Advancing Emergency Department Triage Prediction With Machine Learning to Optimize Triage for Abdominal Pain Surgery Patients.

BACKGROUND: The development of emergency department (ED) triage systems remains challenging in accurately differentiating patients with acute abdominal pain (AAP) who are critical and urgent for surgery due to subjectivity and limitations. We use machine learning models to predict emergency surgical abdominal pain patients in triage, and then compare their performance with conventional Logistic regression models. METHODS: Using 38 214 patients presenting with acute abdominal pain at Zhongnan Hospital of Wuhan University between March 1, 2014, and March 1, 2022, we identified all adult patients (aged ≥18 years). We utilized routinely available triage data in electronic medical records as predictors, including structured data (eg, triage vital signs, gender, and age) and unstructured data (chief complaints and physical examinations in free-text format). The primary outcome measure was whether emergency surgery was performed. The dataset was randomly sampled, with 80% assigned to the training set and 20% to the test set. We developed 5 machine learning models: Light Gradient Boosting Machine (Light GBM), eXtreme Gradient Boosting (XGBoost), Deep Neural Network (DNN), and Random Forest (RF). Logistic regression (LR) served as the reference model. Model performance was calculated for each model, including the area under the receiver-work characteristic curve (AUC) and net benefit (decision curve), as well as the confusion matrix. RESULTS: Of all the 38 214 acute abdominal pain patients, 4208 underwent emergency abdominal surgery while 34 006 received non-surgical treatment. In the surgery outcome prediction, all 4 machine learning models outperformed the reference model (eg, AUC, 0.899 [95%CI 0.891-0.903] in the Light GBM vs. 0.885 [95%CI 0.876-0.891] in the reference model), Similarly, most machine learning models exhibited significant improvements in net reclassification compared to the reference model (eg, NRIs of 0.0812[95%CI, 0.055-0.1105] in the XGBoost), with the exception of the RF model. Decision curve analysis shows that across the entire range of thresholds, the net benefits of the XGBoost and the Light GBM models were higher than the reference model. In particular, the Light GBM model performed well in predicting the need for emergency abdominal surgery with higher sensitivity, specificity, and accuracy. CONCLUSIONS: Machine learning models have demonstrated superior performance in predicting emergency abdominal pain surgery compared to traditional models. Modern machine learning improves clinical triage decisions and ensures that critically needy patients receive priority for emergency resources and timely, effective treatment.

Cognitive appraisals and coping strategies of registered nurses in the emergency department combating COVID-19: A scoping review.

OBJECTIVE: Explore the relevant evidence about stress-related cognitive appraisal and coping strategies among registered nurses in the emergency department (EDRNs) coping with the COVID-19 pandemic. METHODS: This scoping review followed the methodological framework of Arksey and O'Malley to map relevant evidence and synthesize the findings. We searched PubMed, EMBASE, CINAHL, Web of Science, and Scopus electronic databases for related studies from inception through February 2, 2022. This review further conducted study selection based on the PRISMA flow diagram and applied Lazarus and Folkman's Psychological Stress and Coping Theory to systematically organize, summarize, and report the findings. FINDINGS: Sixteen studies were included for synthesis. Most of the studies showed that the majority of EDRNs were overwhelmed by the COVID-19 pandemic. Depression, triaging distress, physical exhaustion, and intention to leave ED nursing were cited as major threats to their wellness. Additionally, comprehensive training, a modified triage system, a safe workplace, psychological support, promotion of resilience, and accepting responsibility may help EDRNs cope with pandemic-related challenges effectively. CONCLUSION: The long-lasting pandemic has affected the physical and mental health of EDRNs because they have increased their effort to respond to the outbreak with dynamically adjusted strategies. Future research should address a modified triage system, prolonged psychological issues, emergency healthcare quality, and solutions facing EDRNs during the COVID-19 or related future pandemics. CLINICAL RELEVANCE: EDRNs have experienced physical and psychological challenges during the pandemic. The ED administrators need to take action to ensure EDRNs' safety in the workplace, an up-to-date triage system, and mental health of frontline nurses to provide high-quality emergency care for combating COVID-19.

