time at the Society of Critical Care Medicine and U.K. Intensive Care Society State of the Art Meeting conferences (p < 0.05), but there was no temporal change at the other three conferences. There is a speaker gender gap at critical care conferences, with male faculty outnumbering female faculty. This gap is more marked among physician speakers than those speakers representing nursing and allied health professionals. Several organizational strategies can

Emergency nurses' knowledge and experience with the triage process in Hunan Province, China.

PubMed

Hammad, Karen; Peng, Lingli; Anikeeva, Olga; Arbon, Paul; Du, Huiyun; Li, Yinglan

2017-11-01

Triage is implemented to facilitate timely and appropriate treatment of patients, and is typically conducted by senior nurses. Triage accuracy and consistency across emergency departments remain a problem in mainland China. This study aimed to investigate the current status of triage practice and knowledge among emergency nurses in Changsha, Hunan Province, China. A sample of 300 emergency nurses was selected from 13 tertiary hospitals in Changsha and a total of 193 completed surveys were returned (response rate=64.3%). Surveys were circulated to head nurses, who then distributed them to nurses who met the selection criteria. Nurses were asked to complete the surveys and return them via dedicated survey return boxes that were placed in discreet locations to ensure anonymity. Just over half (50.8%) of participants reported receiving dedicated triage training, which was provided by their employer (38.6%), an education organisation (30.7%) or at a conference (26.1%). Approximately half (53.2%) reported using formal triage scales, which were predominantly 4-tier (43%) or 5-tier (34%). The findings highlight variability in triage practices and training of emergency nurses in Changsha. This has implications for the comparability of triage data and transferability of triage skills across hospitals. Copyright © 2017 Elsevier Ltd. All rights reserved.

Cultural differences with end-of-life care in the critical care unit.

PubMed

Doolen, Jessica; York, Nancy L

2007-01-01

Critical care nurses are providing healthcare for an increasingly multicultural population. This ever-increasing diversity in cultures and subcultures presents a challenge to nurses who want to provide culturally competent care. It is common for patients and families to face difficult decisions about end-of-life care in critical care units, and minority cultures do not always believe in the Westerner's core values of patient autonomy and self-determination. Knowledge of these cultural differences is fundamental if critical care nurses wish to provide appropriate and culturally competent information regarding end-of-life decisions.

Cost Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services

PubMed Central

Newgard, Craig D; Yang, Zhuo; Nishijima, Daniel; McConnell, K John; Trent, Stacy; Holmes, James F; Daya, Mohamud; Mann, N Clay; Hsia, Renee Y; Rea, Tom; Wang, N Ewen; Staudenmayer, Kristan; Delgado, M Kit

2016-01-01

Background The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥ 95% sensitivity and ≥ 65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared to triage strategies consistent with the national targets. Study Design This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services (EMS) agencies to 105 trauma and non-trauma hospitals in 6 regions of the Western U.S. from 2006 through 2008. Incremental differences in survival, quality adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (ICER; costs per QALY gained) were estimated for each triage strategy over a 1-year and lifetime horizon using a decision analytic Markov model. We considered an ICER threshold of less than $100,000 to be cost-effective. Results For these 6 regions, a high sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, while current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained compared to a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining EMS transport patterns by triage status improved cost-effectiveness. At the trauma system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, while a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year. Conclusions A high-sensitivity approach to field triage consistent with national trauma policy is not cost effective. The most cost effective approach to field triage appears closely tied to triage specificity and adherence to triage-based EMS transport practices. PMID:27178369

The value of registered nurses in ambulatory care settings: a survey.

PubMed

Mastal, Margaret; Levine, June

2012-01-01

Ambulatory care settings employ 25% of the three million registered nurses in the United States. The American Academy of Ambulatory Care Nursing (AAACN) is committed to improving the quality of health care in ambulatory settings, enhancing patient outcomes, and realizing greater health care efficiencies. A survey of ambulatory care registered nurses indicates they are well positioned to lead and facilitate health care reform activities with organizational colleagues. They are well schooled in critical thinking, triage, advocating for patients, educating patients and families, collaborating with medical staff and other professionals, and care coordination. The evolving medical home concept and other health care delivery models reinforces the critical need for registered nurses to provide chronic disease management, care coordination, health risk appraisal, care transitions, health promotion, and disease prevention services. Recommendations are offered for organizational leaders, registered nurses, and AAACN to utilize nursing knowledge and skills in the pursuit of leading change and advancing health.

A survey of psychology practice in critical-care settings.

PubMed

Stucky, Kirk; Jutte, Jennifer E; Warren, Ann Marie; Jackson, James C; Merbitz, Nancy

2016-05-01

The aims of this survey study were to (a) examine the frequency of health-service psychology involvement in intensive and critical-care settings; (b) characterize the distinguishing features of these providers; and (c) examine unique or distinguishing features of the hospital setting in which these providers are offering services. χ2 analyses were conducted for group comparisons of health-service psychologists: (a) providing services in critical care versus those with no or limited critical care activity and (b) involved in both critical care and rehabilitation versus those only involved in critical care. A total of 175 surveys met inclusion criteria and were included in the analyses. Psychologists who worked in critical-care settings at least monthly were more likely to be at a Level-1, χ2(1, N = 157) = 9.654, p = .002, or pediatric, χ2(1, N = 158) = 7.081, p = .008, trauma center. Psychologists involved with critical care were more likely to provide services on general medical-surgical units, χ2(1, N = 167) = 45.679, p = .000. A higher proportion of rehabilitation-oriented providers provided intensive care, critical care, and neurointensive care services relative to nonrehabilitation providers. The findings indicate that health-service psychologists are involved in critical-care settings and in various roles. A more broad-based survey of hospitals across the United States would be required to identify how frequently health-service psychologists are consulted and what specific services are most effective, valued, or desired in critical-care settings. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Cardiovascular genomics: implications for acute and critical care nurses.

PubMed

Quinn Griffin, Mary T; Klein, Deborah; Winkelman, Chris

2013-01-01

As genomic health care becomes commonplace, nurses will be asked to provide genomic care in all health care settings including acute care and critical care. Three common cardiac conditions are reviewed, Marfan syndrome, bicuspid aortic valve, and hypertrophic cardiomyopathy, to provide acute care and critical care nurses with an overview of these pathologies through the lens of genomics and relevant case studies. This information will help critical care nursing leaders become familiar with genetics related to common cardiac conditions and prepare acute care and critical care nurses for a new phase in patient diagnostics, with greater emphasis on early diagnosis and recognition of conditions before sudden cardiac death.

Integrating disease management and wound care critical pathways in home care.

PubMed

Barr, J E

1999-10-01

This article discusses the need for an integration of the concepts of disease management and critical pathways as a foundation of a healthcare delivery system. The steps in the process for development, implementation, and evaluation of a wound care critical pathway are reviewed and variance classifications are defined. Co-pathways and algorithms are presented as methodologies for dealing with variances. A template of a wound care critical pathway that has been developed for use in the home care setting is included.

Empowerment in critical care - a concept analysis.

PubMed

Wåhlin, Ingrid

2017-03-01

The purpose of this paper was to analyse how the concept of empowerment is defined in the scientific literature in relation to critical care. As empowerment is a mutual process affecting all individuals involved, the perspectives of not only patients and next of kin but also staff were sought. A literature review and a concept analysis based on Walker and Avant's analysis procedure were used to identify the basic elements of empowerment in critical care. Twenty-two articles with a focus on critical care were discovered and included in the investigation. A mutual and supportive relationship, knowledge, skills, power within oneself and self-determination were found to be the common attributes of empowerment in critical care. The results could be adapted and used for all parties involved in critical care - whether patients, next of kin or staff - as these defining attributes are assumed to be universal to all three groups, even if the more specific content of each attribute varies between groups and individuals. Even if empowerment is only sparsely used in relation to critical care, it appears to be a very useful concept in this context. The benefits of improving empowerment are extensive: decreased levels of distress and strain, increased sense of coherence and control over situation, and personal and/or professional development and growth, together with increased comfort and inner satisfaction. © 2016 The Authors. Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College.

'Reverse triage' adds to surge capacity.

PubMed

2009-06-01

Providing adequate surge capacity during a disaster is one of the greatest challenges of emergency response. Now, researchers have proposed a new process called "reverse triage" to help create surge capacity that otherwise would not exist. Patients who have only a slight chance of experiencing an adverse event within four days of leaving the hospital may be discharged to free bed space. ED staff can provide a daily initial reverse triage score for patients being admitted, even if a disaster is not imminent. While general guidelines can have great value, take the interests of the patient and their family into account when making discharge decisions.

[Triage duration times: a prospective descriptive study in a level 1° emergency department].

PubMed

Bambi, Stefano; Ruggeri, Marco

2017-01-01

Triage is the most important tool for clinical risk management in emergency departments (ED). The timing measurement of its phases is fundamental to establish indicators and standards for the optimization of the system. To evaluate the duration time of the phases of triage; to evaluate some variables exerting influence on nurses' performance. prospective descriptive study performed in the ED of Careggi Teaching Hospital in Florence. 14 nurses enrolled by stratified randomization proportion (1/3 of the whole staff ), according to classes of length of service. Triage processes on 150 adult patients were recorded. The mean age of nurses was 39.7 years (SD ± 5.2, range 29-50); the average length of service was 10.3 years (SD ± 4.4, range 3-18); average of triage experience was 8.6 years (SD ± 4.3, range 2-13). The median time from patient's arrival to the end of the triage process was 04': 04" (range 00':47"- 18':08"); the median duration of triage was 01':11" (range 00':07" -11':27"). The length of service and triage experience did not influence the medians of recorded intervals of time, but there were some limitations due to the low sample size. Interruptions were observed 111 (74%) of triage cases. the recorded triage time intervals were similar to those reported in international literature. Actions are needed to reduce the impact of interruptions on triage process' times.

Mobile computing in critical care.

PubMed

Lapinsky, Stephen E

2007-03-01

Handheld computing devices are increasingly used by health care workers, and offer a mobile platform for point-of-care information access. Improved technology, with larger memory capacity, higher screen resolution, faster processors, and wireless connectivity has broadened the potential roles for these devices in critical care. In addition to the personal information management functions, handheld computers have been used to access reference information, management guidelines and pharmacopoeias as well as to track the educational experience of trainees. They can act as an interface with a clinical information system, providing rapid access to patient information. Despite their popularity, these devices have limitations related to their small size, and acceptance by physicians has not been uniform. In the critical care environment, the risk of transmitting microorganisms by such a portable device should always be considered.

Critical Care Nurses' Experiences With Spiritual Care: The SPIRIT Study.

PubMed

Bone, Nigel; Swinton, Marilyn; Hoad, Neala; Toledo, Feli; Cook, Deborah

2018-05-01

Little is known about the effect of chaplains on critical care nurses who are caring for critically ill patients and their families. To understand nurses' experiences when they make a referral to the Spiritual Care Department for a patient or the family of a patient who is dying or deceased. Specific aims were to explore spiritual care's effect on nurses and how nurses understand the role of spiritual care in practice. A qualitative descriptive study using in-person, semistructured interviews in a 21-bed medical-surgical intensive care unit in a teaching hospital. Purposeful sampling identified nurses who had at least 5 years of experience and had cared for at least 5 patients who died on their shift and at least 5 patients for whom they initiated a spiritual care referral. Interviews were digitally recorded and anonymized; conventional content analysis was used to analyze transcripts. Three investigators independently coded 5 transcripts and developed the preliminary coding list. As analysis proceeded, investigators organized codes into categories and themes. A total of 25 nurses were interviewed. The central theme that emerged was presence, described through 3 main categories: the value of having chaplains present in the intensive care unit and their role, nurses' experiences working with chaplains, and nurses' experiences providing spiritual care. Nurses considered spiritual care essential to holistic care and valued the support chaplains provide to patients, families, and staff in today's spiritually diverse society. © 2018 American Association of Critical-Care Nurses.

What Is a Pediatric Critical Care Specialist?

MedlinePlus

... mode Turn off more accessible mode Skip Ribbon Commands Skip to main content Turn off Animations Turn ... offered in the PICU. What Kind of Training Do Pediatric Critical Care Specialists Have? Pediatric critical care ...

Using an original triage and on call management tool aids identification and assessment of the acutely unwell surgical patient.

PubMed

Hodge, Stacie; Helliar, Sebastian; Macdonald, Hamish Ian; Mackey, Paul

2018-01-01

Until now, there have been no published surgical triage tools. We have developed the first such tool with a tiered escalation policy, aiming to improve identification and management of critically unwell patients. The existing sheet which is used to track new referrals and admissions to the surgical assessment unit was reviewed. The sheet was updated and a traffic light triage tool generated using National Early Warning Scores (NEWS), sepsis criteria and user discretion. A tiered escalation policy to guide urgency of assessment was introduced and education sessions for all staff undertaken, to ensure understanding and compliance. Through multiple 'plan-do-study-act' cycles, the new system and its efficiency have been analysed. Prior to intervention, documentation of NEWS did not occur and only 13% of admission observations were communicated to the surgical team. Following multiple cycles and interventions, 93% of patients were fully triaged, and 80% of 'red' and 'amber' patients' observations were communicated to the surgical team. The average time for a registrar to review a 'red' patient was 37 min and 79% of 'green' patients were reviewed within an hour of their presentation. Rapid identification of the unwell patient is crucial. Here we publish the first triage tool that enables early assessment of septic and otherwise potentially unwell surgical patients.

Creation and Delphi-method refinement of pediatric disaster triage simulations.

PubMed

Cicero, Mark X; Brown, Linda; Overly, Frank; Yarzebski, Jorge; Meckler, Garth; Fuchs, Susan; Tomassoni, Anthony; Aghababian, Richard; Chung, Sarita; Garrett, Andrew; Fagbuyi, Daniel; Adelgais, Kathleen; Goldman, Ran; Parker, James; Auerbach, Marc; Riera, Antonio; Cone, David; Baum, Carl R

2014-01-01

There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy. We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios. After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10

Improvements in the Hemodynamic Stability of Combat Casualties During En Route Care

DTIC Science & Technology

2013-01-01

IMPROVEMENTS IN THE HEMODYNAMIC STABILITY OF COMBAT CASUALTIES DURING EN ROUTE CARE Amy N. Apodaca,* Jonathan J. Morrison,†‡ Mary Ann Spott,* John J...greater clinical capability is associated with an improved hemodynamic status in critical casualties. The ideal prehospital triage should endeavor to...before out of theater medical evacuation (MEDEVAC). As SI is measure of hemodynamic stability, patients with isolated severe brain injury or

Advanced technology development for remote triage applications in bleeding combat casualties.

PubMed

Ryan, Kathy L; Rickards, Caroline A; Hinojosa-Laborde, Carmen; Gerhardt, Robert T; Cain, Jeffrey; Convertino, Victor A

2011-01-01

Combat developers within the Army have envisioned development of a "wear-and-forget" physiological status monitor (PSM) that will enhance far forward capabilities for assessment of Warrior readiness for battle, as well as for remote triage, diagnosis and decision-making once Soldiers are injured. This paper will review recent work testing remote triage system prototypes in both the laboratory and during field exercises. Current PSM prototypes measure the electrocardiogram and respiration, but we have shown that information derived from these measurements alone will not be suited for specific, accurate triage of combat injuries. Because of this, we have suggested that development of a capability to provide a metric of circulating blood volume status is required for remote triage. Recently, volume status has been successfully modeled using low-level physiological signals obtained from wearable devices as input to machine-learning algorithms; these algorithms are already able to discriminate between a state of physical activity (common in combat) and that of central hypovolemia, and thus show promise for use in wearable remote triage devices.

Recent advances in multidisciplinary critical care.

