Outcomes of Chengdu Pediatric Emergency Triage Criteria: A Retrospective Study of 198,628 Pediatric Patient Records.

BACKGROUND The Chengdu pediatric emergency triage criteria were developed at our hospital and consist of 4 triage levels: immediate treatment (level 1), treatment within 10 min (level 2), treatment within 30 min (level 3), and treatment within 240 min (level 4). This study aimed to evaluate outcomes from the levels 1 to 4 of this triage criteria. MATERIAL AND METHODS A self-designed survey form was used to collect pediatric Emergency Department (ED) patients' general data, including age, sex, and chief concern, and clinical data, including triage level, whether the patient had died, and whether the patient was admitted to our hospital. A total of 198,628 patient records that were triaged during January to May 2022 using Chengdu pediatric emergency triage criteria were included in this retrospective study. The numbers of patients triaged to levels 1, 2, 3, and 4 were 128, 1164, 14,560, and 182,776, respectively. RESULTS Statistically significant differences were found in waiting time for treatment, hospital admission rates, admission conversion rates, and case mix index at admission under different triage levels. The higher the triage priority level, the shorter the waiting time for ED treatment, higher the hospital admission and admission conversion rates, and higher case mix index value. CONCLUSIONS The Chengdu pediatric emergency triage criteria developed and applied within our hospital appears to be characterized by good clinical validity. Equipped with this triage criteria, triage nurses are more capable of determining the severity and emergency of the pediatric ED patients' health conditions and effectively triaging the patients.

An initiative to implement a triage and referral system to make exercise and rehabilitation referrals standard of care in oncology.

BACKGROUND: Clinical guidelines suggest that patients should be referred to exercise while undergoing cancer treatment. Oncology clinicians report being supportive of exercise referrals but not having the time to make referrals. Toward the goal of making exercise referrals standard of care, we implemented and evaluated a novel clinical workflow. METHODS: For this QI project, a rehabilitation navigator was inserted in chemotherapy infusion clinics. Patients were offered a validated electronic triage survey. Exercise or rehabilitation recommendations were communicated to patients during a brief counseling visit by the rehabilitation navigator. The implementation approach was guided by the EPIS framework. Acceptability and feasibility were assessed. RESULTS: Initial meetings with nursing and cancer center leadership ensured buy-in (exploration). The education of medical assistants contributed to the adoption of the triage process (preparation). Audit and feedback ensured leadership was aware of medical assistants' performance (implementation). 100% of medical assistants participated in implementing the triage tool. A total of 587 patients visited the infusion clinics during the 6-month period when this QI project was conducted. Of these, 501 (85.3%) were offered the triage survey and 391 (78%) completed the survey (acceptability). A total of 176 (45%) of triaged patients accepted a referral to exercise or rehabilitation interventions (feasibility). CONCLUSIONS: Implementation of a validated triage tool by medical assistants and brief counseling by a rehabilitation navigator resulted in 45% of infusion patients accepting a referral to exercise or rehabilitation. The triage process showed promise for making exercise referrals standard of care for patients undergoing cancer treatment.

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.

Emergency medical dispatchers' experiences of using the Medical Priority Dispatch System telephone triage to identify maternity emergencies: a qualitative focus group study.

