Clinician perspectives on how situational context and augmented intelligence design features impact perceived usefulness of sepsis prediction scores embedded within a simulated electronic health record.

OBJECTIVE: Obtain clinicians' perspectives on early warning scores (EWS) use within context of clinical cases. MATERIAL AND METHODS: We developed cases mimicking sepsis situations. De-identified data, synthesized physician notes, and EWS representing deterioration risk were displayed in a simulated EHR for analysis. Twelve clinicians participated in semi-structured interviews to ascertain perspectives across four domains: (1) Familiarity with and understanding of artificial intelligence (AI), prediction models and risk scores; (2) Clinical reasoning processes; (3) Impression and response to EWS; and (4) Interface design. Transcripts were coded and analyzed using content and thematic analysis. RESULTS: Analysis revealed clinicians have experience but limited AI and prediction/risk modeling understanding. Case assessments were primarily based on clinical data. EWS went unmentioned during initial case analysis; although when prompted to comment on it, they discussed it in subsequent cases. Clinicians were unsure how to interpret or apply the EWS, and desired evidence on its derivation and validation. Design recommendations centered around EWS display in multi-patient lists for triage, and EWS trends within the patient record. Themes included a "Trust but Verify" approach to AI and early warning information, dichotomy that EWS is helpful for triage yet has disproportional signal-to-high noise ratio, and action driven by clinical judgment, not the EWS. CONCLUSIONS: Clinicians were unsure of how to apply EWS, acted on clinical data, desired score composition and validation information, and felt EWS was most useful when embedded in multi-patient views. Systems providing interactive visualization may facilitate EWS transparency and increase confidence in AI-generated information.

The design of an Obstetric Telephone Triage Guideline (OTTG): a mixed method study.

BACKGROUND: Clarifying the dimensions and characteristics of obstetric telephone triage is important in improving the quality of services in the health system because researchers can evaluate the effectiveness of treatment, care and diagnostic measures in the form of obstetric telephone triage by developing a guideline. Therefore, this study aimed to design an Obstetric Telephone Triage Guideline (OTTG) using a mixed-method study. METHODS: The present study was carried out using an exploratory sequential mixed method study in two qualitative and quantitative phases. An inductive-deductive approach was also used to determine the concept of obstetric telephone triage. In this respect, a qualitative study and a literature review were used in the inductive and deductive stages, respectively. Moreover, the validity of the developed guideline was confirmed based on experts' opinions and results of the AGREE II tool. RESULTS: The guideline included the items for evaluating the severity of obstetric symptoms at five levels including "critical", "urgent", "less urgent", "no urgent", and "recommendations". The validity of the guideline was approved at 96%, 95%, 97%, 95%, 93%, and 100% for six dimensions of AGREE II including scope and purpose, stakeholder involvement, the rigor of development, clarity of presentation, applicability, and editorial independence, respectively. CONCLUSION: The OTTG is a clinically comprehensive, easy-to-use, practical, and valid tool. This guideline is a standardized tool for evaluating the severity of symptoms and determining the urgency for obstetrics triage services. By using this integrated and uniform guideline, personal biases can be avoided, leading to improved performance and ensuring that patients are not overlooked. Additionally, the use of OTTG promotes independent decision-making and reduces errors in triage decision-making.

Personalised exercise rehabilitation in cancer survivorship: the percs triage and referral system study protocol.

BACKGROUND: To effectively embed exercise rehabilitation in cancer survivorship care, a co-ordinated system of acute and community exercise rehabilitation services, forming a stepped model of care, is recommended. Patients can be directed to the exercise rehabilitation service which best meets their needs through a system of assessment, triage and referral. Triage and referral systems are not yet widely applied in cancer survivorship practice and need to be evaluated in real-world contexts. The PERCS (Personalised Exercise Rehabilitation in Cancer Survivorship) study aims to evaluate the real-world application of an exercise rehabilitation triage and referral system in cancer survivors treated during the COVID-19 pandemic. Secondary aims are to evaluate change in physical and psychosocial outcomes, and to qualitatively evaluate the impact of the system and patient experiences, at three months after application of the triage and referral system. METHODS: This study will assess the implementation of an exercise rehabilitation triage and referral system within the context of a physiotherapy-led cancer rehabilitation clinic for cancer survivors who received cancer treatment during the COVID-19 pandemic. The PERCS triage and referral system supports decision making in exercise rehabilitation referral by recommending one of three pathways: independent exercise; fitness professional referral; or health professional referral. Up to 100 adult cancer survivors treated during the COVID-19 pandemic who have completed treatment and have no signs of active disease will be recruited. We will assess participants' physical and psychosocial wellbeing and evaluate whether medical clearance for exercise is needed. Participants will then be triaged to a referral pathway and an exercise recommendation will be collaboratively decided. Reassessment will be after 12 weeks. Primary outcomes are implementation-related, guided by the RE-AIM framework. Secondary outcomes include physical function, psychosocial wellbeing and exercise levels. Qualitative analysis of semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) will provide insights on implementation and system impact. DISCUSSION: The PERCS study will investigate the real-world application of a cancer rehabilitation triage and referral system. This will provide proof of concept evidence for this triage approach and important insights on the implementation of a triage system in a specialist cancer centre. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov, registration number: NCT05615285, date registered: 21st October 2022.

