Modification and Validation of a Complaint-Oriented Emergency Department Triage System: A Multicenter Observational Study.
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ABSTRACT: Purpose
The objective of this study was to modify and validate an emergency department (ED) triage system with improved prediction performance on hospital outcomes by modifying the Korean Triage and Acuity Scale (KTAS).Materials and methods
We performed a retrospective observational study at three academic universities in South Korea. The KTAS code, determined by the chief complaint and the selected modifier of a patient, was used to derive the Modified KTAS (MKTAS). We calculated the area under the receiver operating characteristics curve (AUC) and the test characteristics to evaluate the performance of MKTAS to predict hospital mortality, critical outcome, and admission.Results
A total of 272402 and 128831 ED visits were used for the derivation and validation of MKTAS, respectively. Compared to KTAS, MKTAS had significantly higher AUC values for the prediction of hospital mortality [MKTAS 0.826 (0.818-0.835) vs. KTAS 0.794 (0.784-0.803)], critical outcome [MKTAS 0.836 (0.830-0.841) vs. 0.798 (0.792-0.804)], and admission [MKTAS 0.725 (0.723-0.728) vs. KTAS 0.685 (0.682-0.688)]. The sensitivity for predicting hospital mortality and critical outcome, as well as the specificity for predicting admission, were significantly improved.Conclusion
MKTAS was derived by modifying the KTAS, and then validated. Compared with KTAS, MKTAS showed better discriminating ability to predict hospital outcomes. Continuous efforts to evaluate and modify widely used triage systems are required to improve their performance.
SUBMITTER: Choi DH
PROVIDER: S-EPMC8612858 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundTo date, there are no valid statistics regarding the number of full time staff necessary for nursing care in emergency departments in Europe.Material and methodsStaff requirement calculations were performed using state-of-the art procedures which take both fluctuating patient volume and individual staff shortfall rates into consideration. In a longitudinal observational study, the average nursing staff engagement time per patient was assessed for 503 patients. For this purpose, a full-time staffing calculation was estimated based on the five priority levels of the Manchester Triage System (MTS), taking into account specific workload fluctuations (50th-95th percentiles).ResultsPatients classified to the MTS category red (n = 35) required the most engagement time with an average of 97.93 min per patient. On weighted average, for orange MTS category patients (n = 118), nursing staff were required for 85.07 min, for patients in the yellow MTS category (n = 181), 40.95 min, while the two MTS categories with the least acute patients, green (n = 129) and blue (n = 40) required 23.18 min and 14.99 min engagement time per patient, respectively. Individual staff shortfall due to sick days and vacation time was 20.87% of the total working hours. When extrapolating this to 21,899 (2010) emergency patients, 67-123 emergency patients (50-95% percentile) per month can be seen by one nurse. The calculated full time staffing requirement depending on the percentiles was 14.8 to 27.1.ConclusionPerformance-oriented staff planning offers an objective instrument for calculation of the full-time nursing staff required in emergency departments.
| S-EPMC4854466 | biostudies-literature
Project description:ObjectiveTriage is a tool developed to identify patients who need immediate care and those who can safely wait. The aim of this study was to assess the validity and interrater reliability of a modified version of the pediatric South African triage scale (pSATS) in a single-center tertiary pediatric emergency department in Norway.MethodsThis prospective, observational study included all patients with medical conditions, referred to the pediatric emergency department of a tertiary hospital in Norway from September 1, 2015, to November 17, 2015. Their assigned triage priority was compared with rate of hospitalization and resource utilization. Validity parameters were sensitivity, specificity, positive and negative predictive value, and percentage of over- and undertriage. Interrater agreement and accuracy of the triage ratings were calculated from triage performed by nurses on written case scenarios.ResultsDuring the study period, 1171 patients arrived at the hospital for emergency assessment. A total of 790 patients (67 %) were triaged and included in the study. The percentage of hospital admission increased with increasing level of urgency, from 30 % of the patients triaged to priority green to 81 % of those triaged to priority red. The sensitivity was 74 %, the specificity was 48 %, the positive predictive value was 52 %, and the negative predictive value was 70 % for predicting hospitalization. The level of over- and undertriage was 52 % and 26 %, respectively. Resource utilization correlated with higher triage priority. The interrater agreement had an intraclass correlation coefficient of 0.99 by Cronbach's alpha, and the accuracy was 92 %.ConclusionsThe modified pSATS had a moderate sensitivity and specificity but showed good correlation with resource utilization. The nurses demonstrated excellent interrater agreement and accuracy when triaging written case scenarios.