OBJECTIVES: The ambulance service plays a pivotal role in the provision of care in out-of-hospital maternity emergencies. Telephone triage of this patient group is complex and must be sensitive to an emergency situation to prevent unnecessary delays in treatment. This study aimed to explore emergency medical dispatchers' (EMDs) perceptions of the structured protocol they use. DESIGN: Voluntary participation in semistructured phenomenological focus groups. The participants were asked to discuss their experiences of using Medical Priority Dispatch System Protocol 24 (pregnancy, childbirth and miscarriage). Thematic analysis was applied to code and group topics. Discussion between the EMDs is presented for each theme and their experiences, including quotes, are presented to offer an overview of the maternity protocol and its use. SETTING: A large urban UK ambulance service. PARTICIPANTS: 23 control room staff. RESULTS: Perceptions of maternity emergencies, challenges with key questions, the need for sensitivity surrounding miscarriage, using prearrival instructions and postdispatch instructions to help patients and ideas for additional ProQA functionality emerged as the five overarching themes. Protocol 24 was considered to reflect many of the clinical factors EMDs associate with maternity emergencies although further factors, including some non-clinical, were suggested for inclusion. Miscarriage and termination-related calls were thought to be challenging as the language of the protocol is designed for pregnancy. However, instructions were generally considered well written and user-friendly, although some were thought to be unnecessary. EMDs were largely positive regarding the ProQA software, but felt backward navigation was difficult if a situation changed. CONCLUSIONS: Maternity calls were considered rewarding but complex by EMDs. We suggest changes including the use of more sensitive language in response to miscarriage and termination and make recommendations for the omission and inclusion of specific instructions, as well as enhancements to key questions and functionality. Further research is needed to ensure focus group findings are generalisable to other services, particularly in other countries.

Inter hospital external validation of interpretable machine learning based triage score for the emergency department using common data model.

Emergency departments (ED) are complex, triage is a main task in the ED to prioritize patient with limited medical resources who need them most. Machine learning (ML) based ED triage tool, Score for Emergency Risk Prediction (SERP), was previously developed using an interpretable ML framework with single center. We aimed to develop SERP with 3 Korean multicenter cohorts based on common data model (CDM) without data sharing and compare performance with inter-hospital validation design. This retrospective cohort study included all adult emergency visit patients of 3 hospitals in Korea from 2016 to 2017. We adopted CDM for the standardized multicenter research. The outcome of interest was 2-day mortality after the patients' ED visit. We developed each hospital SERP using interpretable ML framework and validated inter-hospital wisely. We accessed the performance of each hospital's score based on some metrics considering data imbalance strategy. The study population for each hospital included 87,670, 83,363 and 54,423 ED visits from 2016 to 2017. The 2-day mortality rate were 0.51%, 0.56% and 0.65%. Validation results showed accurate for inter hospital validation which has at least AUROC of 0.899 (0.858-0.940). We developed multicenter based Interpretable ML model using CDM for 2-day mortality prediction and executed Inter-hospital external validation which showed enough high accuracy.

Rapid triage and transfer system for patients with proven Covid-19 at emergency department.

BACKGROUND: COVID-19 is a viral disease notorious for frequent worldwide outbreaks. It is difficult to control, thereby resulting in overload of the healthcare system. A possible solution to prevent overcrowding is rapid triage of patients, which makes it possible to focus care on the high-risk patients and minimize the impact of crowding on patient prognosis. METHODS: The triage algorithm assessed self-sufficiency, oximetry, systolic blood pressure, and the Glasgow coma scale. Compliance with the triage protocol was defined as fulfillment of all protocol steps, including assignment of the correct level of care. Triage was considered successful if there was no change in the scope of care (e.g., unscheduled hospital admission, transfer to different level of care) or if there was unexpected death within 48 hours. RESULTS: A total of 929 patients were enrolled in the study. Triage criteria were fulfilled in 825 (88.8%) patients. Within 48 hours, unscheduled hospital admission, transfer to different level of care, or unexpected death occurred in 56 (6.0%), 6 (0.6%), and 5 (0.5%) patients, respectively. The risk of unscheduled hospital admission or transfer to different level of care was significantly increased if triage criteria were not fulfilled [13.1% vs. 76.1%, RR 5.8 (3.8-8.3), p < 0.001; 0.5% vs. 5.2%, RR 11.4 (2.3-57.7), p = 0.036, respectively]. CONCLUSION: The proposed algorithm for triage of patients with proven COVID-19 is a simple, fast, and reliable tool for rapid sorting for outpatient treatment, hospitalization on a standard ward, or assignment to an intensive care unit.

Evaluating emergency response at a hospital near the Gaza border within 24 h of increased conflict.