Triage-clinical reasoning on emergency nursing competency: a multiple linear mediation effect.

BACKGROUND: Triage is the first step in providing prompt and appropriate emergency nursing and addressing diagnostic issues. Rapid clinical reasoning skills of emergency nurses are essential for prompt decision-making and emergency care. Nurses experience limitations in emergency nursing that begin with triage. This cross-sectional study explored the mediating effect of perceived triage competency and clinical reasoning skills on the association between Korean Triage and Acuity Scale (KTAS) proficiency and emergency nursing competency. METHODS: A web-based survey was conducted with 157 emergency nurses working in 20 hospitals in South Korea between mid-May and mid-July 2022. Data were collected utilizing self-administered questionnaires to measure KTAS proficiency (48 tasks), perceived triage competency (30 items), clinical reasoning skills (26 items), and emergency nursing competency (78 items). Data were analyzed using the PROCESS macro (Model 6). RESULTS: Perceived triage competency indirectly mediate the relationship between KTAS proficiency and emergency nursing competency. Perceived triage competency and clinical reasoning skills were significant predictors of emergency nursing competency with a multiple linear mediating effect. The model was found have a good fit (F = 8.990, P <.001) with, a statistical power of 15.0% (R² = 0.150). CONCLUSIONS: This study indicates that improving emergency nursing competency requires enhancing triage proficiency as well as perceived triage competency, which should be followed by developing clinical reasoning skills, starting with triage of emergency nurses.

The Role of Large Language Models (LLMs) in Providing Triage for Maxillofacial Trauma Cases: A Preliminary Study.

BACKGROUND: In the evolving field of maxillofacial surgery, integrating advanced technologies like Large Language Models (LLMs) into medical practices, especially for trauma triage, presents a promising yet largely unexplored potential. This study aimed to evaluate the feasibility of using LLMs for triaging complex maxillofacial trauma cases by comparing their performance against the expertise of a tertiary referral center. METHODS: Utilizing a comprehensive review of patient records in a tertiary referral center over a year-long period, standardized prompts detailing patient demographics, injury characteristics, and medical histories were created. These prompts were used to assess the triage suggestions of ChatGPT 4.0 and Google GEMINI against the center's recommendations, supplemented by evaluating the AI's performance using the QAMAI and AIPI questionnaires. RESULTS: The results in 10 cases of major maxillofacial trauma indicated moderate agreement rates between LLM recommendations and the referral center, with some variances in the suggestion of appropriate examinations (70% ChatGPT and 50% GEMINI) and treatment plans (60% ChatGPT and 45% GEMINI). Notably, the study found no statistically significant differences in several areas of the questionnaires, except in the diagnosis accuracy (GEMINI: 3.30, ChatGPT: 2.30; p = 0.032) and relevance of the recommendations (GEMINI: 2.90, ChatGPT: 3.50; p = 0.021). A Spearman correlation analysis highlighted significant correlations within the two questionnaires, specifically between the QAMAI total score and AIPI treatment scores (rho = 0.767, p = 0.010). CONCLUSIONS: This exploratory investigation underscores the potential of LLMs in enhancing clinical decision making for maxillofacial trauma cases, indicating a need for further research to refine their application in healthcare settings.

Recommendation endpoints and safety of an online self-triage for depression symptoms.