| S-EPMC6205310 | biostudies-literature
Project description:BackgroundA substantial proportion of attendances to ophthalmic emergency departments are for non-urgent presentations. We developed and evaluated a machine learning system (DemDx Ophthalmology Triage System: DOTS) to optimise triage, with the aim of reducing inappropriate emergency attendances and streamlining case referral when necessary.MethodsDOTS was built using retrospective tabular data from 11,315 attendances between July 1st, 2021, to June 15th, 2022 at Moorfields Eye Hospital Emergency Department (MEH) in London, UK. Demographic and clinical features were used as inputs and a triage recommendation was given ("see immediately", "see within a week", or "see electively"). DOTS was validated temporally and compared with triage nurses' performance (1269 attendances at MEH) and validated externally (761 attendances at the Federal University of Minas Gerais - UFMG, Brazil). It was also tested for biases and robustness to variations in disease incidences. All attendances from patients aged at least 18 years with at least one confirmed diagnosis were included in the study.FindingsFor identifying ophthalmic emergency attendances, on temporal validation, DOTS had a sensitivity of 94.5% [95% CI 92.3-96.1] and a specificity of 42.4% [38.8-46.1]. For comparison within the same dataset, triage nurses had a sensitivity of 96.4% [94.5-97.7] and a specificity of 25.1% [22.0-28.5]. On external validation at UFMG, DOTS had a sensitivity of 95.2% [92.5-97.0] and a specificity of 32.2% [27.4-37.0]. In simulated scenarios with varying disease incidences, the sensitivity was ≥92.2% and the specificity was ≥36.8%. No differences in sensitivity were found in subgroups of index of multiple deprivation, but the specificity was higher for Q2 when compared to Q4 (Q4 is less deprived than Q2).InterpretationAt MEH, DOTS had similar sensitivity to triage nurses in determining attendance priority; however, with a specificity of 17.3% higher, DOTS resulted in lower rates of patients triaged to be seen immediately at emergency. DOTS showed consistent performance in temporal and external validation, in social-demographic subgroups and was robust to varying relative disease incidences. Further trials are necessary to validate these findings. This system will be prospectively evaluated, considering human-computer interaction, in a clinical trial.FundingThe Artificial Intelligence in Health and Care Award (AI_AWARD01671) of the NHS AI Lab under National Institute for Health and Care Research (NIHR) and the Accelerated Access Collaborative (AAC).
| S-EPMC10711497 | biostudies-literature
Project description:Objectives:The aim of this study was to develop machine learning (ML) and initial nursing assessment (INA)-based emergency department (ED) triage to predict adverse clinical outcome. Methods:The retrospective study included ED visits between January 2016 and December 2017 that resulted in either intensive care unit admission or emergency room death. We trained four classifiers using logistic regression and a deep learning model on INA and low dimensional (LD) INA, logistic regression on the Korea Triage and acuity scale (KTAS) and Sequential Related Organ Failure Assessment (SOFA). We varied the outcome ratio for external validation. Finally, variables of importance were identified using the random forest model's information gain. The four most influential variables were used for LD modeling for efficiency. Results:A total of 86,304 patient visits were included, with an overall outcome rate of 3.5%. The area under the curve (AUC) values for the KTAS model were 76.8 (74.9-78.6) with logistic regression and 74.0 (72.1-75.9) for the SOFA model, while the AUC values of the INA model were 87.2 (85.9-88.6) and 87.6 (86.3-88.9) with logistic regression and deep learning, suggesting that the ML and INA-based triage system result more accurately predicted the outcomes. The AUC values for the LD model were 81.2 (79.4-82.9) and 80.7 (78.9-82.5) for logistic regression and deep learning, respectively. Conclusions:We developed an ML and INA-based triage system for EDs. The novel system was able to predict clinical outcomes more accurately than existing triage systems, KTAS and SOFA.
| S-EPMC7010940 | biostudies-literature
Project description:Early recognition and prevention comprise the first ring of the Chain of Survival for in-hospital cardiac arrest (IHCA). We previously developed and internally validated an emergency department (ED) triage tool, Emergency Department In-hospital Cardiac Arrest Score (EDICAS), for predicting ED-based IHCA. We aimed to externally validate this novel tool in another ED population. This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center with approximately 130,000 ED visits per year. We retrieved data from 268,208 ED visits over a 2-year period. We selected one ED visit per person and excluded out-of-hospital cardiac arrest or children. Patient demographics and computerized triage information were retrieved, and the EDICAS was calculated to predict the ED-based IHCA. A total of 145,557 adult ED patients were included. Of them, 240 (0.16%) developed IHCA. The EDICAS showed excellent discrimination with an area under the receiver operating characteristic (AUROC) of 0.88. The AUROC of the EDICAS outperformed those of other early warning scores (0.80 for Modified Early Warning Score [MEWS] and 0.83 for Rapid Emergency Medicine Score [REMS]) in the same ED population. An EDICAS of 6 or above (i.e., high-risk patients) corresponded to a sensitivity of 33%, a specificity of 97%, and a positive likelihood ratio of 12.2. In conclusion, we externally validated a tool for predicting imminent IHCA in the ED and demonstrated its superior performance over other early warning scores. The real-world impact of the EDICAS warning system with appropriate interventions would require a future prospective study.