BACKGROUND: Frontline hospitals near active hostilities face unique challenges in delivering emergency care amid threats to infrastructure and personnel safety. Existing literature focuses on individual aspects like mass casualty protocols or medical neutrality, with limited analysis of operating acute services directly under fire. OBJECTIVES: To describe the experience of a hospital situated meters from hostilities and analyze strategies implemented for triage, expanding surge capacity, and maintaining continuity of care during attacks with limited medical staff availability due to hazardous conditions. A focus will be placed on assessing how the hospital functioned and adapted care delivery models in the event of staffing limitations preventing all teams from arriving on site. METHODS: A retrospective case study was conducted of patient records from Barzilai University Medical Center at Ashkelon (BUMCA) Medical Center in Israel within the first 24 h after escalated conflict began on October 7, 2023. Data on 232 admissions were analyzed regarding demographics, treatment protocols, time to disposition, and mortality. Missile alert data correlated patient surges to attacks. Statistical and geospatial analyses were performed. RESULTS: Patients predominantly male soldiers exhibited blast/multisystem trauma. Patient surges at the hospital were found to be correlated with the detection of incoming missile attacks from Gaza within 60 min of launch. While 131 (56%) patients were discharged and 55 (24%) transferred within 24 h, probabilities of survival declined over time reflecting injury severity limitations. 31 deaths occurred from severe presentation. CONCLUSION: Insights gleaned provide a compelling case study on managing mass casualties at the true frontlines. By disseminating BUMCA's trauma response experience, strategies can strengthen frontline hospital protocols optimizing emergency care delivery during hazardous armed conflicts through dynamic surge capacity expansion, early intervention prioritization, and infrastructure/personnel protection measures informed by risks.

Applying Sydney Triage to Admission Risk Tool (START) to improve patient flow in emergency departments: a multicentre randomised, implementation study.

BACKGROUND: To determine the effectiveness of applying the Sydney Triage to Admission Risk Tool (START) in conjunction with senior early assessment in different Emergency Departments (EDs). METHODS: This multicentre implementation study, conducted in two metropolitan EDs, used a convenience sample of ED patients. Patients who were admitted, after presenting to both EDs, and were assessed using the existing senior ED clinician assessment, were included in the study. Patients in the intervention group were assessed with the assistance of START, while patients in the control group were assessed without the assistance of START. Outcomes measured were ED length of stay and proportion of patients correctly identified as an in-patient admission by START. RESULTS: A total of 773 patients were evaluated using the START tool at triage across both sites (Intervention group n = 355 and control group n = 418 patients). The proportion of patients meeting the 4-hour length of stay thresholds was similar between the intervention and control groups (30.1% vs. 28.2%; p = 0.62). The intervention group was associated with a reduced ED length of stay when compared to the control group (351 min, interquartile range (IQR) 221.0-565.0 min versus 383 min, IQR 229.25-580.0 min; p = 0.85). When stratified into admitted and discharged patients, similar results were seen. CONCLUSION: In this extension of the START model of care implementation study in two metropolitan EDs, START, when used in conjunction with senior early assessment was associated with some reduced ED length of stay.

Impact of Triage Systems on Time to Diagnosis and Treatment of Traumatic Brain Injuries.

BACKGROUND: Intracerebral hemorrhage (ICH) is a potential complication from traumatic brain injury, with a 30-day mortality rate of 35-52%. Rapid diagnosis allows for earlier treatment, which impacts patient outcomes. A trauma activation (TA) is called when injury severity meets institutional criteria. The patient is immediately roomed, and a multispecialty team is present. A trauma evaluation (TE) occurs when injuries are identified after standard triage processes. OBJECTIVES: Our aim was to determine whether TA patients with ICH were diagnosed and treated more rapidly than TE patients. METHODS: This was a retrospective study of patients presenting to trauma centers within a large hospital system diagnosed with traumatic ICH between January 2018 and December 2018. Patients were categorized as TA or TE patients. The time to diagnosis was compared between groups, and additional times were evaluated, including time to imaging, computed tomography interpretation, and treatment. RESULTS: A total of 294 patients were included. Groups had similar demographic characteristics and medical history; there was no difference in head Abbreviated Injury Score, Injury Severity Score, or anticoagulant use. Time to diagnosis was decreased for TA patients compared with TE patients (p < 0.0001). In addition, TA patients received treatment sooner (median 107 min) than TE patients (184.5 min) (p < 0.0001). CONCLUSIONS: Diagnosis and treatment times were significantly faster in TA patients than in TE patients. Given the similarities in injury severity between groups, the increased time to treatment may be detrimental for patients. Trauma activations are a resource-heavy process, but TE delays care. These data suggest that an intermediary process may be beneficial.