INTRODUCTION: Online symptom checkers are a way to address patient concerns and potentially offload a burdened healthcare system. However, safety outcomes of self-triage are unknown, so we reviewed triage recommendations and outcomes of our institution's depression symptom checker. METHODS: We examined endpoint recommendations and follow-up encounters seven days afterward during 2 December 2021 to 13 December 2022. Patients with an emergency department visit or hospitalization within seven days of self-triaging had a manual review of the electronic health record to determine if the visit was related to depression, suicidal ideation, or suicide attempt. Charts were reviewed for deaths within seven days of self-triage. RESULTS: There were 287 unique encounters from 263 unique patients. In 86.1% (247/287), the endpoint was an instruction to call nurse triage; in 3.1% of encounters (9/287), instruction was to seek emergency care. Only 20.2% (58/287) followed the recommendations given. Of the 229 patients that did not follow the endpoint recommendations, 121 (52.8%) had some type of follow-up within seven days. Nearly 11% (31/287) were triaged to endpoints not requiring urgent contact and 9.1% (26/287) to an endpoint that would not need any healthcare team input. No patients died in the study period. CONCLUSIONS: Most patients did not follow the recommendations for follow-up care although ultimately most patients did receive care within seven days. Self-triage appears to appropriately sort patients with depressed mood to emergency care. On-line self-triaging tools for depression have the potential to safely offload some work from clinic personnel.

Overtriage of transfers to the pediatric trauma center: the importance of minor head injury.

OBJECTIVE: Accurate triage of minor head injuries remains a challenge for mature trauma systems. More than one-third of trauma transfers are overtriaged, and minor head injuries predominate. Overtriage is inefficient, wasteful of resources, and burdensome for families. The authors studied overtriage at the sole level I pediatric trauma center (PTC) in a small state with a view toward improvement of processes. METHODS: Data on transfer patients were extracted from an institutional trauma registry over an 8-year period. Three definitions of overtriage were examined: one based on transfer criteria from the American College of Surgeons Committee on Trauma, one based on resource utilization, and one adapted to the regional environment of the PTC. Associations of demographic, geographic, clinical, and social factors with overtriage were examined. RESULTS: There were 1754 unique patients transferred from the emergency departments (EDs) of other institutions to the PTC. Thirty-six percent of transfers were overtriaged by all 3 criteria, and 23% of all transfers were minor head injuries overtriaged by all criteria. Infants were more likely to be overtriaged than other age groups. Among racial categories, Black patients were least likely to be overtriaged. Patients with commercial insurance were more likely to be overtriaged. Overtriaged patients averaged shorter trips from the referring ED to the PTC, even though the PTC was farther from their homes. These observations suggest a sensitivity to social expectations in the exercise of ED physician judgments about transfer. CONCLUSIONS: More than one-third of all transfers to the study PTC were overtriaged, and almost one-quarter of all transfers were overtriaged minor head injuries. Minor head injuries are a potentially rewarding focus for system-wide quality improvement, but the interplay of social factors with ED physician judgments must be recognized.

Improving access to chronic pain care with central referral and triage: The 6-year findings from a single-entry model.

Background: Despite the established efficacy of multidisciplinary chronic pain care, barriers such as inflated referral wait times and uncoordinated care further hinder patient health care access. Aims: Here we describe the evolution of a single-entry model (SEM) for coordinating access to chronic pain care across seven hospitals in Toronto and explore the impact on patient care 6 years after implementation. Methods: In 2017, an innovative SEM was implemented for chronic pain referrals in Toronto and surrounding areas. Referrals are received centrally, triaged by a clinical team, and assigned an appointment according to the level of urgency and the most appropriate care setting/provider. To evaluate the impact of the SEM, a retrospective analysis was undertaken to determine referral patterns, patient characteristics, and referral wait times over the past 6 years. Results: Implementation of an SEM streamlined the number of steps in the referral process and led to a standardized referral form with common inclusion and exclusion criteria across sites. Over the 6-year period, referrals increased by 93% and the number of unique providers increased by 91%. Chronic pain service wait times were reduced from 299 (±158) days to 176 (±103) days. However, certain pain diagnoses such as chronic pelvic pain and fibromyalgia far exceed the average. Conclusions: The results indicate that the SEM helped reduce wait times for pain conditions and standardized the referral pathway. Continued data capture efforts can help identify gaps in care to enable further health care refinement and improvement.