Improving the performance of a triage scale for chest pain patients admitted to emergency departments: combining cardiovascular risk factors and electrocardiogram.

BACKGROUND: The triage of patients presenting with chest pain on admission to the emergency department uses scales based on patient clinical presentation or an electrocardiogram (ECG). These scales have different sensitivity and specificity. Although a good sensitivity allows for the prompt identification of high-risk patients, specificity prevent ED overcrowding. Moreover, ECG at triage avoids missing ST elevation myocardial infarction, which requires urgent revascularization. Our study therefore aimed to investigate whether a scale combining ECG and cardiovascular risk factors (CVRF) improves the diagnostic performance of ED chest pain triage scale. METHODS AND RESULTS: In this prospective single-center observational study involving 505 patients, the standard ECG-based FRENCH scale was compared to a scale combining the ECG-based FRENCH scale and the patients CVRF. The new scale was called the "modified" FRENCH. The accuracy of patient CVRF collection was evaluated by comparing the results of triage nurses and ED physicians. Compared with the standard FRENCH scale, the modified FRENCH scale had an increased sensitivity (61% versus 75%) but a decrease in specificity (76% versus 64%) resulting in a similar diagnostic performance. Using CVRF collected by the ED physicians, the modified FRENCH scale had a sensitivity of 87% and a specificity of 56% with a significant improvement in his diagnostic performance compared with standard FRENCH scales. This improvement can be explained by an accurate collection of the CVRF by physicians compared with nurses, as suggested by the weak to moderate correlation between their respective data collection. CONCLUSION: In conclusion, combining ECG and accurately collected cardiovascular risks factor improves the diagnostic performance of the ECG based chest pain triage in the ED. TRIAL REGISTRATION: Trial registration number: NCT03913767 .

Mobile Triage Applications: A Systematic Review in Literature and Play Store.

The main objective of this paper is to review and analysis of the state of the art regarding triage applications (apps) for health emergencies. This research is based on a systematic review of the literature in scientific databases from 2010 to early 2021, following a prism methodology. In addition, a Google Play Store search of the triage apps found in the literature was performed for further evaluation. A total of 26 relevant papers were obtained for this study, of which 13 apps were identified. After searching for each of these apps in the Google Play Store platform, only 2 of them were obtained, and these were subsequently evaluated together with another app obtained from the link provided in the corresponding paper. In the analysis carried out, it was detected that from 2019 onwards there has been an increase in research interest in this area, since the papers obtained from this year onwards represent 38.5% of the relevant papers. This increase may be caused by the need for early selection of the most serious patients in such difficult times for the health service. According to the review carried out, an increase in mobile app research focused on Emergency Triage and a decrease in app studies for triage catastrophe have been identified. In this study it was also observed that despite the existence of many researches in this sense, only 3 apps contained in them are accessible. "TRIAGIST" does not allow the entry of an unidentified user, "Major Trauma Triage Tool" presents negative comments from users who have used it and "ESITriage" lacks updates to improve its performance.

The Quality of Care in the Emergency Management of Cancer Patients With Febrile Neutropenia: A Records-Based Cohort.