PubMed

Blot, Stijn; Afonso, Elsa; Labeau, Sonia

2015-01-01

The intensive care unit is a work environment where superior dedication is crucial for optimizing patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the numerous research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovation in the field. This article broadly summarizes new developments in multidisciplinary intensive care. It provides elementary information about advanced insights in the field via brief descriptions of selected articles grouped by specific topics. Issues considered include care for heart patients, mechanical ventilation, delirium, nutrition, pressure ulcers, early mobility, infection prevention, transplantation and organ donation, care for caregivers, and family matters. ©2015 American Association of Critical-Care Nurses.

Rationing critical care medicine: recent studies and current trends.

PubMed

Ward, Nicholas S

2005-12-01

This paper reviews the literature on the rationing of critical care resources. Although much has been written about the concept of rationing, there have been few scientific studies as to its prevalence. A recent meta-analysis reviewed all previously published studies on rationing access to intensive care units but little is known about practices within the intensive care unit. Much literature in the past few years has focused on the growing use of critical care resources and projections for the future. Several authors suggest there may be a crisis in financial or personnel resources if some rationing does not take place. Other papers have argued that the methods of rationing critical care previously proposed, such as limiting the care of dying patients or using cost-effectiveness analysis to determine care, may not be effective or viewed as ethical by some. Finally, several recent papers review how critical care is practiced and allocated in India and Asian countries that already practice open rationing in their health care systems. There is currently no published evidence that overt rationing is taking place in critical care medicine. There is growing evidence that in the future, the need for critical care may outstrip financial resources unless some form of rationing takes place. It is also clear from the literature that choosing how to ration critical care will be a difficult task.

The Relationship Between Professional Quality of Life and Caring Ability in Critical Care Nurses.

PubMed

Mohammadi, Marzieh; Peyrovi, Hamid; Mahmoodi, Mahmood

Critical care nursing has some features that may affect the ability of critical care nurses to provide care. Professionals as critical care nurses who deal with peoples' health and life often experience some levels of stress that affects their quality of life. This study examined the relationship between professional quality of life and caring ability of critical care nurses. In this descriptive correlational study, 253 critical care nurses working in the medical and surgical intensive care units of Tehran University of Medical Sciences were recruited by convenience sampling method. The data collection tools included demographic data form, Caring Ability Inventory, and questionnaire for professional quality of life version 5. There was a statistically significant positive relationship between the professional quality of life and the caring ability (P < .0001). A significant inverse relationship was found between burn-out subscale of compassion fatigue as one aspect of professional life quality with all 3 aspects of caring ability (knowledge, courage, and patience). Secondary traumatic stress, as another subscale of compassion fatigue (as one aspect of professional quality of life), had no statistically significant correlation with caring ability aspects of knowledge and patience. However, there was a significant inverse correlation between the secondary traumatic stress and courage aspect of caring ability (P < .0001). There was a statistically significant positive relationship between compassion satisfaction aspect of professional life quality with knowledge and patience aspects of caring ability, but there was not any relationship between the compassion satisfaction aspect of professional life quality and the courage aspect of caring ability. Improvement of critical care nurses' professional quality of life may increase their caring ability, thereby leading to better and more effective nursing care. Increased awareness by critical care nurse managers of the

Development of a Mass Casualty Triage Performance Assessment Tool

DTIC Science & Technology

2015-02-01

mass casualty triage and interviews with members of the unit, the triage assessment development involved three steps: (1) identification of key...Unlimited c. THIS PAGE Unlimited Unlimited Unclassified 35 19b. TELEPHONE NUMBER (include area code ) i Technical...in this report was initiated by ARI-FHRU to develop a prototype measure of performance for one of the three collective tasks identified in the

Critical care use during the course of serious illness.

PubMed

Iwashyna, Theodore J

2004-11-01

Despite its expense and importance, it is unknown how common critical care use is. We describe longitudinal patterns of critical care use among a nationally representative cohort of elderly patients monitored from the onset of common serious illnesses. A retrospective population-based cohort study of elderly patients in fee-for-service Medicare is used, with 1,108,060 Medicare beneficiaries at least 68 years of age and newly diagnosed with serious illnesses: 1 of 9 malignancies, stroke, congestive heart failure, hip fracture, or myocardial infarction. Medicare inpatient hospital claims from diagnosis until death (65.1%) or fixed-right censoring (more than 4 years) were reviewed. Distinct hospitalizations involving critical care use (intensive care unit or critical care unit) were counted and associated reimbursements were assessed; repeated use was defined as five or more such hospitalizations. Of the cohort, 54.9% used critical care at some time after diagnosis. Older patients were much less likely to ever use critical care (odds ratio, 0.31; comparing patients more than 90 years old with those 68-70 years old), even after adjustment. A total of 31,348 patients (2.8%) were repeated users of critical care; they accounted for 3.6 billion dollars in hospital charges and 1.4 billion dollars in Medicare reimbursement. We conclude that critical care use is common in serious chronic illness and is not associated solely with preterminal hospitalizations. Use is uneven, and a minority of patients who repeatedly use critical care account for disproportionate costs.

End-of-life care practices of critical care nurses: A national cross-sectional survey.

PubMed

Ranse, Kristen; Yates, Patsy; Coyer, Fiona

2016-05-01

The critical care context presents important opportunities for nurses to deliver skilled, comprehensive care to patients at the end of life and their families. Limited research has identified the actual end-of-life care practices of critical care nurses. To identify the end-of-life care practices of critical care nurses. A national cross-sectional online survey. The survey was distributed to members of an Australian critical care nursing association and 392 critical care nurses (response rate 25%) completed the survey. Exploratory factor analysis using principal axis factoring with oblique rotation was undertaken on survey responses to identify the domains of end-of-life care practice. Descriptive statistics were calculated for individual survey items. Exploratory factor analysis identified six domains of end-of-life care practice: information sharing, environmental modification, emotional support, patient and family centred decision-making, symptom management and spiritual support. Descriptive statistics identified a high level of engagement in information sharing and environmental modification practices and less frequent engagement in items from the emotional support and symptom management practice areas. The findings of this study identified domains of end-of-life care practice, and critical care nurse engagement in these practices. The findings highlight future training and practice development opportunities, including the need for experiential learning targeting the emotional support practice domain. Further research is needed to enhance knowledge of symptom management practices during the provision of end-of-life care to inform and improve practice in this area. Copyright © 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Multiple performance measures are needed to evaluate triage systems in the emergency department.

PubMed

Zachariasse, Joany M; Nieboer, Daan; Oostenbrink, Rianne; Moll, Henriëtte A; Steyerberg, Ewout W

2018-02-01

Emergency department triage systems can be considered prediction rules with an ordinal outcome, where different directions of misclassification have different clinical consequences. We evaluated strategies to compare the performance of triage systems and aimed to propose a set of performance measures that should be used in future studies. We identified performance measures based on literature review and expert knowledge. Their properties are illustrated in a case study evaluating two triage modifications in a cohort of 14,485 pediatric emergency department visits. Strengths and weaknesses of the performance measures were systematically appraised. Commonly reported performance measures are measures of statistical association (34/60 studies) and diagnostic accuracy (17/60 studies). The case study illustrates that none of the performance measures fulfills all criteria for triage evaluation. Decision curves are the performance measures with the most attractive features but require dichotomization. In addition, paired diagnostic accuracy measures can be recommended for dichotomized analysis, and the triage-weighted kappa and Nagelkerke's R 2 for ordinal analyses. Other performance measures provide limited additional information. When comparing modifications of triage systems, decision curves and diagnostic accuracy measures should be used in a dichotomized analysis, and the triage-weighted kappa and Nagelkerke's R 2 in an ordinal approach. Copyright © 2017 Elsevier Inc. All rights reserved.

Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review protocol.

PubMed

Nishi, Fernanda Ayache; de Motta Maia, Flávia Oliveira; de Lopes Monteiro da Cruz, Dina Almeida

2015-11-01

The objective of this review is to assess the sensitivity and specificity of the Manchester Triage System in the evaluation of adult patients with acute coronary syndrome in emergency departments. Acute coronary syndrome (ACS) is a group of clinical conditions that include myocardial infarction with or without elevation of the ST segment and unstable angina. The term acute myocardial infarction (AMI) can be applied when there is evidence of myocardium necrosis with a clinical sign compatible with myocardial ischaemia. Acute myocardial infarction can be identified using clinical methods including electrocardiography (ECG), elevation in myocardium necrosis biomarkers, and imaging. Acute myocardial infarction is one of the leading causes of death and disability worldwide, and may be the first manifestation of coronary artery disease.Estimating the prevalence of coronary diseases in the general population is quite a complex task. In 2010, the prevalence of coronary diseases was reported as 6.4% among the general population in the United States.One of the main manifestations of ACS is chest pain. However, even in the presence of this typical symptom, early diagnosis of ACS is a challenge for health care professionals who initially attend to these patients. Several authors have indicated the importance and difficulty of recognizing chest pain of cardiac origin, where immediate medical attention is required.Triage, or risk classification, is a clinical management tool used in emergency services to guide patient flow when the need for medical attention exceeds that available. The Manchester Triage Group was developed in 1994 in the United Kingdom. The aim was to establish a consensus among physicians and nurses in the emergency room by creating a triage pattern focused on the development of the following:Thus, the Manchester Triage System (MTS) was created. The MTS simplifies the clinical management of each patient, and consequently, the whole service, by utilizing a

Preparing your intensive care unit to respond in crisis: considerations for critical care clinicians.

PubMed

Daugherty, Elizabeth L; Rubinson, Lewis

2011-11-01

In recent years, healthcare disaster planning has grown from its early place as an occasional consideration within the manuals of emergency medical services and emergency department managers to a rapidly growing field, which considers continuity of function, surge capability, and process changes across the spectrum of healthcare delivery. A detailed examination of critical care disaster planning was undertaken in 2007 by the Task Force for Mass Critical Care of the American College of Chest Physicians Critical Care Collaborative Initiative. We summarize the Task Force recommendations and available updated information to answer a fundamental question for critical care disaster planners: What is a prepared intensive care unit and how do I ensure my unit's readiness? Database searches and review of relevant published literature. Preparedness is essential for successful response, but because intensive care units face many competing priorities, without defining "preparedness for what," the task can seem overwhelming. Intensive care unit disaster planners should, therefore, along with the entire hospital, participate in a hospital or regionwide planning process to 1) identify critical care response vulnerabilities; and 2) clarify the hazards for which their community is most at risk. The process should inform a comprehensive written preparedness plan targeting the most worrisome scenarios and including specific guidance on 1) optimal use of space, equipment, and staffing for delivery of critical care to significantly increased patient volumes; 2) allocation of resources for provision of essential critical care services under conditions of absolute scarcity; 3) intensive care unit evacuation; and 4) redundant internal communication systems and means for timely data collection. Critical care disaster planners have a complex, challenging task. Experienced planners will agree that no disaster response is perfect, but careful planning will enable the prepared intensive care

Does good critical thinking equal effective decision-making among critical care nurses? A cross-sectional survey.

PubMed

Ludin, Salizar Mohamed

2018-02-01

A critical thinker may not necessarily be a good decision-maker, but critical care nurses are expected to utilise outstanding critical thinking skills in making complex clinical judgements. Studies have shown that critical care nurses' decisions focus mainly on doing rather than reflecting. To date, the link between critical care nurses' critical thinking and decision-making has not been examined closely in Malaysia. To understand whether critical care nurses' critical thinking disposition affects their clinical decision-making skills. This was a cross-sectional study in which Malay and English translations of the Short Form-Critical Thinking Disposition Inventory-Chinese Version (SF-CTDI-CV) and the Clinical Decision-making Nursing Scale (CDMNS) were used to collect data from 113 nurses working in seven critical care units of a tertiary hospital on the east coast of Malaysia. Participants were recruited through purposive sampling in October 2015. Critical care nurses perceived both their critical thinking disposition and decision-making skills to be high, with a total score of 71.5 and a mean of 48.55 for the SF-CTDI-CV, and a total score of 161 and a mean of 119.77 for the CDMNS. One-way ANOVA test results showed that while age, gender, ethnicity, education level and working experience factors significantly impacted critical thinking (p<0.05), only age and working experience significantly impacted clinical decision-making (p<0.05). Pearson's correlation analysis showed a strong and positive relationship between critical care nurses' critical thinking and clinical decision-making (r=0.637, p=0.001). While this small-scale study has shown a relationship exists between critical care nurses' critical thinking disposition and clinical decision-making in one hospital, further investigation using the same measurement tools is needed into this relationship in diverse clinical contexts and with greater numbers of participants. Critical care nurses' perceived high level of

Decision analytic model exploring the cost and cost-offset implications of street triage

PubMed Central

Heslin, Margaret; Callaghan, Lynne; Packwood, Martin; Badu, Vincent; Byford, Sarah

2016-01-01

Objectives To determine if street triage is effective at reducing the total number of people with mental health needs detained under section 136, and is associated with cost savings compared to usual police response. Design Routine data from a 6-month period in the year before and after the implementation of a street triage scheme were used to explore detentions under section 136, and to populate a decision analytic model to explore the impact of street triage on the cost to the NHS and the criminal justice sector of supporting people with a mental health need. Setting A predefined area of Sussex, South East England, UK. Participants All people who were detained under section 136 within the predefined area or had contact with the street triage team. Interventions The street triage model used here was based on a psychiatric nurse attending incidents with a police constable. Primary and secondary outcome measures The primary outcome was change in the total number of detentions under section 136 between the before and after periods assessed. Secondary analysis focused on whether the additional costs of street triage were offset by cost savings as a result of changes in detentions under section 136. Results Detentions under section 136 in the street triage period were significantly lower than in the usual response period (118 vs 194 incidents, respectively; χ2 (1df) 18.542, p<0.001). Total NHS and criminal justice costs were estimated to be £1043 in the street triage period compared to £1077 in the usual response period. Conclusions Investment in street triage was offset by savings as a result of reduced detentions under section 136, particularly detentions in custody. Data available did not include assessment of patient outcomes, so a full economic evaluation was not possible. PMID:26868943

Medical triage for WMD incidents incidents: an adaptation of daily triage.

PubMed

Donohue, Dave

2008-05-01

It's 2000 HRS on a Friday evening. You're assigned to an ALS engine company, and you're just settling down after a busy day when you're dispatched along with a BLS ambulance to a report of a sick person outside a local club where they're holding a concert. During your response, dispatch advises that they're receiving multiple calls on the incident and are dispatching a second BLS ambulance to the call. * As you turn the corner and approach the scene, you notice a haze in the air coming from an industrial site on the same side of the street and see approximately 200 people exiting the club in haste. Several dozen patrons line the street between the club and the subway station. They're coughing and crying, and several are vomiting. * The driver stops the engine in front of the subway entrance, which is located approximately 500 feet from the club and uphill and upwind from the haze. The scene is overwhelming, even to the captain, who turns to you-as the paramedic on the crew-and asks what you want done first. Your first thought is, Triage. But you know that triaging these patients is more complicated than your everyday two-car collision.

The roles of critical care advanced practice nurse.

PubMed

Sung, Young Hee; Yi, Young Hee; Kwon, In Gak; Cho, Yong Ae

2006-12-01

To determine and compare the perception among nurses and doctors of the roles and tasks of critical care advanced practice nurses (APNs) in order to establish standardized and formally agreed role criteria for such critical care APNs. This study measured and analyzed the necessity of each of the roles and tasks of critical care APNs, as perceived by nurses and doctors, through a survey of 121 participants: 71 nurses in 7 intensive care units (ICUs) at a general hospital in Seoul, and 50 doctors who used ICUs. Data collection utilized a questionnaire of 128 questions in the following fields: direct practice (79), leadership and change agent (17), consultation and collaboration (15), education and counseling (11), and research (6). Both the nurses' and the doctors' groups confirmed the necessity of critical care APNs, with doctors who frequently used ICUs indicating a particularly strong need. As for the priority of each role of critical care APNs, the nurses considered direct practice to be the most critical, followed by education and counseling, research, consultation and collaboration, and leadership and change agent. The doctors also considered direct practice to be the most critical, followed by education and counseling, consultation and collaboration, research, and leadership and change agent. There was a statistically significant difference between how the two groups regarded all the roles, except for the consultation and collaboration roles. As for the necessity of each role of critical care APNs, the nurses considered research to be the most necessary, followed by education and counseling, consultation and collaboration, leadership and change agent, and direct practice. The doctors, on the other hand, considered education and counseling to be the most necessary, followed by research, consultation and collaboration, leadership and change agent, and direct practice. The responses of the two groups to all the roles, except for education and counseling roles

Conversations in end-of-life care: communication tools for critical care practitioners.