Contexte: Malgré l'efficacité établie des soins multidisciplinaires dans le traitement de la douleur chronique, des obstacles tels que des délais d'attente prolongés et l'absence de coordination des soins entravent davantage l'accès des patients aux services de santé.Objectifs: Nous décrivons ici l'évolution d'un modèle à entrée unique visant à coordonner l'accès aux soins pour la douleur chronique dans sept hôpitaux de Toronto. Nous examinons également l'effet de ce modèle sur les soins aux patients six ans après sa mise en œuvre.Méthodes: En 2017, un modèle à entrée unique novateur a été mis en place pour orienter les patients souffrant de douleur chronique à Toronto et dans les régions avoisinantes. Les patients sont reçus de manière centralisée, triés par une équipe clinique et un rendez-vous leur est attribué en fonction du degré d'urgence et de l'établissement de soins ou du prestataire le plus approprié.Pour évaluer l'impact du modèle à entrée unique, une analyse rétrospective a été entreprise afin de déterminer les schémas de consultation, les caractéristiques des patients et les temps d'attente pour les demandes de consultation au cours des six dernières années.Résultats: La mise en œuvre d'un modèle à entrée unique a permis de rationaliser le nombre d'étapes du processus de demande de consultation et a conduit à l'élaboration d'un formulaire de demande de consultation normalisé comprenant des critères d'inclusion et d'exclusion communs à tous les sites. Au cours de la période de six ans, le nombre de demandes de consultation a augmenté et le nombre de prestataires uniques a augmenté de 91 %.Les temps d'attente pour les services de traitement de la douleur chronique ont diminué de 299 (±158) jours à 176 (±103) jours. Cependant, certains diagnostics de douleur, comme la douleur pelvienne chronique et la fibromyalgie, dépassent de loin la moyenne.Conclusions: Les résultats indiquent que le modèle à entrée unique a contribué à réduire les temps d'attente pour les affections douloureuses et à normaliser le parcours de consultation. La poursuite des efforts de collecte des données peut aider à recenser les lacunes dans les soins, permettant ainsi une amélioration continue des soins de santé.

Refining ambulance clinical response models: The impact on ambulance response and emergency department presentations.

OBJECTIVE: The ambulance service in Victoria, Australia implemented a revised clinical response model (CRM) in 2016 which was designed to increase the diversion of low-acuity Triple Zero (000) calls to secondary telephone triage and reduce emergency ambulance dispatches. The present study evaluates the influence of the revised CRM on emergency ambulance response times and ED presentations. METHODS: A retrospective study of emergency calls for ambulance between 1 January 2015 and 31 December 2018. Ambulance data were linked with ED presentations occurring up to 48 h after contact. Interrupted time series analyses were used to evaluate the impact of the revised CRM. RESULTS: A total of 2 365 529 calls were included. The proportion allocated a Code 1 (time-critical, lights/sirens) dispatch decreased from 56.6 to 41.0% after implementation of the revised CRM. The proportion of calls not receiving an emergency ambulance increased from 10.4 to 19.6%. Interrupted time series analyses demonstrated an improvement in Code 1 cases attended within 15 min (Key Performance Indicator). However, for patients with out-of-hospital cardiac arrest or requiring lights and sirens transport to hospital, there was no improvement in response time performance. By the end of the study period, there was also no difference in the proportion of callers presenting to ED when compared with the estimated proportion assuming the revised CRM had not been implemented. CONCLUSION: The revised CRM was associated with improved Code 1 response time performance. However, there was no improvement in response times for high acuity patients, and no change in the proportion of callers presenting to ED.

Interpretable Deep Learning System for Identifying Critical Patients Through the Prediction of Triage Level, Hospitalization, and Length of Stay: Prospective Study.

BACKGROUND: Triage is the process of accurately assessing patients' symptoms and providing them with proper clinical treatment in the emergency department (ED). While many countries have developed their triage process to stratify patients' clinical severity and thus distribute medical resources, there are still some limitations of the current triage process. Since the triage level is mainly identified by experienced nurses based on a mix of subjective and objective criteria, mis-triage often occurs in the ED. It can not only cause adverse effects on patients, but also impose an undue burden on the health care delivery system. OBJECTIVE: Our study aimed to design a prediction system based on triage information, including demographics, vital signs, and chief complaints. The proposed system can not only handle heterogeneous data, including tabular data and free-text data, but also provide interpretability for better acceptance by the ED staff in the hospital. METHODS: In this study, we proposed a system comprising 3 subsystems, with each of them handling a single task, including triage level prediction, hospitalization prediction, and length of stay prediction. We used a large amount of retrospective data to pretrain the model, and then, we fine-tuned the model on a prospective data set with a golden label. The proposed deep learning framework was built with TabNet and MacBERT (Chinese version of bidirectional encoder representations from transformers [BERT]). RESULTS: The performance of our proposed model was evaluated on data collected from the National Taiwan University Hospital (901 patients were included). The model achieved promising results on the collected data set, with accuracy values of 63%, 82%, and 71% for triage level prediction, hospitalization prediction, and length of stay prediction, respectively. CONCLUSIONS: Our system improved the prediction of 3 different medical outcomes when compared with other machine learning methods. With the pretrained vital sign encoder and repretrained mask language modeling MacBERT encoder, our multimodality model can provide a deeper insight into the characteristics of electronic health records. Additionally, by providing interpretability, we believe that the proposed system can assist nursing staff and physicians in taking appropriate medical decisions.