INTRODUCTION: Febrile neutropenia is one of the most severe oncological emergencies associated with the treatment of cancer. Patients with febrile neutropenia are at grave risk of developing life-threatening sepsis unless there is rapid initiation of treatment. The aim of this study was to evaluate the quality of ED care of patients with febrile neutropenia using the 3 quality dimensions of safety, effectiveness, and timeliness of care. METHODS: A retrospective review of all available records of adult cancer patients with febrile neutropenia who presented to 1 urban emergency department in Atlantic Canada was conducted over 5 years. RESULTS: Examining the 9 quality indicators of the 431 patients included in the study identified areas for improvement in each of the 3 dimensions. More than one third of the participants were unsafely discharged from the emergency department despite the severity of their conditions. Patients in the study were not seen promptly by the physician and did not receive timely treatment during different phases of their visit. Most importantly, the delay in antibiotic administration presented a major risk for this population. DISCUSSION: Aspects of care provided to this cohort of febrile neutropenia patients were inconsistent with the recommended evidence. Strengthening ED care is necessary to reduce the gap between evidence-based and actual care. Quality initiatives can be implemented to improve care to become safer, effective, and timely. Nurses who are in direct contact with the patients and who are actively involved in every single process of the health care system are well positioned to lead this change.

Age is associated with increased mortality in the RETTS-A triage scale.

BACKGROUND: Triage is widely used in the emergency department (ED) in order to identify the patient's level of urgency and often based on the patient's chief complaint and vital signs. Age has been shown to be independently associated with short term mortality following an ED visit. However, the most commonly used ED triage tools do not include age as an independent core variable. The aim of this study was to investigate the relationship between age and 7- and 30-day mortality across the triage priority level groups according to Rapid Emergency Triage and Treatment System - Adult (RETTS-A), the most widely used triage tool in Sweden. METHODS: In this cohort, we included all adult patients visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015, n = 639,387. All patients were triaged according to the RETTS-A and subsequently separated into three age strata: 18-59, 60-79 and ≥ 80 years. Descriptive analyses and logistic regression was used. The primary outcome measures were 7- and 30-day mortality. RESULTS: We observed that age was associated with both 7 and 30-day mortality in each triage priority level group. Mortality was higher in older patients across all triage priority levels but the association with age was stronger in the lowest triage group (p-value for interaction = < 0.001). Comparing patients ≥80 years with patients 18-59 years, older patients had a 16 and 7 fold higher risk for 7 day mortality in the lowest and highest triage priority groups, respectively. The corresponding numbers for 30-d mortality were a 21- and 8-foldincreased risk, respectively. CONCLUSION: Compared to younger patients, patients above 60 years have an increased short term mortality across the RETTS-A triage priority level groups and this was most pronounced in the lowest triage level. The reason for our findings are unclear and data suggest a validation of RETTS-A in aged patients.

Construction of learning objectives and content for emergency triage nurses in tertiary general hospitals: A Delphi study.

AIM: To construct learning objectives and educational content for emergency triage nurses based on core competencies. BACKGROUND: The core competencies of emergency triage nurses has an impact on the quality of medical services and patient treatment outcomes. However, research on learning objectives and educational content aimed at cultivating the core competencies of emergency triage nurses is limited. DESIGN: A Delphi study. METHODS: To develop a draft of the teaching objectives and content for emergency triage nurses based on core competencies, a literature review, semistructured interviews and expert group meetings were conducted. Then, 24 experts were invited to provide feedback on the draft and suggest revisions through two rounds of Delphi consultation. RESULTS: Consensus was reached on six core competencies, 30 learning objectives and 43 educational contents. The response rate for the two rounds of expert questionnaires was 100 %, with 79.2 % and 54.2 % of the experts providing feedback in the first and second rounds, respectively. The judgement coefficient (Ca) was 0.910, the familiarity coefficient (Cs) was 0.917 and the authority coefficient (Cr) was 0.914. The Kendall's W coefficients for the two rounds of expert inquiry were 0.321 and 0.334, indicating a statistically significant difference (P<0.05). CONCLUSIONS: Constructing learning objectives and educational content for emergency triage nurses based on core competencies is scientific and reliable and can provide a reference for the training and management of emergency triage nurses.

Impact of triage nurses' recognition of acute coronary syndrome on patients' clinical outcomes: A retrospective study.