PubMed

Shannon, Sarah E; Long-Sutehall, Tracy; Coombs, Maureen

2011-01-01

Communication skills are the key for quality end-of-life care including in the critical care setting. While learning general, transferable communication skills, such as therapeutic listening, has been common in nursing education, learning specific communication tools, such as breaking bad news, has been the norm for medical education. Critical care nurses may also benefit from learning communication tools that are more specific to end-of-life care. We conducted a 90-min interactive workshop at a national conference for a group of 78 experienced critical care nurses where we presented three communication tools using short didactics. We utilized theatre style and paired role play simulation. The Ask-Tell-Ask, Tell Me More and Situation-Background-Assessment-Recommendation (SBAR) tools were demonstrated or practiced using a case of a family member who feels that treatment is being withdrawn prematurely for the patient. The audience actively participated in debriefing the role play to maximize learning. The final communication tool, SBAR, was practiced using an approach of pairing with another member of the audience. At the end of the session, a brief evaluation was completed by 59 nurses (80%) of the audience. These communication tools offer nurses new strategies for approaching potentially difficult and emotionally charged conversations. A case example illustrated strategies for applying these skills to clinical situations. The three tools assist critical care nurses to move beyond compassionate listening to knowing what to say. Ask-Tell-Ask reminds nurses to carefully assess concerns before imparting information. Tell Me More provides a tool for encouraging dialogue in challenging situations. Finally, SBAR can assist nurses to distill complex and often long conversations into concise and informative reports for colleagues. © 2011 The Authors. Nursing in Critical Care © 2011 British Association of Critical Care Nurses.

The challenges of caring in a technological environment: critical care nurses' experiences.

PubMed

McGrath, Mary

2008-04-01

This paper presents and discusses the findings from a phenomenological study which illuminated the lived experiences of experienced critical care nurses caring within a technological environment. While nursing practice is interwoven with technology, much of the literature in this area is speculative. Moreover, there is a debate as to whether and how 'high tech' and 'high touch' are reconcilable; this orientation is referred to as the optimism vs. pessimism debate. On a personal level, the motivation for this study came from the author's 13 years' experience in the critical care area. Following ethical approval, 10 experienced nurses from two cardiothoracic critical care units in Ireland participated in the study. A Heideggerian phenomenological methodology was used. Data collection consisted of unstructured interviews. A method of data analysis described by Walters was used. The findings provide research-based evidence to illuminate further the optimistic/pessimistic debate on technology in nursing. While the study demonstrates that the debate is far from resolved, it reveals a new finding: life-saving technology that supports the lives of critically ill patients can bring experienced nurses very close to their patients/families. The three main themes that emerged: 'alien environment', 'pulling together' and 'sharing the journey' were linked by a common thread of caring. Experienced critical care nurses are able to transcend the obtrusive nature of technology to deliver expert caring to their patients. However, the journey to proficiency in technology is very demanding and novice nurses have difficulty in caring with technology. Relevance to clinical practice. It is recommended that more emphasis be placed on supporting, assisting and educating inexperienced nurses in the critical care area and that the use of technology in nursing be given serious consideration.

Critical care and the World Wide Web.

PubMed

Varon, J; Marik, P E

1999-07-01

The Internet was created in 1969, when the Advanced Research Projects Agency of the United States Department of Defense fired up an experimental network consisting of only four computers. Over the past five years there has been an exponential explosion in the number of computers added to this network. It is estimated that Internet traffic doubles every 100 days with more than 100 million people worldwide now on-line. The Internet is so vast that practically every aspect of human interest is represented is some form or fashion. From recreation to applied science and technology, and from Critical Care Medicine case scenarios to digitized radiology images and pathology specimens, the Internet has become increasingly useful for critical care practitioners. To date, no resource is better equipped to assist critical care providers in many of their daily tasks. This article presents some of the historical developments of the Internet as well as common applications that are useful for critical care practitioners.

Critical Thinking in Critical Care: Five Strategies to Improve Teaching and Learning in the Intensive Care Unit

PubMed Central

Chatterjee, Souvik; Schwartzstein, Richard M.

2017-01-01

Critical thinking, the capacity to be deliberate about thinking, is increasingly the focus of undergraduate medical education, but is not commonly addressed in graduate medical education. Without critical thinking, physicians, and particularly residents, are prone to cognitive errors, which can lead to diagnostic errors, especially in a high-stakes environment such as the intensive care unit. Although challenging, critical thinking skills can be taught. At this time, there is a paucity of data to support an educational gold standard for teaching critical thinking, but we believe that five strategies, routed in cognitive theory and our personal teaching experiences, provide an effective framework to teach critical thinking in the intensive care unit. The five strategies are: make the thinking process explicit by helping learners understand that the brain uses two cognitive processes: type 1, an intuitive pattern-recognizing process, and type 2, an analytic process; discuss cognitive biases, such as premature closure, and teach residents to minimize biases by expressing uncertainty and keeping differentials broad; model and teach inductive reasoning by utilizing concept and mechanism maps and explicitly teach how this reasoning differs from the more commonly used hypothetico-deductive reasoning; use questions to stimulate critical thinking: “how” or “why” questions can be used to coach trainees and to uncover their thought processes; and assess and provide feedback on learner’s critical thinking. We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit. PMID:28157389

Critical Thinking in Critical Care: Five Strategies to Improve Teaching and Learning in the Intensive Care Unit.

PubMed

Hayes, Margaret M; Chatterjee, Souvik; Schwartzstein, Richard M

2017-04-01

Critical thinking, the capacity to be deliberate about thinking, is increasingly the focus of undergraduate medical education, but is not commonly addressed in graduate medical education. Without critical thinking, physicians, and particularly residents, are prone to cognitive errors, which can lead to diagnostic errors, especially in a high-stakes environment such as the intensive care unit. Although challenging, critical thinking skills can be taught. At this time, there is a paucity of data to support an educational gold standard for teaching critical thinking, but we believe that five strategies, routed in cognitive theory and our personal teaching experiences, provide an effective framework to teach critical thinking in the intensive care unit. The five strategies are: make the thinking process explicit by helping learners understand that the brain uses two cognitive processes: type 1, an intuitive pattern-recognizing process, and type 2, an analytic process; discuss cognitive biases, such as premature closure, and teach residents to minimize biases by expressing uncertainty and keeping differentials broad; model and teach inductive reasoning by utilizing concept and mechanism maps and explicitly teach how this reasoning differs from the more commonly used hypothetico-deductive reasoning; use questions to stimulate critical thinking: "how" or "why" questions can be used to coach trainees and to uncover their thought processes; and assess and provide feedback on learner's critical thinking. We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit.

Calibrating Urgency: Triage Decision-Making in a Pediatric Emergency Department

ERIC Educational Resources Information Center

Patel, Vimla L.; Gutnik, Lily A.; Karlin, Daniel R.; Pusic, Martin

2008-01-01

Triage, the first step in the assessment of emergency department patients, occurs in a highly dynamic environment that functions under constraints of time, physical space, and patient needs that may exceed available resources. Through triage, patients are placed into one of a limited number of categories using a subset of diagnostic information.…

[How to implement a unique triage system in the emergency departments of Latium, Italy].

PubMed

De Luca, A; Francia, C; Gabriele, S; Guasticchi, G

2008-01-01

Triage is an efficient system that emergency departments (EDs) use to sort out presenting patients on the basis of the speed with which they need treatment. Because triage is not used consistently in the EDs of Latium, a region in central Italy, the regional Public Health Agency (PHA) planned and implemented a regional model of triage in all EDs. This manuscript describe the regional implementation strategy. The PHA activated the "Regional Triage Program--RTP" including: development and testing of a "triage section" in the computerized EDs clinical chart; production of an operational handbook for the RTP for triage health professionals (HPs); implementation of an continuum educational program on the "RTP" in all EDs of Latium. The computerized triage section was tested and implemented in all EDs in the region. The handbook for triage HPs was produced. The educational program, has been ongoing since 2008 in all regional EDs. Selected HPs, identified as "facilitators", were trained on how to implement the RTP. They will organize, in their own EDs, small groups of nurses to conduct on-site training of the RTP. The RTP was received with enthusiasm by most HPs, however its introduction into current practice could be hampered by organizational/structural problems and conflicts between nurses and doctors. Next actions of the regional program will be to overcome the possible above mentioned troubles.

Caring behaviours directly and indirectly affect nursing students' critical thinking.

PubMed

Chen, Shu-Yueh; Chang, Hsing-Chi; Pai, Hsiang-Chu

2018-03-01

The purpose of this study was to determine the effect of caring behaviours on critical thinking and to examine whether self-reflection mediates the effect of caring on critical thinking. We also tested whether caring behaviours moderated the relationship between self-reflection and critical thinking. For this descriptive, correlational, cross-sectional study, we recruited 293 fifth-year nursing students from a junior college in southern Taiwan. Data were collected in 2014 on critical thinking, caring behaviours and self-reflection with insight using the Taiwan Critical Thinking Disposition Inventory, a Chinese version of the Caring Assessment Report Evaluation Q-sort, and a Chinese version of the Self-Reflection and Insight Scale, respectively. Relationships among variables were analysed by structural equation modelling, with the partial least squares method and Sobel test. The results showed that caring behaviours significantly positively affected critical thinking (β = 0.56, t = 12.37, p < 0.001) and self-reflection with insight (β = 0.54, t = 11.99, p < 0.001). Self-reflection and insight significantly positively affected critical thinking (β = 0.34, t = 6.48, p < 0.001). Further, self-reflection and insight mediated the relationship between caring behaviours and critical thinking. Caring behaviours did not, however, moderate the relationship between self-reflection (β = 0.001, t = 0.021, p > 0.05) and critical thinking. Caring behaviours directly affect self-reflection with insight and critical thinking. In addition, caring behaviours also indirectly affect critical thinking through self-reflection and insight. © 2017 Nordic College of Caring Science.

Portable ultrasound in disaster triage: a focused review.

PubMed

Wydo, S M; Seamon, M J; Melanson, S W; Thomas, P; Bahner, D P; Stawicki, S P

2016-04-01

Ultrasound technology has become ubiquitous in modern medicine. Its applications span the assessment of life-threatening trauma or hemodynamic conditions, to elective procedures such as image-guided peripheral nerve blocks. Sonographers have utilized ultrasound techniques in the pre-hospital setting, emergency departments, operating rooms, intensive care units, outpatient clinics, as well as during mass casualty and disaster management. Currently available ultrasound devices are more affordable, portable, and feature user-friendly interfaces, making them well suited for use in the demanding situation of a mass casualty incident (MCI) or disaster triage. We have reviewed the existing literature regarding the application of sonology in MCI and disaster scenarios, focusing on the most promising and practical ultrasound-based paradigms applicable in these settings.

A comparison of critical care research funding and the financial burden of critical illness in the United States.

PubMed

Coopersmith, Craig M; Wunsch, Hannah; Fink, Mitchell P; Linde-Zwirble, Walter T; Olsen, Keith M; Sommers, Marilyn S; Anand, Kanwaljeet J S; Tchorz, Kathryn M; Angus, Derek C; Deutschman, Clifford S

2012-04-01

To estimate federal dollars spent on critical care research, the cost of providing critical care, and to determine whether the percentage of federal research dollars spent on critical care research is commensurate with the financial burden of critical care. The National Institutes of Health Computer Retrieval of Information on Scientific Projects database was queried to identify funded grants whose title or abstract contained a key word potentially related to critical care. Each grant identified was analyzed by two reviewers (three if the analysis was discordant) to subjectively determine whether it was definitely, possibly, or definitely not related to critical care. Hospital and total costs of critical care were estimated from the Premier Database, state discharge data, and Medicare data. To estimate healthcare expenditures associated with caring for critically ill patients, total costs were calculated as the combination of hospitalization costs that included critical illness as well as additional costs in the year after hospital discharge. Of 19,257 grants funded by the National Institutes of Health, 332 (1.7%) were definitely related to critical care and a maximum of 1212 (6.3%) grants were possibly related to critical care. Between 17.4% and 39.0% of total hospital costs were spent on critical care, and a total of between $121 and $263 billion was estimated to be spent on patients who required intensive care. This represents 5.2% to 11.2%, respectively, of total U.S. healthcare spending. The proportion of research dollars spent on critical care is lower than the percentage of healthcare expenditures related to critical illness.

International expert statement on training standards for critical care ultrasonography.

PubMed

2011-07-01

Training in ultrasound techniques for intensive care medicine physicians should aim at achieving competencies in three main areas: (1) general critical care ultrasound (GCCUS), (2) "basic" critical care echocardiography (CCE), and (3) advanced CCE. A group of 29 experts representing the European Society of Intensive Care Medicine (ESICM) and 11 other critical care societies worldwide worked on a potential framework for organizing training adapted to each area of competence. This framework is mainly aimed at defining minimal requirements but is by no means rigid or restrictive: each training organization can be adapted according to resources available. There was 100% agreement among the participants that general critical care ultrasound and "basic" critical care echocardiography should be mandatory in the curriculum of intensive care unit (ICU) physicians. It is the role of each critical care society to support the implementation of training in GCCUS and basic CCE in its own country.

Critical care: how should we evaluate our progress?

PubMed

Civetta, J M

1992-12-01

Review of the history and accomplishments of the Society of Critical Care Medicine (SCCM) to determine appropriate directions for the future. Historical documents of the SCCM, Critical Care Medicine, bioethics and healthcare financing literature, Instant Library of Quotations. Identified (by the author) material containing specific statements concerning goals and objectives at the time of the founding of the SCCM and at intervals. Material supporting and criticizing predictive indices were identified and bioethical treatises concerning patient autonomy and quality-of-life decisions were chosen. Presidential addresses of the first three SCCM presidents, material relevant to preservation of life and alleviation of suffering from bioethical and healthcare financing perspectives. Relevant quotations. Initial goals and objectives were identified. Societal and economic factors changing critical care were analyzed for their effect on current and future SCCM directions and objectives. The founding members set important goals for critical care and patient care, research, education, and organization. From a perspective of what was foreseeable, these goals have been accomplished to an admirable degree. The SCCM has responded to these goals by providing educational programs and fostering research, especially in its annual meetings and through the publication of guidelines in Critical Care Medicine. The SCCM members would do well to read the first three presidential addresses to experience the eloquence and foresight firsthand, particularly with respect to the founders' spirit, considerations of training, scope of care, humanism, organization and relations within and outside of critical care, integration of care, and development of the scientific process at the bedside. There have been major changes in society since the SCCM was founded: the maturation of the concept of patient's autonomy; recognition of quality-of-life values; healthcare financing; and legal and ethical

Reiki therapy: a nursing intervention for critical care.

PubMed

Toms, Robin

2011-01-01

Complementary and alternative medicine (CAM) is not generally associated with the complexity and intensity of critical care. Most CAM therapies involve slow, calming techniques that seem to be in direct contrast with the fast-paced, highly technical nature of critical care. However, patients in critical care often find themselves coping with the pain and stress of their illness exacerbated by the stress of the critical care environment. Complementary and alternative medicine-related research reveals that complementary therapies, such as Reiki, relieve pain and anxiety and reduce symptoms of stress such as elevated blood pressure and pulse rates. Patients and health care professionals alike have become increasingly interested in complementary and alternative therapies that do not rely on expensive, invasive technology, and are holistic in focus. Reiki is cost-effective, noninvasive, and can easily be incorporated into patient care. The purpose of this article is to examine the science of Reiki therapy and to explore Reiki as a valuable nursing intervention.