Use of Video in Telephone Triage in Out-of-Hours Primary Care: Register-Based Study.

Background: Out-of-hours primary care (OOH-PC) is challenging due to high workloads, workforce shortages, and long waiting and transportation times for patients. Use of video enables triage professionals to visually assess patients, potentially ending more contacts in a telephone triage contact instead of referring patients to more resource-demanding clinic consultations or home visits. Thus, video use may help reduce use of health care resources in OOH-PC. Objective: This study aimed to investigate video use in telephone triage contacts to OOH-PC in Denmark by studying rate of use and potential associations between video use and patient- and contact-related characteristics and between video use and triage outcomes and follow-up contacts. We hypothesized that video use could serve to reduce use of health care resources in OOH-PC. Methods: This register-based study included all telephone triage contacts to OOH-PC in 4 of the 5 Danish regions from March 15, 2020, to December 1, 2021. We linked data from the OOH-PC electronic registration systems to national registers and identified telephone triage contacts with video use (video contact) and without video use (telephone contact). Calculating crude incidence rate ratios and adjusted incidence rate ratios (aIRRs), we investigated the association between patient- and contact-related characteristics and video contacts and measured the frequency of different triage outcomes and follow-up contacts after video contact compared to telephone contact. Results: Of 2,900,566 identified telephone triage contacts to OOH-PC, 9.5% (n=275,203) were conducted as video contacts. The frequency of video contact was unevenly distributed across patient- and contact-related characteristics; it was used more often for employed young patients without comorbidities who contacted OOH-PC more than 4 hours before the opening hours of daytime general practice. Compared to telephone contacts, notably more video contacts ended with advice and self-care (aIRR 1.21, 95% CI 1.21-1.21) and no follow-up contact (aIRR 1.08, 95% CI 1.08-1.09). Conclusions: This study supports our hypothesis that video contacts could reduce use of health care resources in OOH-PC. Video use lowered the frequency of referrals to a clinic consultation or a home visit and also lowered the frequency of follow-up contacts. However, the results could be biased due to confounding by indication, reflecting that triage GPs use video for a specific set of reasons for encounters.

Centiles for the shock index among injured children in the prehospital setting.

OBJECTIVE: The shock index (SI), the ratio of heart rate to systolic blood pressure, is a clinical tool for assessing injury severity. Age-adjusted SI models may improve predictive value for injured children in the out-of-hospital setting. We sought to characterize the proportion of children in the prehospital setting with an abnormal SI using established criteria, describe the age-based distribution of SI among injured children, and determine prehospital interventions by SI. METHODS: We performed a multi-agency retrospective cross-sectional study of children (<18 years) in the prehospital setting with a scene encounter for suspected trauma and transported to the hospital between 2018 and 2022 using the National Emergency Medical Services (EMS) Information System datasets. Our exposure of interest was the first calculated SI. We identified the proportion of children with an abnormal SI when using the SI, pediatric age-adjusted (SIPA); and the pediatric SI (PSI) criteria. We developed and internally validated an age-based distributional model for the SI using generalized additive models for location, scale, and shape to describe the age-based distribution of the SI as a centile or Z-score. We evaluated EMS interventions (basic airway interventions, advanced airway interventions, cardiac interventions, vascular access, intravenous fluids, and vasopressor use) in relation to both the SIPA, PSI, and distributional SI values. RESULTS: We analyzed 1,007,863 pediatric EMS trauma encounters (55.0% male, median age 13 years [IQR, 8-16 years]). The most common dispatch complaint was for traffic/transport related injury (32.9%). When using the PSI and SIPA, 13.1% and 16.3% were classified as having an abnormal SI, respectively. There were broad differences in the percentage of encounters classified as having an abnormal SI across the age range, varying from 5.1 to 22.8% for SIPA and 3.7-20.1% for PSI. The SIPA values ranged from the 75th to 95th centiles, while the PSI corresponded to an SI greater than the 90th centile, except in older children. The centile distribution for SI declined during early childhood and stabilized during adolescence and demonstrated a difference of <0.1% at cutoff values. An abnormal PSI, SIPA and higher SI centiles (>90th centile and >95th centiles) were associated with interventions related to basic and advanced airway management, cardiac procedures, vascular access, and provision of intravenous fluids occurred with greater frequency at higher SI centiles. Some procedures, including airway management and vascular access, had a smaller peak at lower (<10th) centiles. DISCUSSION: We describe the empiric distribution of the pediatric SI across the age range, which may overcome limitations of extant criteria in identifying patients with shock in the prehospital setting. Both high and low SI values were associated with important, potentially lifesaving EMS interventions. Future work may allow for more precise identification of children with significant injury using cutpoint analysis paired to outcome-based criteria. These may additionally be combined with other physiologic and mechanistic criteria to assist in triage decisions.