BACKGROUND: Triage nurses' pivotal role in initial assessment makes their competence crucial. However, the specific impact on Acute Coronary Syndrome (ACS) recognition and outcomes remains unclear in Jordanian healthcare. Understanding this relationship could enhance ACS management and patient outcomes in Jordanian Emergency Departments (EDs). OBJECTIVE: To assess how triage nurses' recognition of ACS diagnosis affects patient outcomes in Jordan. METHODS: This retrospective study examined records of 150 ACS patients admitted to the coronary care unit (CCU). Data extraction assessed triage nurses' accuracy in recognizing ACS symptoms and the timelines for diagnosis procedures (e.g., electrocardiogram [ECG]) and treatment provision (e.g., thrombolytic) based on triage decisions. It also evaluated the impact on treatment outcomes, including length of stay in the ED and hospital. Multiple linear regression analyses quantified the influence of under-triage on treatment outcomes. RESULTS: The sample comprised 150 patients. Most were female (78.7%), aged 45-59.9 years (37.3%). ACS classifications: unstable angina (52.0%), STEMI (38.0%), NSTEMI (10.0%). The study included a cohort of ACS patients, with findings indicating varying degrees of under-triage by triage nurses. Analysis of timelines revealed significant delays in diagnosis and treatment initiation for patients subjected to under-triage. Multiple linear regression analyses demonstrated a robust association between under-triage and prolonged time to essential treatment outcomes, including delays in physician assessment, ECG performance, thrombolytic administration, and extended ED length of stay. CONCLUSION: Triage nurses' knowledge and competency are crucial determinants of accurate ACS recognition and subsequent clinical outcomes for patients presenting to the ED in Jordan. Investing in ongoing education and training programs for triage nurses may lead to improved ACS recognition rates and better patient outcomes in Jordanian healthcare settings.

Research of mortality risk prediction based on hospital admission data for COVID-19 patients.

As COVID-19 continues to spread across the world and causes hundreds of millions of infections and millions of deaths, medical institutions around the world keep facing a crisis of medical runs and shortages of medical resources. In order to study how to effectively predict whether there are risks of death in patients, a variety of machine learning models have been used to learn and predict the clinical demographics and physiological indicators of COVID-19 patients in the United States of America. The results show that the random forest model has the best performance in predicting the risk of death in hospitalized patients with COVID-19, as the COVID-19 patients' mean arterial pressures, ages, C-reactive protein tests' values, values of blood urea nitrogen and their clinical troponin values are the most important implications for their risk of death. Healthcare organizations can use the random forest model to predict the risks of death based on data from patients admitted to a hospital due to COVID-19, or to stratify patients admitted to a hospital due to COVID-19 based on the five key factors this can optimize the diagnosis and treatment process by appropriately arranging ventilators, the intensive care unit and doctors, thus promoting the efficient use of limited medical resources during the COVID-19 pandemic. Healthcare organizations can also establish databases of patient physiological indicators and use similar strategies to deal with other pandemics that may occur in the future, as well as save more lives threatened by infectious diseases. Governments and people also need to take action to prevent possible future pandemics.

Comparison of the novel WEst coast System for Triage (WEST) with Rapid Emergency Triage and Treatment System (RETTS©): an observational pilot study.

