Undertriage in older emergency department patients--tilting against windmills?

OBJECTIVES: The aim of this study was to investigate the long-term effect of a teaching intervention designed to reduce undertriage rates in older ED patients. Further, to test the hypothesis that non-adherence to the Emergency Severity Index (ESI) triage algorithm is associated with undertriage. Additionally, to detect patient related risk factors for undertriage. METHODS: Pre-post-test design. The study sample consisted of all patients aged 65 years or older presenting to the ED of an urban tertiary and primary care center in the study periods. A teaching intervention designed to increase adherence to the triage algorithm. To assess, if the intervention resulted in an increase of factual knowledge, nurses took a test before and immediately after the teaching intervention. Undertriage rates were assessed one year after the intervention and compared to the pre-test period. RESULTS: In the pre-test group 519 patients were included, and 394 in the post-test-group. Factual knowledge among triage nurses was high already before the teaching intervention. Prevalence of undertriaged patients before (22.5%) and one year after the intervention (24.2%) was not significantly different (χ2 = 0.248, df = 1, p = 0.619). Sex, age, mode of arrival, and type of complaint were not identified as independent risk factors for undertriage. However, undertriage rates increased with advancing age. Adherence to the ESI algorithm is associated with correct triage decisions. CONCLUSIONS: Undertriage of older ED patients remained unchanged over time. Reasons for undertriage seem to be more complex than anticipated. Therefore, additional contributing factors should be addressed.

The efficacy of ventricular pacing with device automaticity in paediatric patients.

AIMS: To compare pacemaker reprogramming and re-intervention rates in children with AutoCapture (AC) and conventionally (Conv) programmed devices, and to assess reliability of device automaticity. METHODS AND RESULTS: Data of children with AC (group AC, n = 49) and conventionally programmed devices (group Conv, n = 41) were analysed. A total of 1106 outpatient visits and 147 Holter recordings were screened for device reprogramming and invasive re-intervention. At 2 and 5 years, freedom from reprogramming differed significantly between groups (AC: 63/35% vs. Conv: 13/4%; P < 0.0001), whereas freedom from re-intervention was not different (AC: 95/90% vs. Conv: 95/85%; P = 0.26). Mean yearly rate of reprogramming was lower in group AC (AC: 0.67 +/- 0.55 vs. Conv: 1.13 +/- 0.82; P = 0.005). Follow-up duration correlated with a decreasing number of reprogramming per year in group Conv (rho = -0.73, P < 0.001). No ventricular output reprogramming was required in group AC. Holter recordings required 0.07 +/- 0.13 reprogramming per year in group Conv, none in group AC (P < 0.001). Holter-detected lead dysfunction prompted re-intervention in one patient of each group. CONCLUSION: Estimated freedom from as well as total yearly rate of device reprogramming was favourable for AC-programmed devices. No difference was seen for the incidence of invasive re-interventions. AC ventricular output control was effective. Structured device follow-up and Holter recordings in specific patient groups remain mandatory for all devices in paediatric patients.