Potential Drug-Nutrient Interactions of 45 Vitamins, Minerals, Trace Elements, and Associated Dietary Compounds with Acetylsalicylic Acid and Warfarin-A Review of the Literature.

In cardiology, acetylsalicylic acid (ASA) and warfarin are among the most commonly used prophylactic therapies against thromboembolic events. Drug-drug interactions are generally well-known. Less known are the drug-nutrient interactions (DNIs), impeding drug absorption and altering micronutritional status. ASA and warfarin might influence the micronutritional status of patients through different mechanisms such as binding or modification of binding properties of ligands, absorption, transport, cellular use or concentration, or excretion. Our article reviews the drug-nutrient interactions that alter micronutritional status. Some of these mechanisms could be investigated with the aim to potentiate the drug effects. DNIs are seen occasionally in ASA and warfarin and could be managed through simple strategies such as risk stratification of DNIs on an individual patient basis; micronutritional status assessment as part of the medical history; extensive use of the drug-interaction probability scale to reference little-known interactions, and application of a personal, predictive, and preventive medical model using omics.

The Value of Emergency Care Data Set (ECDS) Presentation Codes for Predicting Mortality and Inpatient Admission.

BACKGROUND:  Early identification of patients at higher risk of death and hospital admission is an important problem in Emergency Departments (ED). Most triage scales were developed before current electronic healthcare records were developed. The implementation of a national Emergency Care Data Set (ECDS) allows for the standardised recording of presenting complaints and the use of Electronic Patient Records (EPR) offers the potential for automated triage. The mortality risk and need for hospital admission associated with the different presenting complaints in a standardised national data set has not been previously reported. This study aimed to quantify the risks of death and hospitalisation from presenting complaints. This would be valuable in developing automated triage tools and decision support software. METHODS: We conducted an observational retrospective cohort study on patients who visited a single ED in 2021. The presenting complaints related to subsequent attendances were excluded. This patient list was then manually matched with a routinely collected list of deaths. All deaths that occurred within 30 days of attendance were included. RESULTS: Data was collected from 84,999 patients, of which 1,159 people died within 30 days of attendance. The mortality rate was the highest in cardiac arrest [32 (78.1%)], cardiac arrest due to trauma [2(50%)] and respiratory arrest [3(50%)]. Drowsy [17(12%)], hypothermia [3(13%)] and cyanosis [1(10%)] were also high-risk categories. Chest pain [34(0.6%)] was not a high-risk presenting complaint. CONCLUSION: The initial presenting complaint in ECDS may be useful to identify people at higher and lower risk of death. This information is useful for building automated triage models.

Emergency care visits at a South African hospital: Implications for healthcare services and policy.

BACKGROUND:  A robust knowledge on the pattern of use of emergency care resources not only serves as an indicator of universal access to care but also provides a basis for quality improvement within the health system. This study was undertaken to describe the pattern of emergency room visits at Brits District Hospital (BDH) in North West province, South Africa. The objectives of this study were to determine the sociodemographic characteristics of emergency department (ED) users and other patterns of ED use. METHODS:  This was a cross-sectional descriptive study that was conducted at a district hospital. All patients who reported for emergency care in the ED in 2016 were eligible for the study. Data were extracted and analysed from a systematic sample of 355 clinical notes and hospital administrative records. RESULTS:  The age group that visited the ED most frequently (25.3%) was 25-34 years old. A high proportion of the ED users (60%) were self-referred, and only 38% were transported by the emergency medical response services (EMRS). Few (5.6%) presentations were of a non-urgent nature. Trauma-related conditions accounted for the most frequent presentation at the ED (36.5%). CONCLUSION:  Although most ED users were self-referred, their clinical presentations were appropriate and underscore the need for policy strategies to reduce the burden of trauma in the catchment populationContribution: The study findings may have an impact on future health policies by providing decision-makers with baseline information on the pattern of use of ED resources, ensuring better resource deployment and greater access to care.

