Ability of triage nurses to predict, at the time of triage, the eventual disposition of patients attending the emergency department (ED): a systematic literature review and meta-analysis.

INTRODUCTION: Exit block is the most significant cause of poor patient flow and crowding in the emergency department (ED). One proposed strategy to reduce exit block is early admission predictions by triage nurses to allow proactive bed management. We report a systematic review and meta-analysis of the accuracy of nurse prediction of admission at triage. METHODOLOGY: We searched MEDLINE, Cochrane, Embase, CINAHL and grey literature, up to and including February 2019. Our criteria were as follows: prospective studies analysing the accuracy of triage nurse intuition-after gathering standard triage information-for predicting disposition for adult ED patients. We analysed the results of this test-nurse prediction of disposition-in a diagnostic test analysis review style, assessing methodology with the Quality Assessment of Diagnostic Accuracy Studies 2 checklist. We generated sensitivity, specificity and likelihood ratios (LRs). We used LRs and pretest probability of admission (baseline admission rate) to find positive and negative post-test probabilities. RESULTS: We reviewed 10 articles. Of these, seven had meta-analysable data (12 282 participants). The studies varied in participant selection and admission rate, but the majority were of moderate quality and exclusion of each in sensitivity analyses made little difference. Sensitivity was 72% and specificity was 83%. Pretest probability of admission was 29%. Positive and negative post-test probabilities of admission were 63% and 12%, respectively. CONCLUSION: Triage nurse prediction of disposition is not accurate enough to expedite admission for ED patients on a one-to-one basis. Future research should explore the benefit, and best method, of predicting total demand.

It is time to think inside the (collimation) box; a quality improvement project to reduce over-scanning in CT scanning of the kidneys, ureters and bladder.

OBJECTIVE: The Royal College of Radiologists (RCR) recommend CT of the kidneys, ureters and bladder (CTKUB) as the first-line investigation for renal colic, stating that excess scan length above the upper pole of the highest kidney should not exceed 10% of the total scan length. The project aim was to determine what proportion of CTKUB scans performed at a district general hospital (DGH) were meeting this standard and explore improvement options as necessary. METHODS: A retrospective study was performed on 100 consecutive patients who attended a Radiology Department with renal colic. The number of CTKUB slices above the upper pole of the highest kidney, relative to scan length, was recorded. The DGH radiographers believed over scanning could be reduced by viewing image acquisition in real-time and manually stopping the scan at the top of the highest kidney. This was implemented and a re-audit of 50 patients was performed. RESULTS: Scan length exceeded the standard on 81% of scans (81/100). Over scanning was reduced to 14% (7/50) post-intervention. CONCLUSION: This DGH was over scanning a large proportion of patients. Manually stopping the CTKUB significantly reduced over scanning. ADVANCES IN KNOWLEDGE: A small change to CTKUB scanning technique can significantly improve adherence to RCR guidelines.