Recent advances in medical device triage technologies for chemical, biological, radiological, and nuclear events.

PubMed

Lansdowne, Krystal; Scully, Christopher G; Galeotti, Loriano; Schwartz, Suzanne; Marcozzi, David; Strauss, David G

2015-06-01

In 2010, the US Food and Drug Administration (Silver Spring, Maryland USA) created the Medical Countermeasures Initiative with the mission of development and promoting medical countermeasures that would be needed to protect the nation from identified, high-priority chemical, biological, radiological, or nuclear (CBRN) threats and emerging infectious diseases. The aim of this review was to promote regulatory science research of medical devices and to analyze how the devices can be employed in different CBRN scenarios. Triage in CBRN scenarios presents unique challenges for first responders because the effects of CBRN agents and the clinical presentations of casualties at each triage stage can vary. The uniqueness of a CBRN event can render standard patient monitoring medical device and conventional triage algorithms ineffective. Despite the challenges, there have been recent advances in CBRN triage technology that include: novel technologies; mobile medical applications ("medical apps") for CBRN disasters; electronic triage tags, such as eTriage; diagnostic field devices, such as the Joint Biological Agent Identification System; and decision support systems, such as the Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST). Further research and medical device validation can help to advance prehospital triage technology for CBRN events.

Community triage of otology patients using a store-and-forward telemedicine device: A feasibility study.

PubMed

Gupta, Nishi; Chawla, Neeraj; Gupta, Digant; Dhawan, Nidhi; Janaki, Vidya R

2017-07-01

Chronic otitis media is a major contributor to acquired hearing loss in developing countries. Developing countries such as India, with huge populations and poor health infrastructures, have always felt the shortage of trained specialists who can provide quality care to meet the enormous demand for treatment of this disease. This pilot study assessed the feasibility of empowering trained health workers equipped with ENTraview, a store-and-forward telemedicine device that integrates a camera- enabled smart phone with an otoscope. This device allows the screening of otology patients within the community. Three months of extensive training was provided to five community health workers on primary ear and hearing care, including training on the use of the ENTraview device. Community otology screenings were conducted to triage otology patients and provide them with specialized ENT care at a tertiary hospital. In the initial 6 months of the project, 45 screening camps were organized, which screened 3,000 patients free of cost. Of these 3,000 screened patients, 54% (1,619) were referred for ENT consultation and 215 patients reported. Nearly 50% (103) of the 215 reporting patients required surgical intervention, and 29 patients underwent surgery. Reaching out to the community by remote screening of ear diseases by trained technicians with a telemedicine device seems to be an effective and cost-effective way to triage patients with otologic pathologies.

Legal considerations during pediatric emergency mass critical care events.

PubMed

Courtney, Brooke; Hodge, James G

2011-11-01

Recent public health emergencies, such as the 2009 Influenza A/H1N1 Pandemic and Hurricane Katrina, underscore the importance of developing healthcare response plans and protocols for disasters impacting large populations. Significant research and scholarship, including the 2009 Institute of Medicine report on crisis standards of care and the 2008 Task Force for Mass Critical Care recommendations, provide guidance for healthcare responses to catastrophic emergencies. Most of these efforts recognize but do not focus on the unique needs of pediatric populations. In 2008, the Centers for Disease Control and Prevention supported the formation of a task force to address pediatric emergency mass critical care response issues, including legal issues. Liability is a significant concern for healthcare practitioners and facilities during pediatric emergency mass critical care that necessitates a shift to crisis standards of care. This article describes the legal considerations inherent in planning for and responding to catastrophic health emergencies and makes recommendations for pediatric emergency mass critical care legal preparedness. The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010, to review the pediatric emergency mass critical care recommendations developed by a 17-member steering committee. During the meeting, experts determined that the recommendations would be strengthened by a manuscript addressing legal issues. Authors drafted the manuscript through consensus-based study of peer-reviewed research, literature reviews, and expert opinion. The manuscript was reviewed by Pediatric Emergency Mass Critical Care Steering Committee members and additional legal counsel and revised. While the legal issues associated with providing pediatric emergency mass critical care are not unique within the overall context of disaster healthcare

Understanding Decision Making in Critical Care

PubMed Central

Lighthall, Geoffrey K.; Vazquez-Guillamet, Cristina

2015-01-01

Background Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action. Rationale There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature. Content This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition. PMID:26387708

Intensive Care in Critical Access Hospitals

ERIC Educational Resources Information Center

Freeman, Victoria A.; Walsh, Joan; Rudolf, Matthew; Slifkin, Rebecca T.; Skinner, Asheley Cockrell

2007-01-01

Context: Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. Purpose: To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of…

Integrating advanced practice providers into medical critical care teams.

PubMed

McCarthy, Christine; O'Rourke, Nancy C; Madison, J Mark

2013-03-01

Because there is increasing demand for critical care providers in the United States, many medical ICUs for adults have begun to integrate nurse practitioners and physician assistants into their medical teams. Studies suggest that such advanced practice providers (APPs), when appropriately trained in acute care, can be highly effective in helping to deliver high-quality medical critical care and can be important elements of teams with multiple providers, including those with medical house staff. One aspect of building an integrated team is a practice model that features appropriate coding and billing of services by all providers. Therefore, it is important to understand an APP's scope of practice, when they are qualified for reimbursement, and how they may appropriately coordinate coding and billing with other team providers. In particular, understanding when and how to appropriately code for critical care services (Current Procedural Terminology [CPT] code 99291, critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 min; CPT code 99292, critical care, each additional 30 min) and procedures is vital for creating a sustainable program. Because APPs will likely play a growing role in medical critical care units in the future, more studies are needed to compare different practice models and to determine the best way to deploy this talent in specific ICU settings.

[Neurologically critical patient. Nurses' care].

PubMed

López Díaz, Cristina

2009-12-01

Handling a neurologically critical patient requires some necessary knowledge and aptitudes in order to avoid risks and complications which could worsen a patient's prognosis. To that end, in this article the author deals with two important points nursing personnel need to bear in mind: the distinct methods and catheters which can be used to monitor intracranial pressure, obtaining an important parameter for evaluation purposes and therapeutic follow-up on these patients, placing special emphasis on ventricular drainage and nursing care, and the operations nurses take when dealing with patients who present a risk of intracranial hypertension, setting up a protocol based on seven necessities in the Virginia Henderson model: breathing, elimination, temperature, hygiene and skin, feeding and hydration, mobility and safety. In each of these necessities, the author studies the problems these patients present, identifying them with a series of diagnoses according to NANDA (North American Nursing Diagnosis Association), and defining the care or nursing activities for each of them, which will prove essential to prevent cerebral ischemia after suffering a primary cerebral injury due to a "TCE"(Cranial Encephalic Trauma) hemorrhage, etc. Nurses' role in caring for neurologically critical patients proves to be of vital importance since these professionals must be capable of evaluating, preventing, controlling and identifying those risk situations which neurologically critical patients could present, avoiding possible complications, aiding their recuperation, and providing quality health care.

Systems modeling and simulation applications for critical care medicine

PubMed Central

2012-01-01

Critical care delivery is a complex, expensive, error prone, medical specialty and remains the focal point of major improvement efforts in healthcare delivery. Various modeling and simulation techniques offer unique opportunities to better understand the interactions between clinical physiology and care delivery. The novel insights gained from the systems perspective can then be used to develop and test new treatment strategies and make critical care delivery more efficient and effective. However, modeling and simulation applications in critical care remain underutilized. This article provides an overview of major computer-based simulation techniques as applied to critical care medicine. We provide three application examples of different simulation techniques, including a) pathophysiological model of acute lung injury, b) process modeling of critical care delivery, and c) an agent-based model to study interaction between pathophysiology and healthcare delivery. Finally, we identify certain challenges to, and opportunities for, future research in the area. PMID:22703718

Critical Care Nurses' Perceived Need for Guidance in Addressing Spirituality in Critically Ill Patients.

PubMed

Canfield, Christina; Taylor, Debi; Nagy, Kimberly; Strauser, Claire; VanKerkhove, Karen; Wills, Stephanie; Sawicki, Patricia; Sorrell, Jeanne

2016-05-01

The term spirituality is highly subjective. No common or universally accepted definition for the term exists. Without a clear definition, each nurse must reconcile his or her own beliefs within a framework mutually suitable for both nurse and patient. To examine individual critical care nurses' definition of spirituality, their comfort in providing spiritual care to patients, and their perceived need for education in providing this care. Individual interviews with 30 nurses who worked in a critical care unit at a large Midwestern teaching hospital. Nurses generally feel comfortable providing spiritual care to critically ill patients but need further education about multicultural considerations. Nurses identified opportunities to address spiritual needs throughout a patient's stay but noted that these needs are usually not addressed until the end of life. A working definition for spirituality in health care was developed: That part of person that gives meaning and purpose to the person's life. Belief in a higher power that may inspire hope, seek resolution, and transcend physical and conscious constraints. ©2016 American Association of Critical-Care Nurses.

Impact on mortality of prompt admission to critical care for deteriorating ward patients: an instrumental variable analysis using critical care bed strain.

PubMed

Harris, Steve; Singer, Mervyn; Sanderson, Colin; Grieve, Richard; Harrison, David; Rowan, Kathryn

2018-05-07

To estimate the effect of prompt admission to critical care on mortality for deteriorating ward patients. We performed a prospective cohort study of consecutive ward patients assessed for critical care. Prompt admissions (within 4 h of assessment) were compared to a 'watchful waiting' cohort. We used critical care strain (bed occupancy) as a natural randomisation event that would predict prompt transfer to critical care. Strain was classified as low, medium or high (2+, 1 or 0 empty beds). This instrumental variable (IV) analysis was repeated for the subgroup of referrals with a recommendation for critical care once assessed. Risk-adjusted 90-day survival models were also constructed. A total of 12,380 patients from 48 hospitals were available for analysis. There were 2411 (19%) prompt admissions (median delay 1 h, IQR 1-2) and 9969 (81%) controls; 1990 (20%) controls were admitted later (median delay 11 h, IQR 6-26). Prompt admissions were less frequent (p < 0.0001) as strain increased from low (22%), to medium (15%) to high (9%); the median delay to admission was 3, 4 and 5 h respectively. In the IV analysis, prompt admission reduced 90-day mortality by 7.4% (95% CI 1.7-18.5%, p = 0.117) overall, and 16.2% (95% CI 1.1-31.3%, p = 0.036) for those recommended for critical care. In the risk-adjust survival model, 90-day mortality was similar. After allowing for unobserved prognostic differences between the groups, we find that prompt admission to critical care leads to lower 90-day mortality for patients assessed and recommended to critical care.

International comparisons in critical care: a necessity and challenge.

PubMed

Wunsch, Hannah; Rowan, Kathryn M; Angus, Derek C

2007-12-01

Understanding variation in critical care resources, and delivery of care between countries will allow for improved disaster planning, evaluation of research findings, and assessment of the utility of critical care itself. This review describes the available data for international comparisons and the many factors that need to be addressed for an appropriate interpretation of results. Recent studies on subgroups of critical care patients include data from many different countries. These new studies provide important information on the overall incidence of these disease states, but most of these international studies do not take into account the critical care resources of the countries being discussed. For an appropriate interpretation of findings the relevant baseline critical care resources, prevalence of diseases, and cultural practices, need to be quantified. The existence of these other factors prevents the use of a severity of illness scoring system alone to account for differences between countries. Many recent critical care studies include data from multiple countries. With continued movement towards international studies, and improvements in data collection systems, comparisons between countries are becoming easier. These findings need to be interpreted in the context of all the relevant country information.

Serious gaming technology in major incident triage training: a pragmatic controlled trial.

PubMed

Knight, James F; Carley, Simon; Tregunna, Bryan; Jarvis, Steve; Smithies, Richard; de Freitas, Sara; Dunwell, Ian; Mackway-Jones, Kevin

2010-09-01

By exploiting video games technology, serious games strive to deliver affordable, accessible and usable interactive virtual worlds, supporting applications in training, education, marketing and design. The aim of the present study was to evaluate the effectiveness of such a serious game in the teaching of major incident triage by comparing it with traditional training methods. Pragmatic controlled trial. During Major Incident Medical Management and Support Courses, 91 learners were randomly distributed into one of two training groups: 44 participants practiced triage sieve protocol using a card-sort exercise, whilst the remaining 47 participants used a serious game. Following the training sessions, each participant undertook an evaluation exercise, whereby they were required to triage eight casualties in a simulated live exercise. Performance was assessed in terms of tagging accuracy (assigning the correct triage tag to the casualty), step accuracy (following correct procedure) and time taken to triage all casualties. Additionally, the usability of both the card-sort exercise and video game were measured using a questionnaire. Tagging accuracy by participants who underwent the serious game training was significantly higher than those who undertook the card-sort exercise [Chi2=13.126, p=0.02]. Step accuracy was also higher in the serious game group but only for the numbers of participants that followed correct procedure when triaging all eight casualties [Chi2=5.45, p=0.0196]. There was no significant difference in time to triage all casualties (card-sort=435+/-74 s vs video game=456+/-62 s, p=0.155). Serious game technologies offer the potential to enhance learning and improve subsequent performance when compared to traditional educational methods. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

Decision analytic model exploring the cost and cost-offset implications of street triage.

PubMed

Heslin, Margaret; Callaghan, Lynne; Packwood, Martin; Badu, Vincent; Byford, Sarah

2016-02-11

To determine if street triage is effective at reducing the total number of people with mental health needs detained under section 136, and is associated with cost savings compared to usual police response. Routine data from a 6-month period in the year before and after the implementation of a street triage scheme were used to explore detentions under section 136, and to populate a decision analytic model to explore the impact of street triage on the cost to the NHS and the criminal justice sector of supporting people with a mental health need. A predefined area of Sussex, South East England, UK. All people who were detained under section 136 within the predefined area or had contact with the street triage team. The street triage model used here was based on a psychiatric nurse attending incidents with a police constable. The primary outcome was change in the total number of detentions under section 136 between the before and after periods assessed. Secondary analysis focused on whether the additional costs of street triage were offset by cost savings as a result of changes in detentions under section 136. Detentions under section 136 in the street triage period were significantly lower than in the usual response period (118 vs 194 incidents, respectively; χ(2) (1df) 18.542, p<0.001). Total NHS and criminal justice costs were estimated to be £1043 in the street triage period compared to £1077 in the usual response period. Investment in street triage was offset by savings as a result of reduced detentions under section 136, particularly detentions in custody. Data available did not include assessment of patient outcomes, so a full economic evaluation was not possible. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Critical Care Implications of the Affordable Care Act

PubMed Central

Dogra, Anjali P.; Dorman, Todd

2015-01-01

Objectives To provide an overview of key elements of the Affordable Care Act (ACA). To evaluate ways in which the ACA will likely impact the practice of critical care medicine. To describe strategies that may help health systems and providers effectively adapt to changes brought about by the ACA. Data Sources and Synthesis Data sources for this concise review include search results from the PubMed and Embase databases, as well as sources relevant to public policy such as the text of the Patient Protection and Affordable Care Act and reports of the Congressional Budget Office (CBO). As all of the ACA's provisions will not be fully implemented until 2019, we also drew upon cost, population and utilization projections as well as the experience of existing state-based healthcare reforms. Conclusion The ACA represents the furthest reaching regulatory changes in the US healthcare system since the 1965 Medicare and Medicaid provisions of the Social Security Act. The ACA aims to expand health insurance coverage to millions of Americans and place an emphasis on quality and cost-effectiveness of care. From models which link pay and performance to those which center on episodic care, the ACA outlines sweeping changes to health systems, reimbursement structures, and the delivery of critical care. Staffing models that include daily rounding by an intensivist, palliative care integration, and expansion of the role of telemedicine in areas where intensivists are inaccessible are potential strategies that may improve quality and profitability of ICU care in the post-ACA era. PMID:26565630

Using 'reverse triage' to create hospital surge capacity: Royal Darwin Hospital's response to the Ashmore Reef disaster.