BACKGROUND: Most Swedish emergency departments (ED) use the triage system Rapid Emergency Triage and Treatment System (RETTS©), which over time has proven to prioritize patients to higher triage levels. When many patients are prioritized to high triage levels, challenges with identifying true high-risk patients and increased waiting time for these patients has emerged. In order to achieve a more balanced triage in relation to actual medical risk, the triage system WEst coast System for Triage (WEST) was developed, based on the South African Triage Scale (SATS). The aim of this study was to perform an initial evaluation of the novel emergency triage system WEST compared to the existing RETTS©. METHODS: Both RETTS© and WEST are five level triage systems illustrated by colors. Nurses from each of the three adult EDs of Sahlgrenska University Hospital in Gothenburg and the ambulance service assessed and triaged 1510 patients according to RETTS© and immediately thereafter filled out the WEST triage form. Data from each triage report were analyzed and grouped according to the triage color, chief complaint, and outcome of each patient. Data on discharge categories and events within 72 h were also collected. Data were analyzed with descriptive statistical methods. RESULTS: In general, WEST displayed lower levels of prioritization compared to RETTS©, with no observed impact on patients' medical outcomes. In RETTS© orange triage level, approximately 50% of the patients were down prioritized in WEST to yellow or green triage levels. Also, in the RETTS© yellow triage level, more than 55% were down prioritized to green triage level in WEST. The number of patients who experienced a serious event during the first 72 h was few. Three patients died, these were all prioritized to red triage level in RETTS©. In WEST two of these patients were prioritized to red triage level and one to orange triage level. All these patients were admitted to hospital before deterioration. CONCLUSIONS: WEST may reduce over prioritization at the ED, especially in the orange and yellow triage levels of RETTS©, with no observed increase in medical risk. WEST can be recommended for a clinical comparative study.

Effect of In-Situation Versus Manchester Triage System-Based Initial Case Management on Hospital-Based Mortality: A Before and After Study.

OBJECTIVE: To compare mortality and treatment-initiation time pre- and post introduction of Manchester Triage System (MTS) in patients of age group 1 mo to 15 y admitted in a tertiary care hospital in India. METHODS: Pre- and post intervention study conducted on a prospective cohort of patients hospitalized over a period of 6 mo, who were triaged using MTS and compared with a retrospective cohort, who were not formally triaged using any system and were admitted to the hospital during the past 6 mo, prior to commencement of the study. Intervention was training of resident doctors for five MTS urgencies using flowcharts and discriminators and displaying them in the emergency room. Data on clinical and outcome variables were abstracted from hospital case record sheets in both the cohorts. RESULTS: The present study was conducted from May 2019 to April 2020 including 450 patients hospitalized from August 2019 to January 2020 in a prospective cohort and a retrospective cohort of 450 patients hospitalized from January 2019 to June 2019. Overall mortality in pre-MTS group was 26.2% (118/450) as compared to 20.9% (94/450) in post-MTS group (p value = 0.021). Average treatment time was reduced from 30 to 10 min after implementation of MTS (p value = 0.001). CONCLUSION: Implementation of MTS in pediatric emergency leads to statistically significant reduction of mortality and average treatment-initiation time.

Collaborative Interprofessional Health Science Student Led Realistic Mass Casualty Incident Simulation.

In collaboration, a health science university and a fire department offered a mass casualty incident (MCI) simulation. The purpose of this study was to evaluate a cross-section of student health care providers to determine their working knowledge of an MCI. Students were given a pretest using the Emergency Preparedness Information Questionnaire (EPIQ) and the Simple Triage and Rapid Transport (START) Quiz. The EPIQ instrument related to knowledge of triage, first aid, bio-agent detection, critical reporting, incident command, isolation/quarantine/decontamination, psychological issues, epidemiology, and communications. The START Quiz gave 10 scenarios. Didactic online content was given followed by the simulation a few weeks later. A posttest with the same instruments was given after the simulation. Participants were majority female (81.7%), aged between 25-34 (41.7%), and 61.7% (n = 74) had undergraduate or post-graduate degrees. The overall pretest mean was 2.92 and posttest mean was 3.64. The START Quiz found participants struggled to correctly assign triage levels. Students also experienced challenges correctly assigning patients to specific triage categories. Findings will assist educators to understand knowledge gaps, so revisions can be made to enhance learning in disaster management. Concentration in proper field triage is also a needed focus.

A mixed-methods study on evaluating an updated, francophone version of ETAT+ training in Madagascar.