| S-EPMC9130149 | biostudies-literature
Project description:ObjectivesThis multicenter study examines the performance of the Manchester Triage System (MTS) after changing discriminators, and with the addition use of abnormal vital sign in patients presenting to pediatric emergency departments (EDs).DesignInternational multicenter study.SettingsEDs of two hospitals in The Netherlands (2006-2009), one in Portugal (November-December 2010), and one in UK (June-November 2010).PatientsChildren (<16 years) triaged with the MTS who presented at the ED.MethodsChanges to discriminators (MTS 1) and the value of including abnormal vital signs (MTS 2) were studied to test if this would decrease the number of incorrect assignment. Admission to hospital using the new MTS was compared with those in the original MTS. Likelihood ratios, diagnostic odds ratios (DORs), and c-statistics were calculated as measures for performance and compared with the original MTS. To calculate likelihood ratios and DORs, the MTS had to be dichotomized in low urgent and high urgent.Results60,375 patients were included, of whom 13% were admitted. When MTS 1 was used, admission to hospital increased from 25% to 29% for MTS 'very urgent' patients and remained similar in lower MTS urgency levels. The diagnostic odds ratio improved from 4.8 (95%CI 4.5-5.1) to 6.2 (95%CI 5.9-6.6) and the c-statistic remained 0.74. MTS 2 did not improve the performance of the MTS.ConclusionsMTS 1 performed slightly better than the original MTS. The use of vital signs (MTS 2) did not improve the MTS performance.
| S-EPMC3893080 | biostudies-literature
Project description:ObjectivesTo determine the validity of the Manchester Triage System (MTS) in emergency care for the general population of patients attending the emergency department, for children and elderly, and for commonly used MTS flowcharts and discriminators across three different emergency care settings.MethodsThis was a prospective observational study in three European emergency departments. All consecutive patients attending the emergency department during a 1-year study period (2010-2012) were included. Validity of the MTS was assessed by comparing MTS urgency as determined by triage nurses with patient urgency according to a predefined 3-category reference standard as proxy for true patient urgency.Results288,663 patients were included in the analysis. Sensitivity of the MTS in the three hospitals ranged from 0.47 (95%CI 0.44-0.49) to 0.87 (95%CI 0.85-0.90), and specificity from 0.84 (95%CI 0.84-0.84) to 0.94 (95%CI 0.94-0.94) for the triage of adult patients. In children, sensitivity ranged from 0.65 (95%CI 0.61-0.70) to 0.83 (95%CI 0.79-0.87), and specificity from 0.83 (95%CI 0.82-0.83) to 0.89 (95%CI 0.88-0.90). The diagnostic odds ratio ranged from 13.5 (95%CI 12.1-15.0) to 35.3 (95%CI 28.4-43.9) in adults and from 9.8 (95%CI 6.7-14.5) to 23.8 (95%CI 17.7-32.0) in children, and was lowest in the youngest patients in 2 out of 3 settings and in the oldest patients in all settings. Performance varied considerably between the different emergency departments.ConclusionsValidity of the MTS in emergency care is moderate to good, with lowest performance in the young and elderly patients. Future studies on the validity of triage systems should be restricted to large, multicenter studies to define modifications and improve generalizability of the findings.