PubMed

Satterthwaite, Peter S; Atkinson, Carol J

2012-02-01

This report analyses the impact of reverse triage, as described by Kelen, to rapidly assess the need for continuing inpatient care and to expedite patient discharge to create surge capacity for disaster victims. The Royal Darwin Hospital was asked to take up to 30 casualties suffering from blast injuries from a boat carrying asylum seekers that had exploded 840 km west of Darwin. The hospital was full, with a backlog of cases awaiting admission in the emergency department. The Disaster Response Team convened at 10:00 to develop the surge capacity to admit up to 30 casualties. By 14:00, 56 beds (16% of capacity) were predicted to be available by 18:00. The special circumstances of a disaster enabled staff to suspend their usual activities and place a priority on triaging inpatients' suitability for discharge. The External Disaster Plan was activated and response protocols were followed. Normal elective activity was suspended. Multidisciplinary teams immediately assessed patients and completed the necessary clinical and administrative requirements to discharge them quickly. As per the Plan there was increased use of community care options: respite nursing home beds and community nursing services. Through a combination of cancellation of all planned admissions, discharging 19 patients at least 1 day earlier than planned and discharging all patients earlier in the day surge capacity was made available in Royal Darwin Hospital to accommodate blast victims. Notably, reverse triage resulted in no increase in clinical risk with only one patient who was discharged early returning for further treatment.

Providing care for critically ill surgical patients: challenges and recommendations.

PubMed

Tisherman, Samuel A; Kaplan, Lewis; Gracias, Vicente H; Beilman, Gregory J; Toevs, Christine; Byrnes, Matthew C; Coopersmith, Craig M

2013-07-01

Providing optimal care for critically ill and injured surgical patients will become more challenging with staff shortages for surgeons and intensivists. This white paper addresses the historical issues behind the present situation, the need for all intensivists to engage in dedicated critical care per the intensivist model, and the recognition that intensivists from all specialties can provide optimal care for the critically ill surgical patient, particularly with continuing involvement by the surgeon of record. The new acute care surgery training paradigm (including trauma, surgical critical care, and emergency general surgery) has been developed to increase interest in trauma and surgical critical care, but the number of interested trainees remains too few. Recommendations are made for broadening the multidisciplinary training and practice opportunities in surgical critical care for intensivists from all base specialties and for maintaining the intensivist model within acute care surgery practice. Support from academic and administrative leadership, as well as national organizations, will be needed.

Stability in shifting sands: contemporary leadership roles in critical care.

PubMed

Endacott, R; Boulanger, C; Chamberlain, W; Hendry, J; Ryan, H; Chaboyer, W

2008-10-01

Contemporary nursing leadership roles in critical care are a reflection of the changing environment in which critical care is provided. In the UK, critical care nursing faces challenges in the form of: reduced number and seniority of medical staff cover for acute wards; mandated responsibility for management of patients outside of critical care units, without corresponding responsibility for managing staff; increased public and political awareness of deficits in critical care; increased use of Assistant Practitioners; and emphasis on longer-term outcomes from intensive care. New leadership roles have met these challenges head on with two main foci: patient management across the acute/critical care interface and hospital wide policies and practice. The leadership roles examined in this paper highlight three underpinning goals: improved quality and safety of patient care; improved communication between professionals; and empowerment of junior nurses and doctors. There has been considerable investment in strategic leadership roles for critical care nursing; evidence is developing of the return on this investment for patient and service outcomes. Consideration must now be given to the preparation, mentorship and development of leadership roles for the next generation of nurse leaders.

A leadership programme for critical care.

PubMed

Crofts, Linda

2006-08-01

This paper describes the genesis, design and implementation of a leadership programme for critical care. This was an initiative funded by the National Health Service (NHS) Nursing Leadership Project and had at the core of its design flexibility to meet the needs of the individual hospitals, which took part in it. Participation was from the multi-disciplinary critical care team. Six NHS hospitals took part in the programme which was of 20 days duration and took place on hospital sites. The programme used the leadership model of as its template and had a number of distinct components; a baseline assessment, personal development, principles of leadership and critical case reviews. The programme was underpinned by three themes; working effectively in multi-professional teams to provide patient focussed care, managing change through effective leadership and developing the virtual critical care service. Each group set objectives pertinent to their own organisation's needs. The programme was evaluated by a self-reporting questionnaire; group feedback and feedback from stakeholders. Programme evaluation was positive from all the hospitals but it was clear that the impact of the programme varied considerably between the groups who took part. It was noted that there was some correlation between the success of the programme and organisational 'buy in' as well as the organisational culture within which the participants operated. A key feature of the programme success was the critical case reviews, which were considered to be a powerful learning tool and medium for group learning and change management.

A consensus-based gold standard for the evaluation of mass casualty triage systems.

PubMed

Lerner, E Brooke; McKee, Courtney H; Cady, Charles E; Cone, David C; Colella, M Riccardo; Cooper, Arthur; Coule, Phillip L; Lairet, Julio R; Liu, J Marc; Pirrallo, Ronald G; Sasser, Scott M; Schwartz, Richard; Shepherd, Greene; Swienton, Raymond E

2015-01-01

Accuracy and effectiveness analyses of mass casualty triage systems are limited because there are no gold standard definitions for each of the triage categories. Until there is agreement on which patients should be identified by each triage category, it will be impossible to calculate sensitivity and specificity or to compare accuracy between triage systems. To develop a consensus-based, functional gold standard definition for each mass casualty triage category. National experts were recruited through the lead investigators' contacts and their suggested contacts. Key informant interviews were conducted to develop a list of potential criteria for defining each triage category. Panelists were interviewed in order of their availability until redundancy of themes was achieved. Panelists were blinded to each other's responses during the interviews. A modified Delphi survey was developed with the potential criteria identified during the interview and delivered to all recruited experts. In the early rounds, panelists could add, remove, or modify criteria. In the final rounds edits were made to the criteria until at least 80% agreement was achieved. Thirteen national and local experts were recruited to participate in the project. Six interviews were conducted. Three rounds of voting were performed, with 12 panelists participating in the first round, 12 in the second round, and 13 in the third round. After the first two rounds, the criteria were modified according to respondent suggestions. In the final round, over 90% agreement was achieved for all but one criterion. A single e-mail vote was conducted on edits to the final criterion and consensus was achieved. A consensus-based, functional gold standard definition for each mass casualty triage category was developed. These gold standard definitions can be used to evaluate the accuracy of mass casualty triage systems after an actual incident, during training, or for research.

The fate of triaged and rejected manuscripts.

PubMed

Zoccali, Carmine; Amodeo, Daniela; Argiles, Angel; Arici, Mustafa; D'arrigo, Graziella; Evenepoel, Pieter; Fliser, Danilo; Fox, Jonathan; Gesualdo, Loreto; Jadoul, Michel; Ketteler, Markus; Malyszko, Jolanta; Massy, Ziad; Mayer, Gert; Ortiz, Alberto; Sever, Mehmet; Vanholder, Raymond; Vinck, Caroline; Wanner, Christopher; Więcek, Andrzej

2015-12-01

In 2011, Nephrology Dialysis and Transplantation (NDT) established a more restrictive selection process for manuscripts submitted to the journal, reducing the acceptance rate from 25% (2008-2009) to currently about 12-15%. To achieve this goal, we decided to score the priority of manuscripts submitted to NDT and to reject more papers at triage than in the past. This new scoring system allows a rapid decision for the authors without external review. However, the risk of such a restrictive policy may be that the journal might fail to capture important studies that are eventually published in higher-ranked journals. To look into this problem, we analysed random samples of papers (∼10%) rejected by NDT in 2012. Of the papers rejected at triage and those rejected after regular peer review, 59 and 61%, respectively, were accepted in other journals. A detailed analysis of these papers showed that only 4 out of 104 and 7 out of 93 of the triaged and rejected papers, respectively, were published in journals with an impact factor higher than that of NDT. Furthermore, for all these papers, independent assessors confirmed the evaluation made by the original reviewers. The number of citations of these papers was similar to that typically obtained by publications in the corresponding journals. Even though the analyses seem reassuring, previous observations made by leading journals warn that the risk of 'big misses', resulting from selective editorial policies, remains a real possibility. We will therefore continue to maintain a high degree of alertness and will periodically track the history of manuscripts rejected by NDT, particularly papers that are rejected at triage by our journal. © The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

An Injury Severity-, Time Sensitivity-, and Predictability-Based Advanced Automatic Crash Notification Algorithm Improves Motor Vehicle Crash Occupant Triage.

PubMed

Stitzel, Joel D; Weaver, Ashley A; Talton, Jennifer W; Barnard, Ryan T; Schoell, Samantha L; Doud, Andrea N; Martin, R Shayn; Meredith, J Wayne

2016-06-01

Advanced Automatic Crash Notification algorithms use vehicle telemetry measurements to predict risk of serious motor vehicle crash injury. The objective of the study was to develop an Advanced Automatic Crash Notification algorithm to reduce response time, increase triage efficiency, and improve patient outcomes by minimizing undertriage (<5%) and overtriage (<50%), as recommended by the American College of Surgeons. A list of injuries associated with a patient's need for Level I/II trauma center treatment known as the Target Injury List was determined using an approach based on 3 facets of injury: severity, time sensitivity, and predictability. Multivariable logistic regression was used to predict an occupant's risk of sustaining an injury on the Target Injury List based on crash severity and restraint factors for occupants in the National Automotive Sampling System - Crashworthiness Data System 2000-2011. The Advanced Automatic Crash Notification algorithm was optimized and evaluated to minimize triage rates, per American College of Surgeons recommendations. The following rates were achieved: <50% overtriage and <5% undertriage in side impacts and 6% to 16% undertriage in other crash modes. Nationwide implementation of our algorithm is estimated to improve triage decisions for 44% of undertriaged and 38% of overtriaged occupants. Annually, this translates to more appropriate care for >2,700 seriously injured occupants and reduces unnecessary use of trauma center resources for >162,000 minimally injured occupants. The algorithm could be incorporated into vehicles to inform emergency personnel of recommended motor vehicle crash triage decisions. Lower under- and overtriage was achieved, and nationwide implementation of the algorithm would yield improved triage decision making for an estimated 165,000 occupants annually. Copyright © 2016. Published by Elsevier Inc.

Application of a first impression triage in the Japan railway west disaster.

PubMed

Hashimoto, Atsunori; Ueda, Takahiro; Kuboyama, Kazutoshi; Yamada, Taihei; Terashima, Mariko; Miyawaki, Atsushi; Nakao, Atsunori; Kotani, Joji

2013-01-01

On April 25, 2005, a Japanese express train derailed into a building, resulting in 107 deaths and 549 injuries. We used "First Impression Triage (FIT)", our new triage strategy based on general inspection and palpation without counting pulse/respiratory rates, and determined the feasibility of FIT in the chaotic situation of treating a large number of injured people in a brief time period. The subjects included 39 patients who required hospitalization among 113 victims transferred to our hospital. After initial assessment with FIT by an emergency physician, patients were retrospectively reassessed with the preexisting the modified Simple Triage and Rapid Treatment (START) methodology, based on Injury Severity Score, probability of survival, and ICU stay. FIT resulted in shorter waiting time for triage. FIT designations comprised 11 red (immediate), 28 yellow (delayed), while START assigned six to red and 32 to yellow. There were no statistical differences between FIT and START in the accuracy rate calculated by means of probability of survival and ICU stay. Overall validity and reliability of FIT determined by outcome assessment were similar to those of START. FIT would be a simple and accurate technique to quickly triage a large number of patients.

Low micronutrient intake may accelerate the degenerative diseases of aging through allocation of scarce micronutrients by triage

PubMed Central

Ames, Bruce N.

2006-01-01

Inadequate dietary intakes of vitamins and minerals are widespread, most likely due to excessive consumption of energy-rich, micronutrient-poor, refined food. Inadequate intakes may result in chronic metabolic disruption, including mitochondrial decay. Deficiencies in many micronutrients cause DNA damage, such as chromosome breaks, in cultured human cells or in vivo. Some of these deficiencies also cause mitochondrial decay with oxidant leakage and cellular aging and are associated with late onset diseases such as cancer. I propose DNA damage and late onset disease are consequences of a triage allocation response to micronutrient scarcity. Episodic shortages of micronutrients were common during evolution. Natural selection favors short-term survival at the expense of long-term health. I hypothesize that short-term survival was achieved by allocating scarce micronutrients by triage, in part through an adjustment of the binding affinity of proteins for required micronutrients. If this hypothesis is correct, micronutrient deficiencies that trigger the triage response would accelerate cancer, aging, and neural decay but would leave critical metabolic functions, such as ATP production, intact. Evidence that micronutrient malnutrition increases late onset diseases, such as cancer, is discussed. A multivitamin-mineral supplement is one low-cost way to ensure intake of the Recommended Dietary Allowance of micronutrients throughout life. PMID:17101959

Interrater reliability of the Australasian Triage Scale for mental health patients.

PubMed

Creaton, Anne; Liew, Don; Knott, Jonathan; Wright, Melissa

2008-12-01

To evaluate interrater reliability of the Australasian Triage Scale (ATS) for mental health patients in ED. In a prospective descriptive study, triage nurses were shown video vignettes of simulated scenarios of mental health presentations. Trieurs (raters) were asked to allocate an ATS category (rating) to each case. The primary outcome was the degree of interrater reliability for each simulated case. Also assessed were differences between raters or settings, grouped by level of ED activity, state of origin, hospital type and familiarity with appropriate guidelines. Chi-squared analysis was used for independent categorical variables; the Friedman test was used to compare the triage scores between busy and quiet ED scenarios. Ordinal data results were compared using opartchi. All 90 eligible participants were enrolled. The highest interrater concordance was 65.6% whereas the lowest interrater concordance was 53.3%. Significant association occurred between the distribution of triage ratings, ED activity level and the state of origin. A busy ED resulted in the assignment of a more urgent ATS category and decrease in concordance. There is a need to develop and implement a validated, standardized national triage tool for mental health patients. The ATS per se is insufficient to ensure acceptable interrater reliability, particularly during busy periods in the ED, and between states. Given the influence the ATS has on key outcomes, it is imperative for this tool to be robust.

CE: critical care recovery center: an innovative collaborative care model for ICU survivors.

PubMed

Khan, Babar A; Lasiter, Sue; Boustani, Malaz A

2015-03-01

Five million Americans require admission to ICUs annually owing to life-threatening illnesses. Recent medical advances have resulted in higher survival rates for critically ill patients, who often have significant cognitive, physical, and psychological sequelae, known as postintensive care syndrome (PICS). This growing population threatens to overwhelm the current U.S. health care system, which lacks established clinical models for managing their care. Novel innovative models are urgently needed. To this end, the pulmonary/critical care and geriatrics divisions at the Indiana University School of Medicine joined forces to develop and implement a collaborative care model, the Critical Care Recovery Center (CCRC). Its mission is to maximize the cognitive, physical, and psychological recovery of ICU survivors. Developed around the principles of implementation and complexity science, the CCRC opened in 2011 as a clinical center with a secondary research focus. Care is provided through a pre-CCRC patient and caregiver needs assessment, an initial diagnostic workup visit, and a follow-up visit that includes a family conference. With its sole focus on the prevention and treatment of PICS, the CCRC represents an innovative prototype aimed at modifying post-critical illness morbidities and improving the ICU survivor's quality of life.

The impact of aging physiology in critical care.