Background: Madagascar needs major efforts to achieve the UN Sustainable Development Goals, despite the considerable reduction of child mortality during past years. In this context, implementation of emergency triage assessment and treatment (ETAT) plays an important role. In recent years, ETAT training activities rarely took place in Madagascar. To strengthen ETAT in Madagascar, a pilot training course was conducted in December 2019 at the University Hospital Mahajanga. Objectives: This study aims to evaluate if the ETAT+ pilot training content matches clinical needs in Madagascar and whether participants achieved their learning objectives. Methods: In this cross-sectional mixed-methods study, a 41-item questionnaire was used at the end of the ETAT+ training to evaluate their learning experience from the 12 participants (paediatricians, physicians, nurses and midwives). Six weeks after the training, guided interviews were conducted among five participants to describe how training content could be transferred into clinical practice in five health facilities. Results: Results suggest that this pilot project designed to contribute to the re-establishment of ETAT in Madagascar meets participants' needs and is adapted to clinical realities in terms of transmitted knowledge, skills and competencies. However, results also show that considerable multi-disciplinary efforts are needed to advance ETAT+ implementation in Madagascar. Conclusion: Implementation processes of ETAT training programmes need re-evaluation to assure their validity to contribute to quality of care improvements efficiently. Further operational research is required to evaluate sustainable, innovative implementation strategies adapted to contexts in Madagascar. Contributions of the study: This study aims to evaluate an updated Malagasy version of the Emergency Triage Assessment and Treatment Plus (ETAT+). The training met the participants' needs and was adapted to the clinical realities in Madagascar relating to transmitted knowledge, skills and competencies.

A longitudinal, retrospective registry-based validation study of RETTS©, the Swedish adult ED context version.

BACKGROUND: Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. The Rapid Emergency Triage and Treatment System (RETTS©), with annual updates, is the most applied triage system. However, the national implementation has been performed despite low scientific foundation for triage as a method, mainly related to the absence of adjustment to age and gender. Furthermore, there is a lack of studies of RETTS© in Swedish ED context, especially of RETTS© validity. Hence, the aim the study was to determine the validity of RETTS©. METHODS: A longitudinal retrospective register study based on cohort data from a healthcare region comprising two EDs in southern Sweden. Two editions of RETTS© was selected; year 2013 and 2016, enabling comparison of crude data, and adjusted for age-combined Charlson comorbidity index (ACCI) and gender. All patients ≥ 18 years visiting either of the two EDs seeing a physician, was included. Primary outcome was ten-day mortality, secondary outcome was admission to Intensive Care Unit (ICU). The data was analysed with descriptive, and inferential statistics. RESULTS: Totally 74,845 patients were included. There was an increase in patients allocated red or orange triage levels (unstable) between the years, but a decrease of admission, both to general ward and ICU. Of all patients, 1031 (1.4%) died within ten-days. Both cohorts demonstrated a statistically significant difference between the triage levels, i.e. a higher risk for ten-day mortality and ICU admission for patients in all triage levels compared to those in green triage level. Furthermore, significant statistically differences were demonstrated for ICU admission, crude as well as adjusted, and for adjusted data ten-day mortality, indicating that ACCI explained ten-day mortality, but not ICU admission. However, no statistically significant difference was found for the two annual editions of RETTS© considering ten-day mortality, crude data. CONCLUSION: The annual upgrade of RETTS© had no statistically significant impact on the validity of the triage system, considering the risk for ten-day mortality. However, the inclusion of ACCI, or at least age, can improve the validity of the triage system.

Potential Clinical Value of Biomarker-Guided Emergency Triage for Thoracic Aortic Dissection.