COVID-19 critical care triage across Canada: a narrative synthesis and ethical analysis of early provincial triage protocols.

PURPOSE: The COVID-19 pandemic created conditions of scarcity that led many provinces within Canada to develop triage protocols for critical care resources. In this study, we sought to undertake a narrative synthesis and ethical analysis of early provincial pandemic triage protocols. METHODS: We collected provincial triage protocols through personal correspondence with academic and political stakeholders between June and August 2020. Protocol data were extracted independently by two researchers and compared for accuracy and agreement. We separated data into three categories for comparative content analysis: protocol development, ethical framework, and protocol content. Our ethical analysis was informed by a procedural justice framework. RESULTS: We obtained a total of eight provincial triage protocols. Protocols were similar in content, although age, physiologic scores, and functional status were variably incorporated. Most protocols were developed through a multidisciplinary, expert-driven, consensus process, and many were informed by influenza pandemic guidelines previously developed in Ontario. All protocols employed tiered morality-focused exclusion criteria to determine scarce resource allocation at the level of regional health care systems. None included a public engagement phase, although targeted consultation with public advocacy groups and relevant stakeholders was undertaken in select provinces. Most protocols were not publicly available in 2020. CONCLUSIONS: Early provincial COVID-19 triage protocols were developed by dedicated expert committees under challenging circumstances. Nonetheless, few were publicly available, and public consultation was limited. No protocols were ever implemented, including during periods of extreme critical care surge. A national approach to pandemic triage that incorporates additional aspects of procedural justice should be considered in preparation for future pandemics.

RéSUMé: OBJECTIF: La pandémie de COVID-19 a créé des conditions de pénurie qui ont amené de nombreuses provinces canadiennes à élaborer des protocoles de triage pour l'allocation des ressources en soins intensifs. Dans le cadre de cette étude, nous avons cherché à réaliser une synthèse narrative et une analyse éthique des premiers protocoles provinciaux de triage lors de la pandémie. MéTHODE: Nous avons recueilli les protocoles de triage provinciaux en correspondant de façon personnelle avec des intervenant·es universitaires et politiques entre juin et août 2020. Les données des protocoles ont été extraites indépendamment par deux personnes de l'équipe de recherche et comparées pour en vérifier l'exactitude et la concordance. Nous avons séparé les données en trois catégories pour l'analyse comparative du contenu : l'élaboration d'un protocole, le cadre éthique et le contenu du protocole. Notre analyse éthique s'est appuyée sur un cadre de justice procédurale. RéSULTATS: Nous avons obtenu un total de huit protocoles de triage provinciaux. Les protocoles étaient similaires dans leur contenu, bien que l'âge, les scores physiologiques et l'état fonctionnel aient été incorporés de manière variable. La plupart des protocoles ont été élaborés dans le cadre d'un processus consensuel multidisciplinaire dirigé par des expert·es, et bon nombre d'entre eux ont été élaborés en fonction des lignes directrices sur la pandémie de grippe élaborées antérieurement en Ontario. Tous les protocoles utilisaient des critères d'exclusion à plusieurs niveaux axés sur la moralité pour déterminer l'affectation de ressources limitées au niveau des systèmes de soins de santé régionaux. Aucun ne comportait de phase de mobilisation du public, bien que des consultations ciblées aient été menées auprès des groupes de défense des droits du public et des instances concernées dans certaines provinces. La plupart des protocoles n'étaient pas accessibles au public en 2020. CONCLUSION: Les premiers protocoles provinciaux de triage pour la COVID-19 ont été élaborés par des comités spécialisés d'expert·es dans des circonstances difficiles. Néanmoins, peu d'entre eux étaient accessibles au public et la consultation publique était limitée. Aucun protocole n'a été mis en œuvre, même pendant les périodes de pointe extrême en soins intensifs. Une approche nationale du triage en cas de pandémie qui intègre d'autres aspects de justice procédurale devrait être envisagée en prévision de futures pandémies.

iPad-Based Neurocognitive Testing (ImPACT-QT) in Acute Adult Mild Traumatic Brain Injury/Concussion: Study on Practicality and Bedside Cognitive Scores in a Level-1 Trauma Center.