| S-EPMC5289484 | biostudies-literature
Project description:BackgroundStudies on the reliability of the MTS and its predictive power for hospitalisation and mortality in the older population have demonstrated mixed results. The objective is to evaluate the performance of the Manchester Triage System (MTS) in older patients (?65?years) by assessing the predictive ability of the MTS for emergency department resource utilisation, emergency department length of stay (ED-LOS), hospitalisation, and in-hospital mortality rate. The secondary goal was to evaluate the performance of the MTS in older surgical versus medical patients.MethodsA retrospective cohort study was conducted of all emergency department visits by patients ?65?years between 01 and 09-2011 and 31-08-2012. Performance of the MTS was assessed by comparing the association of the MTS with emergency department resource utilisation, ED-LOS, hospital admission, and in-hospital mortality in older patients and the reference group (18-64?years), and by estimating the area under the receiver operating characteristics curves.ResultsData on 7108 emergency department visits by older patients and 13,767 emergency department visits by patients aged 18-64?years were included. In both patient groups, a higher emergency department resource utilisation was associated with a higher MTS urgency. The AUC for the MTS and hospitalisation was 0.74 (95%CI 0.73-0.75) in older patients and 0.76 (95%CI 0.76-0.77) in patients aged 18-64?years. Comparison of the predictive ability of the MTS for in-hospital mortality in older patients with patients aged 18-64?years revealed an AUC of 0.71 (95%CI 0.68-0.74) versus 0.79 (95%CI 0.72-0.85). The majority of older patients (54.8%) were evaluated by a medical specialty and 45.2% by a surgical specialty. The predictive ability of the MTS for hospitalisation and in-hospital mortality was higher in older surgical patients than in medical patients (AUC 0.74, 95%CI 0.72-0.76 and 0.74, 95%CI 0.68-0.81 versus 0.69, 95%CI 0.67-0.71 and 0.66, 95%CI 0.62-0.69).ConclusionThe performance of the MTS appeared inferior in older patients than younger patients, illustrated by a worse predictive ability of the MTS for in-hospital mortality in older patients. The MTS demonstrated a better performance in older surgical patients than older medical patients regarding hospitalisation and in-hospital mortality.
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Project description:Reduction in emergency department (ED) use is frequently viewed as a potential source for cost savings. One consideration has been to deny payment if the patient's diagnosis upon ED discharge appears to reflect a "nonemergency" condition. This approach does not incorporate other clinical factors such as chief complaint that may inform necessity for ED care.To determine whether ED presenting complaint and ED discharge diagnosis correspond sufficiently to support use of discharge diagnosis as the basis for policies discouraging ED use.The New York University emergency department algorithm has been commonly used to identify nonemergency ED visits. We applied the algorithm to publicly available ED visit data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) for the purpose of identifying all "primary care-treatable" visits. The 2009 NHAMCS data set contains 34,942 records, each representing a unique ED visit. For each visit with a discharge diagnosis classified as primary care treatable, we identified the chief complaint. To determine whether these chief complaints correspond to nonemergency ED visits, we then examined all ED visits with this same group of chief complaints to ascertain the ED course, final disposition, and discharge diagnoses.Patient demographics, clinical characteristics, and disposition associated with chief complaints related to nonemergency ED visits.Although only 6.3% (95% CI, 5.8%-6.7%) of visits were determined to have primary care-treatable diagnoses based on discharge diagnosis and our modification of the algorithm, the chief complaints reported for these ED visits with primary care-treatable ED discharge diagnoses were the same chief complaints reported for 88.7% (95% CI, 88.1%-89.4%) of all ED visits. Of these visits, 11.1% (95% CI, 9.3%-13.0%) were identified at ED triage as needing immediate or emergency care; 12.5% (95% CI, 11.8%-14.3%) required hospital admission; and 3.4% (95% CI, 2.5%-4.3%) of admitted patients went directly from the ED to the operating room.Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.
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Project description:We aimed to describe red blood cell (RBC) transfusions in the emergency department (ED) with a particular focus on the hemoglobin (Hb) level thresholds that are used in this setting. This was a cross-sectional study of 12 EDs including all adult patients that received RBC transfusion in January and February 2018. Descriptive statistics were reported. Logistic regression was performed to assess variables that were independently associated with a pre-transfusion Hb level ≥ 8 g/dL. During the study period, 529 patients received RBC transfusion. The median age was 74 (59-85) years. The patients had a history of cancer or hematological disease in 185 (35.2%) cases. Acute bleeding was observed in the ED for 242 (44.7%) patients, among which 145 (59.9%) were gastrointestinal. Anemia was chronic in 191 (40.2%) cases, mostly due to vitamin or iron deficiency or to malignancy with transfusion support. Pre-transfusion Hb level was 6.9 (6.0-7.8) g/dL. The transfusion motive was not notified in the medical chart in 206 (38.9%) cases. In the multivariable logistic regression, variables that were associated with a higher pre-transfusion Hb level (≥8 g/dL) were a history of coronary artery disease (OR: 2.09; 95% CI: 1.29-3.41), the presence of acute bleeding (OR: 2.44; 95% CI: 1.53-3.94), and older age (OR: 1.02/year; 95% CI: 1.01-1.04). RBC transfusion in the ED was an everyday concern and involved patients with heterogeneous medical situations and severity. Pre-transfusion Hb level was rather restrictive. Almost half of transfusions were provided because of acute bleeding which was associated with a higher Hb threshold.
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