PubMed

Walker, Mandi; Spivak, Mark; Sebastian, Mary

2014-03-01

Aging physiology greatly impacts care delivery in the geriatric patient population. Consideration should be given to addressing the patient-specific needs regarding the systemic changes seen in the aging patient. Each major body system presents its own unique challenges to the critical care practitioner, and a comprehensive understanding of these changes is necessary to effectively care for this patient population. This article summarizes these changes and provides key points for the practitioner to consider when caring for the aging patient in the critical care arena. Copyright © 2014 Elsevier Inc. All rights reserved.

Development of metabolic and inflammatory mediator biomarker phenotyping for early diagnosis and triage of pediatric sepsis.

PubMed

Mickiewicz, Beata; Thompson, Graham C; Blackwood, Jaime; Jenne, Craig N; Winston, Brent W; Vogel, Hans J; Joffe, Ari R

2015-09-09

The first steps in goal-directed therapy for sepsis are early diagnosis followed by appropriate triage. These steps are usually left to the physician's judgment, as there is no accepted biomarker available. We aimed to determine biomarker phenotypes that differentiate children with sepsis who require intensive care from those who do not. We conducted a prospective, observational nested cohort study at two pediatric intensive care units (PICUs) and one pediatric emergency department (ED). Children ages 2-17 years presenting to the PICU or ED with sepsis or presenting for procedural sedation to the ED were enrolled. We used the judgment of regional pediatric ED and PICU attending physicians as the standard to determine triage location (PICU or ED). We performed metabolic and inflammatory protein mediator profiling with serum and plasma samples, respectively, collected upon presentation, followed by multivariate statistical analysis. Ninety-four PICU sepsis, 81 ED sepsis, and 63 ED control patients were included. Metabolomic profiling revealed clear separation of groups, differentiating PICU sepsis from ED sepsis with accuracy of 0.89, area under the receiver operating characteristic curve (AUROC) of 0.96 (standard deviation [SD] 0.01), and predictive ability (Q(2)) of 0.60. Protein mediator profiling also showed clear separation of the groups, differentiating PICU sepsis from ED sepsis with accuracy of 0.78 and AUROC of 0.88 (SD 0.03). Combining metabolomic and protein mediator profiling improved the model (Q(2) =0.62), differentiating PICU sepsis from ED sepsis with accuracy of 0.87 and AUROC of 0.95 (SD 0.01). Separation of PICU sepsis or ED sepsis from ED controls was even more accurate. Prespecified age subgroups (2-5 years old and 6-17 years old) improved model accuracy minimally. Seventeen metabolites or protein mediators accounted for separation of PICU sepsis and ED sepsis with 95% confidence. In children ages 2-17 years, combining metabolomic and

Supplies and equipment for pediatric emergency mass critical care.

PubMed

Bohn, Desmond; Kanter, Robert K; Burns, Jeffrey; Barfield, Wanda D; Kissoon, Niranjan

2011-11-01

Epidemics of acute respiratory disease, such as severe acute respiratory syndrome in 2003, and natural disasters, such as Hurricane Katrina in 2005, have prompted planning in hospitals that offer adult critical care to increase their capacity and equipment inventory for responding to a major demand surge. However, planning at a national, state, or local level to address the particular medical resource needs of children for mass critical care has yet to occur in any coordinated way. This paper presents the consensus opinion of the Task Force regarding supplies and equipment that would be required during a pediatric mass critical care crisis. In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations.Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6-7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010.The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29-30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. The Task Force endorsed the view that

Critical Care of Pet Birds.

PubMed

Jenkins, Jeffrey Rowe

2016-05-01

Successful care of the critical pet bird patient is dependent on preparation and planning and begins with the veterinarian and hospital staff. An understanding of avian physiology and pathophysiology is key. Physical preparation of the hospital or clinic includes proper equipment and understanding of the procedures necessary to provide therapeutic and supportive care to the avian patient. An overview of patient intake and assessment, intensive care environment, and fluid therapy is included. Copyright © 2016 Elsevier Inc. All rights reserved.

Critical care unit design: a nursing perspective.

PubMed

Williams, M

2001-11-01

The task of designing a new critical care unit is best accomplished with the input of people representing multiple disciplines including architects, engineers, physicians, nurses, and equipment manufacturers. It is imperative that the critical care nursing staff and management take an active role in planning the layout of the unit and patient rooms, as the nurses will be the bedside providers 24 hours a day. The new unit should be designed to offer efficient patient care as well as a healing, comfortable environment for both the patients and their families.

Pediatric Critical Care Nursing Research Priorities-Initiating International Dialogue.

PubMed

Tume, Lyvonne N; Coetzee, Minette; Dryden-Palmer, Karen; Hickey, Patricia A; Kinney, Sharon; Latour, Jos M; Pedreira, Mavilde L G; Sefton, Gerri R; Sorce, Lauren; Curley, Martha A Q

2015-07-01

To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice. One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical care nursing, nine international nurse researchers presented state-of-the-art lectures. Each identified knowledge gaps in their assigned practice domain and then poised three research questions to fill that gap. Then, meeting participants prioritized the proposed research questions using an interactive multivoting process. Seventh World Congress on Pediatric Intensive and Critical Care in Istanbul, Turkey. Pediatric critical care nurses and nurse scientists attending the open consensus meeting. Systematic review, gap analysis, and interactive multivoting. The participants prioritized 27 nursing research questions in nine content domains. The top four research questions were 1) identifying nursing interventions that directly impact the child and family's experience during the withdrawal of life support, 2) evaluating the long-term psychosocial impact of a child's critical illness on family outcomes, 3) articulating core nursing competencies that prevent unstable situations from deteriorating into crises, and 4) describing the level of nursing education and experience in pediatric critical care that has a protective effect on the mortality and morbidity of critically ill children. The consensus meeting was effective in organizing pediatric critical care nursing knowledge, identifying knowledge gaps and in prioritizing nursing research initiatives that could be used to advance nursing science across world regions.

The Critical Care Obesity Paradox and Implications for Nutrition Support.

PubMed

Patel, Jayshil J; Rosenthal, Martin D; Miller, Keith R; Codner, Panna; Kiraly, Laszlo; Martindale, Robert G

2016-09-01

Obesity is a leading cause of preventable death worldwide. The prevalence of obesity has been increasing and is associated with an increased risk for other co-morbidities. In the critical care setting, nearly one third of patients are obese. Obese critically ill patients pose significant physical and on-physical challenges to providers, including optimization of nutrition therapy. Intuitively, obese patients would have worse critical care-related outcome. On the contrary, emerging data suggests that critically ill obese patients have improved outcomes, and this phenomenon has been coined "the obesity paradox." The purposes of this review will be to outline the historical views and pathophysiology of obesity and epidemiology of obesity, describe the challenges associated with obesity in the intensive care unit setting, review critical care outcomes in the obese, define the obesity-critical care paradox, and identify the challenges and role of nutrition support in the critically ill obese patient.

The use of a kiosk-model bilingual self-triage system in the pediatric emergency department.

PubMed

Sinha, Madhumita; Khor, Kai-Ning; Amresh, Ashish; Drachman, David; Frechette, Alan

2014-01-01

Streamlining the triage process is the key in improving emergency department (ED) workflow. Our objective was to determine if parents of pediatric ED patients in, low-literacy, inner-city hospital, who used the audio-assisted bilingual (English/Spanish) self-triage kiosk, were able to enter their child's medical history data using a touch screen panel with greater speed and accuracy than routine nurse-initiated triage. Parent/child dyads visiting the pediatric ED for nonurgent conditions (February to April 2012) were randomized prospectively to self-triage kiosk group (n = 200) and standard nurse triage group (n = 200). Both groups underwent routine nurse-initiated triage that included verbal elicitation of basic medical history and manual entry into patients' electronic medical records. The kiosk user was a parent in 88.5% of the cases, a patient (range, 11-17 years) in 9.5% of the cases, and a proxy user (sibling or friend) in 2% of the cases. Language choice for kiosk use was equally distributed (English vs Spanish, 50.5% vs 49.5%). The mean (SD) time to enter medical history data by the kiosk group was significantly shorter than the standard nurse triage group (94.38 [38.61] vs 126.72 [62.61] seconds; P < 0.001). Significant inverse relationship was observed between parent education level and kiosk usage time (r = -0.26; P < 0.001). The mean inaccuracies were significantly lower for kiosk group (P < 0.05) in areas of medical, medication and immunization histories, and total discrepancy score. Kiosk triage enabled users to enter basic medical triage history data quickly and accurately in an ED setting with future potential for its wider use in improving ED workflow efficiency.

Teaching and evaluating critical thinking in respiratory care.

PubMed

Mishoe, Shelley C; Hernlen, Kitty

2005-09-01

The capacity to perform critical thinking in respiratory care may be enhanced through awareness and education to improve skills, abilities, and opportunities. The essential skills for critical thinking in respiratory care include prioritizing, anticipating, troubleshooting, communicating, negotiating, decision making, and reflecting. In addition to these skills, critical thinkers exhibit certain characteristics such as critical evaluation, judgment,insight, motivation, and lifelong learning. The teaching of critical thinking may be accomplished though problem-based learning using an evidenced-based approach to solve clinical problems similar to those encountered in professional practice. Other traditional strategies such as discussion, debate, case study, and case presentations can be used. Web-based curriculum and technologic advances have created opportunities such as bulletin boards, real-time chats, and interactive media tools that can incorporate critical thinking. Many concerns and controversies surround the assessment of critical thinking, and individuals who administer critical thinking tests must be aware of the strengths and limitations of these assessment tools, as well as their relevance to the workplace. The foundational works reported in this article summarize the current status of assessment of critical thinking and can stimulate further investigation and application of the skills, characteristics, educational strategies, and measurement of critical thinking in respiratory care.

Outcome evaluation of a new model of critical care orientation.

PubMed

Morris, Linda L; Pfeifer, Pamela; Catalano, Rene; Fortney, Robert; Nelson, Greta; Rabito, Robb; Harap, Rebecca

2009-05-01

The shortage of critical care nurses and the service expansion of 2 intensive care units provided a unique opportunity to create a new model of critical care orientation. The goal was to design a program that assessed critical thinking, validated competence, and provided learning pathways that accommodated diverse experience. To determine the effect of a new model of critical care orientation on satisfaction, retention, turnover, vacancy, preparedness to manage patient care assignment, length of orientation, and cost of orientation. A prospective, quasi-experimental design with both quantitative and qualitative methods. The new model improved satisfaction scores, retention rates, and recruitment of critical care nurses. Length of orientation was unchanged. Cost was increased, primarily because a full-time education consultant was added. A new model for nurse orientation that was focused on critical thinking and competence validation improved retention and satisfaction and serves as a template for orientation of nurses throughout the medical center.

[Unmanned aerial vehicles: usefulness for victim searches and triage in disasters].

PubMed

Pardo Ríos, Manuel; Pérez Alonso, Nuria; Lasheras Velasco, Joaquín; Juguera Rodríguez, Laura; López Ayuso, Belén; Muñoz Solera, Rubén; Martínez Riquelme, Carolina; Nieto Fernández-Pacheco, Antonio

2016-01-01

To analyze the influence of drones equipped with thermal cameras for finding victims and aiding triage during disasters. We carried out a prospective, cross-sectional analysis and 6 experimental simulations, each with 25 victims to locate and triage. Nurses were randomized to a control group or a drone group. Drone-group nurses were given access to images from the thermal cameras 10 minutes before the exercise started. The mean (SD) distance the nurses searched in the control group (1091.11 [146.41] m) was significantly greater than the distance searched by nurses in the drone group (920 [ 71.93] m (P = .0031). The control group found a mean of 66.7% of the victims, a significantly smaller percentage than the drone group's mean of 92% (P = .0001). Triage quality (undertriage and overtriage) was similar in the 2 groups as shown by maneuvers undertaken to open airways and control bleeding. Drones with thermal cameras were useful in searching for victims of simulated disasters in this study, although they had no impact on the quality of the nurses' triage.

Physician training in critical care in the United States: Update 2018.

PubMed

Napolitano, Lena M; Rajajee, Venkatakrishna; Gunnerson, Kyle J; Maile, Michael D; Quasney, Michael; Hyzy, Robert C

2018-06-01

Critical care fellowship training in the United States differs based on specific specialty and includes medicine, surgery, anesthesiology, pediatrics, emergency medicine, and neurocritical care training pathways. We provide an update regarding the number and growth of US critical care fellowship training programs, on-duty residents and certified diplomates, and review the different critical care physician training pathways available to residents interested in pursuing a fellowship in critical care. Data were obtained from the Accreditation Council for Graduate Medical Education and specialty boards (American Board of Internal Medicine, American Board of Surgery, American Board of Anesthesiology, American Board of Pediatrics American Board of Emergency Medicine) and the United Council for Neurologic Subspecialties for the last 16 years (2001-2017). The number of critical care fellowship training programs has increased 22.6%, with a 49.4% increase in the number of on-duty residents annually, over the last 16 years. This is in contrast to the period of 1995 to 2000 when the number of physicians enrolled in critical care fellowship programs had decreased or remained unchanged. Although more than 80% of intensivists in the US train in internal medicine critical care Accreditation Council for Graduate Medical Education-approved fellowships, there has been a significant increase in the number of residents from surgery, anesthesiology, pediatrics, emergency medicine, and other specialties who complete specialty fellowship training and certification in critical care. Matriculation in neurocritical care fellowships is rapidly rising with 60 programs and over 1,200 neurocritical care diplomates. Critical care is now an increasingly popular fellowship in all specialties. This rapid growth of all critical care specialties highlights the magnitude of the heterogeneity that will exist between intensivists in the future.

A critical care network pressure ulcer prevention quality improvement project.

PubMed

McBride, Joanna; Richardson, Annette

2015-03-30

Pressure ulcer prevention is an important safety issue, often underrated and an extremely painful event harming patients. Critically ill patients are one of the highest risk groups in hospital. The impact of pressure ulcers are wide ranging, and they can result in increased critical care and the hospital length of stay, significant interference with functional recovery and rehabilitation and increase cost. This quality improvement project had four aims: (1) to establish a critical care network pressure ulcer prevention group; (2) to establish baseline pressure ulcer prevention practices; (3) to measure, compare and monitor pressure ulcers prevalence; (4) to develop network pressure ulcer prevention standards. The approach used to improve quality included strong critical care nursing leadership to develop a cross-organisational pressure ulcer prevention group and a benchmarking exercise of current practices across a well-established critical care Network in the North of England. The National Safety Thermometer tool was used to measure pressure ulcer prevalence in 23 critical care units, and best available evidence, local consensus and another Critical Care Networks' bundle of interventions were used to develop a local pressure ulcer prevention standards document. The aims of the quality improvement project were achieved. This project was driven by successful leadership and had an agreed common goal. The National Safety Thermometer tool was an innovative approach to measure and compare pressure ulcer prevalence rates at a regional level. A limitation was the exclusion of moisture lesions. The project showed excellent engagement and collaborate working in the quest to prevent pressure ulcers from many critical care nurses with the North of England Critical Care Network. A concise set of Network standards was developed for use in conjunction with local guidelines to enhance pressure ulcer prevention. © 2015 British Association of Critical Care Nurses.

Practical strategies for increasing efficiency and effectiveness in critical care education.

PubMed

Joyce, Maurice F; Berg, Sheri; Bittner, Edward A

2017-02-04

Technological advances and evolving demands in medical care have led to challenges in ensuring adequate training for providers of critical care. Reliance on the traditional experience-based training model alone is insufficient for ensuring quality and safety in patient care. This article provides a brief overview of the existing educational practice within the critical care environment. Challenges to education within common daily activities of critical care practice are reviewed. Some practical evidence-based educational approaches are then described which can be incorporated into the daily practice of critical care without disrupting workflow or compromising the quality of patient care. It is hoped that such approaches for improving the efficiency and efficacy of critical care education will be integrated into training programs.