Aim: Thoracic aortic dissection (TAD) is a high-risk vascular disease. The mortality rate of untreated TADs in 24 h was as high as 50%. Thus, rapid diagnosis of TAD in the emergency department would get patients to the right treatments to save their lives. Methods: We profiled the proteome of aortic tissues from TAD patients using a label-free quantification proteomics method. The differentially expressed proteins were screened and subjected to bioinformatics analysis. Candidate biomarkers were selected and validated in independent serum samples using enzyme-linked immunosorbent assays (ELISAs). The diagnostic values were further predicted via receiver operating characteristic (ROC) curve analysis. Results: A total of 1,141 differentially expressed proteins were identified in aortic tissues from 17 TAD patients and eight myocardial infarction (MI) patients. Six proteins were selected as candidate biomarkers for ELISAs in an independent training set of 20 serum samples (TAD = 10, MI = 10). Of these proteins, four with a P-value < 0.01 were further validated in another independent set of 64 serum samples (TAD = 32, MI = 32) via ELISAs. ITGA2, COL2A1, and MIF had P-values < 0.0001, and their areas under the curve (AUCs) were 0.801 (95% CI: 0.691-0.911), 0.773 (95% CI: 0.660-0.887), and 0.701 (95% CI: 0.574-0.828), respectively. Conclusion: ITGA2, COL2A1, and MIF were identified as promising biomarkers for discriminating TAD from emergency patients with severe chest pain. Biomarker-guided emergency triage could further shorten the time for patients to get more effective treatments.

Identifying a Clinical Risk Triage Score for Adult Emergency Department.

Emergency triage is crucial for the treatment and prognosis of emergency patients, but its validity needs further improvement. The purpose of this study was to identify a risk score for adult triage. We conducted a regression analysis of physiological and biochemical data from 1,522 adult patients. A 60-point triage scoring model included temperature, pulse, systolic blood pressure, oxygen saturation, consciousness, dyspnea, admission mode, syncope history, chest pain or chest tightness, complexion, hematochezia or hematemesis, hemoptysis, white blood count, creatinine, bicarbonate, platelets, and creatine kinase. The area under curve in predicting ICU admission was 0.929 (95% CI [0.913-0.944]) for the derivation cohort and 0.911 (95% CI [0.884-0.938]) for the validation cohort. Four categories: critical level (≥13 points), severe level (6-12 points), urgency level (1-5 points), and sub-acute level (0 points) were divided, which significantly distinguished the severity of emergency patients.

Capacity Building for Health Care Workers and Support Staff in Pediatric Emergency Triage Assessment and Treatment (ETAT) at Primary Health Care Level in Resource Limited Settings: Experiences from Malawi.

Primary health care facilities offer an entry point to the health care system in Malawi. Challenges experienced by these facilities include limited resources (both material and human), poor or inadequate knowledge, skills and attitudes of health care workers in emergency management, and delay in referral from primary care level to other levels of care. These contribute to poor outcomes including children dying within the first 24 hours of hospital admission. Training of health care workers and support staff in Emergency Triage Assessment and Treatment (ETAT) at primary care levels can help improve care of children with acute and severe illnesses. Health care workers and support staff in the primary care settings were trained in pediatric ETAT. The training package for health care workers was adapted from the Ministry of Health ETAT training for district and tertiary health care. Content for support staff focused on non-technical responsibility for lifesaving in emergency situations. The primary health care facilities were provided with a minimum treatment package comprising emergency equipment, supplies and drugs. Supportive supervisory visits were conducted quarterly. The training manual for health care workers was adapted from the Ministry of Health package and the support staff training manual was developed from the adapted package. Eight hundred and seventy-seven participants were trained (336 health care workers and 541 support staff). Following the training, triaging of patients improved and patients were managed as emergency, priority or non-urgent. This reduced the number of referral cases and children were stabilized before referral. Capacity building of health care workers and support staff in pediatric ETAT and the provision of a basic health center package improved practice at the primary care level. The practice was sustained through institutional mentorship and pre-service and in-service training. The practice of triage and treatment including stabilization of children with dangerous signs at the primary health care facility improves emergency care of patients, reduces the burden of patients on referral hospitals and increases the number of successful referrals.