BACKGROUND: There lacks rapid standardized bedside testing to screen cognitive deficits following mild traumatic brain injury (mTBI). Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test (ImPACT-QT) is an abbreviated-iPad form of computerized cognitive testing. The aim of this study is to test ImPACT-QT utility in inpatient settings. We hypothesize ImPACT-QT is feasible in the acute trauma setting. METHOD: Trauma patients ages 12-70 were administered ImPACT-QT (09/2022-09/2023). Encephalopathic/medically unstable patients were excluded. Mild traumatic brain injury was defined as documented-head trauma with loss-of-consciousness <30 minutes and arrival Glasgow Coma Scale 13-15. Patients answered Likert-scale surveys. Bivariate analyses compared demographics, attention, motor speed, and memory scores between mTBI and non-TBI controls. Multivariable logistic regression assessed memory score as a predictor of mTBI diagnosis. RESULTS: Of 233 patients evaluated (36 years [IQR 23-50], 71% [166/233] female), 179 (76%) were mTBI patients. For all patients, mean test-time was 9.3 ± 2 minutes with 93% (73/76) finding the test "easy to understand." Mild traumatic brain injury patients than non-TBI control had lower memory scores (25 [IQR 7-100] vs 43 [26-100], P = .001) while attention (5 [1-23] vs 11 [1-32]) and motor score (14 [3-28] vs 13 [4-32]) showed no significant differences. Multivariable-regression (adjustment: age, sex, race, education level, ISS, and time to test) demonstrated memory score predicted mTBI positive status (OR .96, CI .94-.98, P = .004). DISCUSSION: Immediate Post-Concussion Assessment & Cognitive Testing-Quick Test is feasible in trauma patients. Preliminary findings suggest acute mTBIs have lower memory but not attention/motor scores vs non-TBI trauma controls.

Development and validation of a nomogram for assessing comorbidity and frailty in triage: a multicentre observational study.

Assessing patient frailty in the Emergency Department (ED) is crucial; however, triage frailty and comorbidity assessment scores developed in recent years are unsatisfactory. The underlying causes of this phenomenon could reside in the nature of the tools used, which were not designed specifically for the emergency context and, thus, are difficult to adapt to the emergency environment. The objective of this study was to create and internally validate a nomogram for identifying different levels of patient frailty during triage. Multicenter, prospective, observational exploratory study conducted in two ED. The study was conducted from April 1 to October 31, 2022. Following the triage assessment, the nurse collected variables related to the patient's comorbidities and chronic conditions using a predefined form. The primary outcome was the 90-day mortality rate. A total of 1345 patients were enrolled in this study; 6% died within 90 days. In the multivariate analysis, the Charlson Comorbidity Index, an altered motor condition, an altered cognitive condition, an autonomous chronic condition, arrival in an ambulance, and a previous hospitalization within 90 days were independently associated with death. The internal validation of the nomogram reported an area under the receiver operating characteristic of 0.91 (95% CI 0.884-0.937). A nomogram was created for assessing comorbidity and frailty during triage and was demonstrated to be capable of determining comorbidity and frailty in the ED setting. Integrating a tool capable of identifying frail patients at the first triage assessment could improve patient stratification.

Randomized controlled open-label trial to evaluate prioritization software for the secondary triage of patients in the pediatric emergency department.

BACKGROUND: The continual increase in patient attendance at the emergency department (ED) is a worldwide health issue. The aim of this study was to determine whether the use of a secondary prioritization software reduces the patients' median length of stay (LOS) in the pediatric ED. METHODS: A randomized, controlled, open-label trial was conducted over a 30-day period between March 15th and April 23rd 2021 at Lille University Hospital. Work days were randomized to use the patient prioritization software or the pediatric ED's standard dashboard. All time intervals between admission and discharge were recorded prospectively by a physician not involved in patient care during the study period. The study's primary endpoint was the LOS in the pediatric ED, which was expected to be 15 min shorter in the intervention group than in the control group. The secondary endpoints were specific time intervals during the stay in the pediatric ED and levels of staff satisfaction. RESULTS: 1599 patients were included: 798 in the intervention group and 801 in the control group. The median [interquartile range] LOS was 172 min [113-255] in the intervention group and 167 min [108-254) in the control group (p = 0.46). In the intervention group, the time interval between admission to the first medical evaluation for high-priority patients and the time interval between the senior physician's final evaluation and patient discharge were shorter (p < 0.01). The median satisfaction score was 68 [55-80] (average). CONCLUSION: The patients' total LOS was not significantly shorter on days of intervention. However, use of the electronic patient prioritization tool was associated with significant decreases in some important time intervals during care in the pediatric ED. CLINICALTRIALS: gov: NCT05994196 Trial registration number: NCT05994196. Date of registration: August 16th, 2023.