Using Video from Mobile Phones to Improve Pediatric Phone Triage in an Underserved Population.

PubMed

Freeman, Brandi; Mayne, Stephanie; Localio, A Russell; Luberti, Anthony; Zorc, Joseph J; Fiks, Alexander G

2017-02-01

Video-capable mobile phones are widely available, but few studies have evaluated their use in telephone triage for pediatric patients. We assessed the feasibility, acceptability, and utility of videos sent via mobile phones to enhance pediatric telephone triage for an underserved population with asthma. We recruited children who presented to an urban pediatric emergency department with an asthma exacerbation along with their parent/guardian. Parents and the research team each obtained a video of the child's respiratory exam, and the research team conducted a concurrent in-person rating of respiratory status. We measured the acceptability of families sending videos as part of telephone triage (survey) and the feasibility of this approach (rates of successful video transmission by parents to the research team). To estimate the utility of the video in appropriately triaging children, four clinicians reviewed each video and rated whether they found the video reassuring, neutral, or raising concerns. Among 60 families (78% Medicaid, 85% Black), 80% of parents reported that sending a video would be helpful and 68% reported that a nurse's review of a video would increase their trust in the triage assessment. Most families (75%) successfully transmitted a video to the research team. All clinician raters found the video reassuring regarding the severity of the child's asthma exacerbation for 68% of children. Obtaining mobile phone videos for telephone triage is acceptable to families, feasible, and may help improve the quality of telephone triage in an urban, minority population.

The Top Ten Websites in Critical Care Medicine Education Today.

PubMed

Wolbrink, Traci A; Rubin, Lucy; Burns, Jeffrey P; Markovitz, Barry

2018-01-01

The number of websites for the critical care provider is rapidly growing, including websites that are part of the Free Open Access Med(ical ed)ucation (FOAM) movement. With this rapidly expanding number of websites, critical appraisal is needed to identify quality websites. The last major review of critical care websites was published in 2011, and thus a new review of the websites relevant to the critical care clinician is necessary. A new assessment tool for evaluating critical care medicine education websites, the Critical Care Medical Education Website Quality Evaluation Tool (CCMEWQET), was modified from existing tools. A PubMed and Startpage search from 2007 to 2017 was conducted to identify websites relevant to critical care medicine education. These websites were scored based on the CCMEWQET. Ninety-seven websites relevant for critical care medicine education were identified and scored, and the top ten websites were described in detail. Common types of resources available on these websites included blog posts, podcasts, videos, online journal clubs, and interactive components such as quizzes. Almost one quarter of websites (n = 22) classified themselves as FOAM websites. The top ten websites most often included an editorial process, high-quality and appropriately attributed graphics and multimedia, scored much higher for comprehensiveness and ease of access, and included opportunities for interactive learning. Many excellent online resources for critical care medicine education currently exist, and the number is likely to continue to increase. Opportunities for improvement in many websites include more active engagement of learners, upgrading navigation abilities, incorporating an editorial process, and providing appropriate attribution for graphics and media.

Multisociety Task Force for Critical Care Research: key issues and recommendations.

PubMed

Deutschman, Clifford S; Ahrens, Tom; Cairns, Charles B; Sessler, Curtis N; Parsons, Polly E

2012-01-01

Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the US Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: 1) the traditional "silo-ed" approach to critical care research is counterproductive and should be modified; 2) an approach that more effectively links areas of research (i.e., basic and translational research, or clinical research and implementation) should be embraced; 3) future approaches to human research should account for disease complexity and patient heterogeneity; and 4) an enhanced infrastructure for critical care research is essential for future success. This document contains the themes/recommendations developed by a large, multiprofessional cross section of critical care scientists

Multisociety task force for critical care research: key issues and recommendations.

PubMed

Deutschman, Clifford S; Ahrens, Tom; Cairns, Charles B; Sessler, Curtis N; Parsons, Polly E

2012-01-01

Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the U.S. Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: (1) the traditional "silo-ed" approach to critical care research is counterproductive and should be modified; (2) an approach that more effectively links areas of research (i.e., basic and translational research, or clinical research and implementation) should be embraced; (3) future approaches to human research should account for disease complexity and patient heterogeneity; and (4) an enhanced infrastructure for critical care research is essential for future success. This document contains the themes/recommendations developed by a large, multiprofessional cross-section of critical care scientists

Multisociety task force for critical care research: key issues and recommendations.

PubMed

Deutschman, Clifford S; Ahrens, Tom; Cairns, Charles B; Sessler, Curtis N; Parsons, Polly E

2012-01-01

Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the US Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: 1) the traditional "silo-ed" approach to critical care research is counterproductive and should be modified; 2) an approach that more effectively links areas of research (ie, basic and translational research, or clinical research and implementation) should be embraced; 3) future approaches to human research should account for disease complexity and patient heterogeneity; and 4) an enhanced infrastructure for critical care research is essential for future success. This document contains the themes/recommendations developed by a large, multiprofessional cross section of critical care scientists

Multisociety Task Force for Critical Care Research: Key Issues and Recommendations

PubMed Central

Deutschman, Clifford S.; Ahrens, Tom; Cairns, Charles B.; Sessler, Curtis N.; Parsons, Polly E.

2012-01-01

Background: Research in critical care extends from the bench to the bedside, involving multiple departments, specialties, and funding organizations. Because of this diversity, it has been difficult for all stakeholders to collectively identify challenges and establish priorities. Objective: To define a comprehensive agenda for critical care research using input from a broad range of stakeholders to serve as a blueprint for future initiatives. Methods: The Critical Care Societies Collaborative (CCSC), consisting of the leadership of the American Association of Critical-Care Nurses (AACN), the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM), joined the U.S. Critical Illness and Injury Trials Group (USCIITG) in forming a task force to define a comprehensive critical care research agenda. This group of 25 identified experts was divided into subgroups to address basic, translational, clinical, implementation, and educational research. The subgroups met via conference calls, and the entire task force met in person for a 2-day session. The result was a detailed discussion of the research priorities that served as the basis for this report. Results: The task force identified challenges, specific priority areas, and recommendations for process improvements to support critical care research. Additionally, four overarching themes emerged: (1) the traditional “silo-ed” approach to critical care research is counterproductive and should be modified; (2) an approach that more effectively links areas of research (i.e., basic and translational research, or clinical research and implementation) should be embraced; (3) future approaches to human research should account for disease complexity and patient heterogeneity; and (4) an enhanced infrastructure for critical care research is essential for future success. Conclusions: This document contains the themes/recommendations developed by a large

History of pulmonary critical care nursing and where we are going.

PubMed

Lareau, Suzanne C; Mealer, Meredith

2012-09-01

Pulmonary critical care nurses have played a prominent role in the ICUs from the inception of critical care units. This article describes how the history of pulmonary critical care nursing has evolved and discusses a few of the challenges in the years to come: stress imposed by working in a critical care environment, enhancing the care of patients by altering patterns of sedation and promoting early mobilization, and dealing with increasing infection rates.

The accuracy and consistency of rural, remote and outpost triage nurse decision making in one Western Australia Country Health Service Region.

PubMed

Ekins, Kylie; Morphet, Julia

2015-11-01

The Australasian Triage Scale aims to ensure that the triage category allocated, reflects the urgency with which the patient needs medical assistance. This is dependent on triage nurse accuracy in decision making. The Australasian Triage Scale also aims to facilitate triage decision consistency between individuals and organisations. Various studies have explored the accuracy and consistency of triage decisions throughout Australia, yet no studies have specifically focussed on triage decision making in rural health services. Further, no standard has been identified by which accuracy or consistency should be measured. Australian emergency departments are measured against a set of standard performance indicators, including time from triage to patient review, and patient length of stay. There are currently no performance indicators for triage consistency. An online questionnaire was developed to collect demographic data and measure triage accuracy and consistency. The questionnaire utilised previously validated triage scenarios.(1) Triage decision accuracy was measured, and consistency was compared by health site type using Fleiss' kappa. Forty-six triage nurses participated in this study. The accuracy of participants' triage decision-making decreased with each less urgent triage category. Post-graduate qualifications had no bearing on triage accuracy. There was no significant difference in the consistency of decision-making between paediatric and adult scenarios. Overall inter-rater agreement using Fleiss' kappa coefficient, was 0.4. This represents a fair-to-good level of inter-rater agreement. A standard definition of accuracy and consistency in triage nurse decision making is required. Inaccurate triage decisions can result in increased morbidity and mortality. It is recommended that emergency department performance indicator thresholds be utilised as a benchmark for national triage consistency. Crown Copyright © 2015. Published by Elsevier Ltd. All rights

Social Media Engagement and the Critical Care Medicine Community.

PubMed

Barnes, Sean S; Kaul, Viren; Kudchadkar, Sapna R

2018-01-01

Over the last decade, social media has transformed how we communicate in the medical community. Microblogging through platforms such as Twitter has made social media a vehicle for succinct, targeted, and innovative dissemination of content in critical care medicine. Common uses of social media in medicine include dissemination of information, knowledge acquisition, professional networking, and patient advocacy. Social media engagement at conferences represents all of these categories and is often the first time health-care providers are introduced to Twitter. Most of the major critical care medicine conferences, journals, and societies leverage social media for education, research, and advocacy, and social media users can tailor the inflow of content based on their own interests. From these interactions, networks and communities are built within critical care medicine and beyond, overcoming the barriers of physical proximity. In this review, we summarize the history and current status of health-care social media as it relates to critical care medicine and provide a primer for those new to health-care social media with a focus on Twitter, one of the most popular microblogging platforms.

Mass Casualty Incident Primary Triage Methods in China.

PubMed

Chen, Jin-Hong; Yang, Jun; Yang, Yu; Zheng, Jing-Chen

2015-10-05

To evaluate the technical characteristics and application of mass casualty incident (MCI) primary triage (PT) methods applied in China. Chinese literature was searched by Chinese Academic Journal Network Publishing Database (founded in June 2014). The English literature was searched by PubMed (MEDLINE) (1950 to June 2014). We also searched Official Websites of Chinese Central Government's (http://www.gov.cn/), National Health and Family Planning Commission of China (http://www.nhfpc.gov.cn/), and China Earthquake Information (http://www.csi.ac.cn/). We included studies associated with mass casualty events related to China, the PT applied in China, guidelines and standards, and application and development of the carding PT method in China. From 3976 potentially relevant articles, 22 met the inclusion criteria, 20 Chinese, and 2 English. These articles included 13 case reports, 3 retrospective analyses of MCI, two methods introductions, three national or sectoral criteria, and one simulated field testing and validation. There were a total of 19 kinds of MCI PT methods that have been reported in China from 1950 to 2014. In addition, there were 15 kinds of PT methods reported in the literature from the instance of the application. The national and sectoral current triage criteria are developed mainly for earthquake relief. Classification is not clear. Vague criteria (especially between moderate and severe injuries) operability are not practical. There are no triage methods and research for children and special populations. There is no data and evidence supported triage method. We should revise our existing classification and criteria so it is clearer and easier to be grasped in order to build a real, practical, and efficient PT method.

Characterising the research profile of the critical care physiotherapy workforce and engagement with critical care research: a UK national survey

PubMed Central

Allum, Laura; Shaw, Michelle; Pattison, Natalie; Dark, Paul

2018-01-01

Objective To characterise the research profile of UK critical care physiotherapists including experience, training needs, and barriers and enablers to engagement in critical care research. ‘Research’ was defined broadly to encompass activities related to quantitative and qualitative studies, service evaluations, clinical audit and quality improvements. Design Closed-question online survey, with optional free-text responses. Setting UK critical care community. Participants UK critical care physiotherapists, regardless of clinical grade or existing research experience. Results 268 eligible survey responses were received during the 12-week study period (21 incomplete, 7.8%). Respondents were based in university-affiliated (n=133, 49.6%) and district general (n=111, 41.4%) hospitals, and generally of senior clinical grade. Nearly two-thirds had postgraduate qualifications at master’s level or above (n=163, 60.8%). Seven had a doctoral-level qualification. Respondents reported a range of research experience, predominantly data acquisition (n=144, 53.7%) and protocol development (n=119, 44.4%). Perceived research training needs were prevalent, including topics of research methods, critical literature appraisal, protocol development and statistical analysis (each reported by ≥50% respondents). Multiple formats for delivery of future research training were identified. Major barriers to research engagement included lack of protected time (n=220, 82.1%), funding (n=177, 66.0%) and perceived experience (n=151, 56.3%). Barriers were conceptually categorised into capability, opportunity and motivation themes. Key enabling strategies centred on greater information provision about clinical research opportunities, access to research training, secondment roles and professional networks. Conclusions UK critical care physiotherapists are skilled, experienced and motivated to participate in research, including pursuing defined academic research pathways. Nonetheless wide

Challenges of postgraduate critical care nursing program in Iran.

PubMed

Dehghan Nayeri, Nahid; Shariat, Esmaeil; Tayebi, Zahra; Ghorbanzadeh, Majid

2017-01-01

Background: The main philosophy of postgraduate preparation for working in critical care units is to ensure the safety and quality of patients' care. Increasing the complexity of technology, decision-making challenges and the high demand for advanced communication skills necessitate the need to educate learners. Within this aim, a master's degree in critical care nursing has been established in Iran. Current study was designed to collect critical care nursing students' experiences as well as their feedback to the field critical care nursing. Methods: This study used qualitative content analysis through in-depth semi-structured interviews. Graneheim and Lundman method was used for data analysis. Results: The results of the total 15 interviews were classified in the following domains: The vision of hope and illusion; shades of grey attitude; inefficient program and planning; inadequacy to run the program; and multiple outcomes: Far from the effectiveness. Overall findings indicated the necessity to review the curriculum and the way the program is implemented. Conclusion: The findings of this study provided valuable information to improve the critical care-nursing program. It also facilitated the next review of the program by the authorities.

Supplies and equipment for pediatric emergency mass critical care

PubMed Central

Bohn, Desmond; Kanter, Robert K.; Burns, Jeffrey; Barfield, Wanda D.; Kissoon, Niranjan

2015-01-01

Introduction Epidemics of acute respiratory disease, such as severe acute respiratory syndrome in 2003, and natural disasters, such as Hurricane Katrina in 2005, have prompted planning in hospitals that offer adult critical care to increase their capacity and equipment inventory for responding to a major demand surge. However, planning at a national, state, or local level to address the particular medical resource needs of children for mass critical care has yet to occur in any coordinated way. This paper presents the consensus opinion of the Task Force regarding supplies and equipment that would be required during a pediatric mass critical care crisis. Methods In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations. Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6 –7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010. The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29 –30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. Task Force

Examining critical care nurses' critical incident stress after in hospital cardiopulmonary resuscitation (CPR).

PubMed

Laws, T

2001-05-01

The object of this study was to determine if critical care nurses' emotional responses to having performed cardiopulmonary resuscitation were indicative of critical incident stress. A descriptive approach was employed using a survey questionnaire of 31 critical care nurses, with supportive interview data from 18 of those participants. Analysis of the data generated from the questionnaire indicated that the respondents experienced thought intrusion and avoidance behaviour. A majority of those interviewed disclosed that they had experienced a wide range of emotional stressors and physical manifestations in response to having performed the procedure. The findings from both questionnaire and interview data were congruent with signs of critical incident stress, as described in the literature. This has been found to be detrimental to employees' mental health status and, for this reason, employers have a duty of care to minimise the risk of its occurrence and to manage problems as they arise.