The Oncological Emergency of Intestinal Obstruction: ED Recognition and Treatment Outcomes.

OBJECTIVES: Gastrointestinal complications, like blockage, are among the most common oncological emergencies. We investigated whether individuals with cancer presenting at the emergency department (ED) with intestinal obstruction were triaged accurately, and we further evaluated the triage decisions' effect on their ED treatment outcomes. DATA SOURCES: A retrospective review was completed on all available records of adult cancer patients who were admitted with intestinal obstruction to a tertiary referral hospital. Over 3 years, 46 cancer patients were admitted from the ED with a provisional diagnosis of intestinal obstruction, confirmed by radiological examination. More than half the patients were undertriaged, which often resulted in these patients experiencing a series of risky time delays in the ED. Patients were significantly delayed in reaching five treatment outcomes: first assessment with a physician, initiation of treatment, decision to admit, length of ED stay, and length of hospital stay. CONCLUSION: The application of triage in practice was inconsistent, inaccurate, and had a significant negative impact on patient treatment outcomes. IMPLICATIONS FOR NURSING PRACTICE: The study results indicated the need to critically analyze current triage training and policies to increase their effectiveness. Improvement strategies are identified in the literature, and several are discussed. Involving triage nurses in this work is essential.

Effect of Undertriage on the Outcomes of Cancer Patients with Febrile Neutropenia, Sepsis, and Septic Shock.

Sepsis and neutropenia are considered the primary life-threatening complications of cancer treatment and are the leading cause of hospitalization and death. The objective was to study whether patients with neutropenia, sepsis, and septic shock were identified appropriately at triage and receive timely treatment within the emergency setting. Also, we investigated the effect of undertriage on key treatment outcomes. We conducted a retrospective analysis of all accessible records of admitted adult cancer patients with febrile neutropenia, sepsis, and septic shock. Our results identified that the majority of patients were inappropriately triaged to less urgent triage categories. Patients' undertriage significantly prolonged multiple emergency timeliness indicators and extended length of stay within the emergency department and hospital. These effects suggest that triage implementation must be objective, consistent, and accurate because of the several influences of the assigned triage scoring on treatment and health outcomes.

An updated national survey of triage and triage related work in Sweden: a cross-sectional descriptive and comparative study.

BACKGROUND: Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. According to two national surveys from 2005 to 2011, triage was carried out with different triage scales and without guidelines or formal education. Furthermore, a review from 2010 questioned the scientific evidence for both triage as a method as well as the Swedish five level triage scale Medical Emergency Triage and Treatment System (METTS); nevertheless, METTS was applied in 65% of the EDs in 2011. Subsequently, METTS was renamed to Rapid Emergency Triage and Treatment System (RETTS©). The hypothesis for this study is that the method of triage is still applied nationally and that the use of METTS/RETTS© has increased. Hence, the aim is to describe the occurrence and application of triage and triage related work at Swedish Emergency Departments, in comparison with previous national surveys. METHODS: In this cross-sectional study with a descriptive and comparative design, an electronic questionnaire was developed, based on questionnaire from previous studies. The survey was distributed to all hospital affiliated EDs from late March to the middle of July in 2019. The data was analysed with descriptive statistics, by IBM SPSS Statistics, version 26. RESULTS: Of the 51 (75%) EDs partaking in the study, all (100%) applied triage, and 92% used the Swedish triage scale RETTS©. Even so, there was low concordance in how RETTS© was applied regarding time frames i.e., how long a patient in respective triage level could wait for assessment by a physician. Additionally, the results show a major diversion in how the EDs performed education in triage. CONCLUSION: This study confirms that triage method is nationally implemented across Swedish EDs. RETTS© is the dominating triage scale but cannot be considered as one triage scale due to the variation with regard to time frames per triage level. Further, a diversion in introduction and education in the pivotal role of triage has been shown. This can be counteracted by national guidelines in what triage scale to use and how to perform triage education.