Integration of Palliative Care in Chronic Critical Illness Management

PubMed Central

Nelson, Judith E; Hope, Aluko A

2016-01-01

Palliative care is an essential component of comprehensive care for all patients with chronic critical illness, including those receiving restorative or life-sustaining therapies. Core elements include alleviation of symptom distress, communication about care goals, alignment of treatment with the patient’s values and preferences, transitional planning, and family support. Here we address strategies for assessment and management of symptoms, including pain, dyspnea, and depression, and for assisting patients to communicate while endotracheally intubated. We also discuss approaches to optimize communication among clinicians, patients, and families about care goals. Challenges for supporting families and planning for transitions between care settings are identified, while the value of interdisciplinary input is emphasized. We review “consultative” and “integrative” models for integrating palliative care and restorative critical care. Finally, we highlight key ethical issues that arise in the care of chronically critically ill patients and their families. PMID:22663973

Critical care nurses' knowledge and practice of delirium assessment.

PubMed

Rowley-Conwy, Gabby

2017-04-13

The aim of this study was to examine perceived barriers to assessment of delirium for critical care nurses, and the impact of education on their knowledge and practice. Delirium is a significant problem in critical care, leading to increased morbidity and mortality. Many authors have found variations in assessment by critical care nurses, but there has been limited analysis of the reasons for this. Education on the topic improves knowledge and practice, but the best approach has not been examined. A questionnaire survey design. A self-reported questionnaire was distributed to critical care nurses (n=31) at a district general hospital. Data were analysed with descriptive statistics. Knowledge and practice were variable, but correlation was seen between nursing band and years of experience with better scores. Any type of education led to significantly improved scores. Several barriers to assessment were found, with the most common being lack of knowledge and difficulty in assessing intubated patients. It is essential to improve practice in delirium assessment and management. Education is vital to improve the knowledge and practice of critical care nurses regarding delirium.

Virtual reality and live simulation: a comparison between two simulation tools for assessing mass casualty triage skills.

PubMed

Luigi Ingrassia, Pier; Ragazzoni, Luca; Carenzo, Luca; Colombo, Davide; Ripoll Gallardo, Alba; Della Corte, Francesco

2015-04-01

This study tested the hypothesis that virtual reality simulation is equivalent to live simulation for testing naive medical students' abilities to perform mass casualty triage using the Simple Triage and Rapid Treatment (START) algorithm in a simulated disaster scenario and to detect the improvement in these skills after a teaching session. Fifty-six students in their last year of medical school were randomized into two groups (A and B). The same scenario, a car accident, was developed identically on the two simulation methodologies: virtual reality and live simulation. On day 1, group A was exposed to the live scenario and group B was exposed to the virtual reality scenario, aiming to triage 10 victims. On day 2, all students attended a 2-h lecture on mass casualty triage, specifically the START triage method. On day 3, groups A and B were crossed over. The groups' abilities to perform mass casualty triage in terms of triage accuracy, intervention correctness, and speed in the scenarios were assessed. Triage and lifesaving treatment scores were assessed equally by virtual reality and live simulation on day 1 and on day 3. Both simulation methodologies detected an improvement in triage accuracy and treatment correctness from day 1 to day 3 (P<0.001). The time to complete each scenario and its decrease from day 1 to day 3 were detected equally in the two groups (P<0.05). Virtual reality simulation proved to be a valuable tool, equivalent to live simulation, to test medical students' abilities to perform mass casualty triage and to detect improvement in such skills.

Evaluating the construct of triage acuity against a set of reference vignettes developed via modified Delphi method.

PubMed

Twomey, Michèle; Wallis, Lee A; Myers, Jonathan E

2014-07-01

To evaluate the construct of triage acuity as measured by the South African Triage Scale (SATS) against a set of reference vignettes. A modified Delphi method was used to develop a set of reference vignettes. Delphi participants completed a 2-round consensus-building process, and independently assigned triage acuity ratings to 100 written vignettes unaware of the ratings given by others. Triage acuity ratings were summarised for all vignettes, and only those that reached 80% consensus during round 2 were included in the reference set. Triage ratings for the reference vignettes given by two independent experts using the SATS were compared with the ratings given by the international Delphi panel. Measures of sensitivity, specificity, associated percentages for over-triage/under-triage were used to evaluate the construct of triage acuity (as measured by the SATS) by examining the association between the ratings by the two experts and the international panel. On completion of the Delphi process, 42 of the 100 vignettes reached 80% consensus on their acuity rating and made up the reference set. On average, over all acuity levels, sensitivity was 74% (CI 64% to 82%), specificity 92% (CI 87% to 94%), under-triage occurred 14% (CI 8% to 23%) and over-triage 12% (CI 8% to 23%) of the time. The results of this study provide an alternative to evaluating triage scales against the construct of acuity as measured with the SATS. This method of using 80% consensus vignettes may, however, systematically bias the validity estimate towards better performance. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

SARP: a value-based approach to hospice admissions triage.

PubMed

MacDonald, D

1995-01-01

As hospices become established and case referrals increase, many programs are faced with the necessity of instituting waiting lists. Prioritizing cases for order of admission requires a triage method that is rational, fair, and consistent. This article describes the SARP method of hospice admissions triage, which evaluates prospective cases according to seniority, acuity, risk, and political significance. SARP's essential features, operative assumptions, advantages, and limitations are discussed, as well as the core hospice values which underlie its use. The article concludes with a call for trial and evaluation of SARP in other hospice settings.

A New Triage Support Tool in Case of Explosion.

PubMed

Yavari-Sartakhti, Olivier; Briche, Frédérique; Jost, Daniel; Michaud, Nicolas; Bignand, Michel; Tourtier, Jean-Pierre

2018-04-01

Deafness frequently observed in explosion victims, currently following terrorist attack, is a barrier to communication between victims and first responders. This may result in a delay in the initial triage and evacuation. In such situations, Paris Fire Brigade (Paris, France) proposes the use of assistance cards to help conscious, but deafened patients at the site of an attack where there may be numerous victims. Yavari-Sartakhti O , Briche F , Jost D , Michaud N , Bignand M , Tourtier JP . A new triage support tool in case of explosion. Prehosp Disaster Med. 2018;33(2):213-214.

Ambulance Clinical Triage for Acute Stroke Treatment: Paramedic Triage Algorithm for Large Vessel Occlusion.

PubMed

Zhao, Henry; Pesavento, Lauren; Coote, Skye; Rodrigues, Edrich; Salvaris, Patrick; Smith, Karen; Bernard, Stephen; Stephenson, Michael; Churilov, Leonid; Yassi, Nawaf; Davis, Stephen M; Campbell, Bruce C V

2018-04-01

Clinical triage scales for prehospital recognition of large vessel occlusion (LVO) are limited by low specificity when applied by paramedics. We created the 3-step ambulance clinical triage for acute stroke treatment (ACT-FAST) as the first algorithmic LVO identification tool, designed to improve specificity by recognizing only severe clinical syndromes and optimizing paramedic usability and reliability. The ACT-FAST algorithm consists of (1) unilateral arm drift to stretcher <10 seconds, (2) severe language deficit (if right arm is weak) or gaze deviation/hemineglect assessed by simple shoulder tap test (if left arm is weak), and (3) eligibility and stroke mimic screen. ACT-FAST examination steps were retrospectively validated, and then prospectively validated by paramedics transporting culturally and linguistically diverse patients with suspected stroke in the emergency department, for the identification of internal carotid or proximal middle cerebral artery occlusion. The diagnostic performance of the full ACT-FAST algorithm was then validated for patients accepted for thrombectomy. In retrospective (n=565) and prospective paramedic (n=104) validation, ACT-FAST displayed higher overall accuracy and specificity, when compared with existing LVO triage scales. Agreement of ACT-FAST between paramedics and doctors was excellent (κ=0.91; 95% confidence interval, 0.79-1.0). The full ACT-FAST algorithm (n=60) assessed by paramedics showed high overall accuracy (91.7%), sensitivity (85.7%), specificity (93.5%), and positive predictive value (80%) for recognition of endovascular-eligible LVO. The 3-step ACT-FAST algorithm shows higher specificity and reliability than existing scales for clinical LVO recognition, despite requiring just 2 examination steps. The inclusion of an eligibility step allowed recognition of endovascular-eligible patients with high accuracy. Using a sequential algorithmic approach eliminates scoring confusion and reduces assessment time. Future

The Certified Clinical Nurse Leader in Critical Care.

PubMed

L'Ecuyer, Kristine M; Shatto, Bobbi J; Hoffmann, Rosemary L; Crecelius, Matthew L

2016-01-01

Challenges of the current health system in the United States call for collaboration of health care professionals, careful utilization of resources, and greater efficiency of system processes. Innovations to the delivery of care include the introduction of the clinical nurse leader role to provide leadership at the point of care, where it is needed most. Clinical nurse leaders have demonstrated their ability to address needed changes and implement improvements in processes that impact the efficiency and quality of patient care across the continuum and in a variety of settings, including critical care. This article describes the role of the certified clinical nurse leader, their education and skill set, and outlines outcomes that have been realized by their efforts. Specific examples of how clinical nurse leaders impact critical care nursing are discussed.

Clinical review: Medication errors in critical care

PubMed Central

Moyen, Eric; Camiré, Eric; Stelfox, Henry Thomas

2008-01-01

Medication errors in critical care are frequent, serious, and predictable. Critically ill patients are prescribed twice as many medications as patients outside of the intensive care unit (ICU) and nearly all will suffer a potentially life-threatening error at some point during their stay. The aim of this article is to provide a basic review of medication errors in the ICU, identify risk factors for medication errors, and suggest strategies to prevent errors and manage their consequences. PMID:18373883

Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine's Task Force for intensive care unit triage during an influenza epidemic or mass disaster.

PubMed

Sprung, Charles L; Zimmerman, Janice L; Christian, Michael D; Joynt, Gavin M; Hick, John L; Taylor, Bruce; Richards, Guy A; Sandrock, Christian; Cohen, Robert; Adini, Bruria

2010-03-01

To provide recommendations and standard operating procedures for intensive care units and hospital preparedness for an influenza pandemic. Based on a literature review and expert opinion, a Delphi process was used to define the essential topics. Key recommendations include: Hospitals should increase their ICU beds to the maximal extent by expanding ICU capacity and expanding ICUs into other areas. Hospitals should have appropriate beds and monitors for these expansion areas. Establish a management system with control groups at facility, local, regional and/or national levels to exercise authority over resources. Establish a system of communication, coordination and collaboration between the ICU and key interface departments. A plan to access, coordinate and increase labor resources is required with a central inventory of all clinical and non-clinical staff. Delegate duties not within the usual scope of workers' practice. Ensure that adequate essential medical equipment, pharmaceuticals and supplies are available. Protect patients and staff with infection control practices and supporting occupational health policies. Maintain staff confidence with reassurance plans for legal protection and assistance. Have objective, ethical, transparent triage criteria that are applied equitably and publically disclosed. ICU triage of patients should be based on the likelihood for patients to benefit most or a 'first come, first served' basis. Develop protocols for safe performance of high-risk procedures. Train and educate staff. Mortality, although inevitable during a severe influenza outbreak or disaster, can be reduced by adequate preparation.

Emergency department triage scales and their components: a systematic review of the scientific evidence.

PubMed

Farrohknia, Nasim; Castrén, Maaret; Ehrenberg, Anna; Lind, Lars; Oredsson, Sven; Jonsson, Håkan; Asplund, Kjell; Göransson, Katarina E

2011-06-30

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED?2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥ 15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted.We found ED triage scales to be supported, at best, by limited and often insufficient evidence.The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other

Emergency Department Triage Scales and Their Components: A Systematic Review of the Scientific Evidence

PubMed Central

2011-01-01

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED? 2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted. We found ED triage scales to be supported, at best, by limited and often insufficient evidence. The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other

Mass Casualty Incident Primary Triage Methods in China

PubMed Central

Chen, Jin-Hong; Yang, Jun; Yang, Yu; Zheng, Jing-Chen

2015-01-01

Objective: To evaluate the technical characteristics and application of mass casualty incident (MCI) primary triage (PT) methods applied in China. Data Sources: Chinese literature was searched by Chinese Academic Journal Network Publishing Database (founded in June 2014). The English literature was searched by PubMed (MEDLINE) (1950 to June 2014). We also searched Official Websites of Chinese Central Government's (http://www.gov.cn/), National Health and Family Planning Commission of China (http://www.nhfpc.gov.cn/), and China Earthquake Information (http://www.csi.ac.cn/). Study Selection: We included studies associated with mass casualty events related to China, the PT applied in China, guidelines and standards, and application and development of the carding PT method in China. Results: From 3976 potentially relevant articles, 22 met the inclusion criteria, 20 Chinese, and 2 English. These articles included 13 case reports, 3 retrospective analyses of MCI, two methods introductions, three national or sectoral criteria, and one simulated field testing and validation. There were a total of 19 kinds of MCI PT methods that have been reported in China from 1950 to 2014. In addition, there were 15 kinds of PT methods reported in the literature from the instance of the application. Conclusions: The national and sectoral current triage criteria are developed mainly for earthquake relief. Classification is not clear. Vague criteria (especially between moderate and severe injuries) operability are not practical. There are no triage methods and research for children and special populations. There is no data and evidence supported triage method. We should revise our existing classification and criteria so it is clearer and easier to be grasped in order to build a real, practical, and efficient PT method. PMID:26415807

Effect of caring behavior on disposition toward critical thinking of nursing students.

PubMed

Pai, Hsiang-Chu; Eng, Cheng-Joo; Ko, Hui-Ling

2013-01-01

The purpose of this study was to explore the relationship between caring behavior and the disposition toward critical thinking of nursing students in clinical practice. A structural equation model was used to test the hypothesized relationship between caring behavior and critical thinking skills. Caring is the core of nursing practice, and the disposition toward critical thinking is needed for competent nursing care. In a fast-paced and complex environment, however, "caring" may be lost. Because nursing students will become professional nurses, it is essential to explore their caring behaviors and critical thinking skills and to understand how to improve their critical thinking skills based on their caring behavior. A cross-sectional study was used, with convenience sampling of students who were participating in associate degree nursing programs at 3 colleges of nursing. The following instruments were used: critical thinking disposition inventory Chinese version and caring behaviors scale. The study found that individuals with a higher frequency of caring behaviors had a higher score on critical thinking about nursing practice (β = .44, t = 5.14, P < .001). Specifically, caring behaviors accounted for 19.4% of the variance in students' critical thinking. The findings of this study revealed the importance of caring behavior and its relationship with the disposition toward critical thinking. Thus, it is recommended that nursing education should emphasize a curriculum related to caring behavior to improve the disposition toward critical thinking of nursing students. Copyright © 2013 Elsevier Inc. All rights reserved.

Strategic Planning for Research in Pediatric Critical Care.

PubMed

Tamburro, Robert F; Jenkins, Tammara L; Kochanek, Patrick M

2016-11-01

To summarize the scientific priorities and potential future research directions for pediatric critical care research discussed by a panel of experts at the inaugural Strategic Planning Conference of the Pediatric Trauma and Critical Illness Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Expert opinion expressed during the Strategic Planning Conference. Not applicable. Chaired by an experienced expert from the field, issues relevant to the conduct of pediatric critical care research were discussed and debated by the invited participants. Common themes and suggested priorities were identified and coalesced. Of the many pathophysiologic conditions discussed, the multiple organ dysfunction syndrome emerged as a topic in need of more study that is most relevant to the field. Additionally, the experts offered that the interrelationship and impact of critical illness on child development and family functioning are important research priorities. Consequently, long-term outcomes research was encouraged. The expert group also suggested that multidisciplinary conferences are needed to help identify key knowledge gaps to advance and direct research in the field. The Pediatric Critical Care and Trauma Scientist Development National K12 Program and the Collaborative Pediatric Critical Care Research Network were recognized as successful and important programs supported by the branch. The development of core data resources including biorepositories with robust phenotypic data using common data elements was also suggested to foster data sharing among investigators and to enhance disease diagnosis and discovery. Multicenter clinical trials and innovative study designs to address understudied and poorly understood conditions were considered important for field advancement. Finally, the growth of the pediatric critical care research workforce was offered as a priority that could be spawned in many ways including by expanded