Developing Systems of Care for Stroke in Resource-limited Settings.

Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.

Experiences from a cluster-randomized trial (ParaNASPP) exploring triage and diagnostic accuracy in paramedic-suspected stroke: a qualitative interview study.

BACKGROUND AND PURPOSE: Timely prehospital stroke recognition was explored in the Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) by implementation of stroke education for paramedics and use of the National Institutes of Health Stroke Scale (NIHSS) through a mobile application. The study tested triage and facilitated communication between paramedics and stroke physicians. To complement the quantitative results of the clinical trial, a qualitative approach was used to identify factors that influence triage decisions and diagnostic accuracy in prehospital stroke recognition experienced by paramedics and stroke physicians. METHOD: Semi-structured qualitative individual interviews were performed following an interview guide. Informants were recruited from the enrolled paramedics and stroke physicians who participated in the ParaNASPP trial from Oslo University Hospital. Interviews were audio recorded, transcribed verbatim and approached inductively using the principles of thematic analysis. RESULTS: Fourteen interviews were conducted, with seven paramedics and seven stroke physicians. Across both groups two overarching themes were identified related to triage decisions and diagnostic accuracy in prehospital stroke recognition: prehospital NIHSS reliably improves clinical assessment and communication quality; overtriage is widely accepted whilst undertriage is not. CONCLUSION: Paramedics and stroke physicians described how prehospital NIHSS improved communication quality and reliably improved prehospital clinical assessment. The qualitative results support a rationale of an application algorithm to decide which NIHSS items should prompt immediate prenotification rather than a complete NIHSS as default.

Identifying key items to be addressed by non-clinical operators to manage out-of-hours telephone triage services for older adults seeking non-urgent unplanned care in Belgium: an e-Delphi study.

BACKGROUND: This study aimed to achieve expert consensus regarding key items to be addressed by non-clinical operators using computer-software integrated medical dispatch protocols to manage out-of-hours telephone triage (OOH-TT) services for calls involving older adults seeking non-urgent unplanned care across Belgium. METHODS: A three-part classic e-Delphi study was conducted. A purposive sample of experts specialized in out-of-hours unplanned care and/or older persons across Belgium were recruited as panelists. Eligibility criteria included experts with at least 2 years of relevant experience. Level of consensus was defined to be reached when at least 70% of the panelists agreed or disagreed regarding the value of each item proposed within a survey for the top 10 most frequently used protocols for triaging older adults. Responses were analyzed over several rounds until expert consensus was found. Descriptive and thematic analyses were used to aggregate responses. RESULTS: N = 12 panelists agreed that several important missing protocol topics were not covered by the existing OOH-TT service. They also agreed about the nature of use (for the top 10 most frequently used protocols) but justified that some modifications should be made to keywords, interrogation questions, degree of urgency and/or flowcharts used for the algorithms to help operators gain better comprehensive understanding patient profiles, medical habits and history, level of support from informal caregivers, known comorbidities and frailty status. Furthermore, panelists also stressed the importance of considering feasibility in implementing protocols within the real-world setting and prioritizing the right type of training for operators which can facilitate the delivery of high-quality triage. Overall, consensus was found for nine of the top 10 most frequently used protocols for triaging older adults with no consensus found for the protocol on triaging patients unwell for no apparent reason. CONCLUSION: Our findings show that overall, a combination of patient related factors must be addressed to provide high quality triage for adults seeking non-urgent unplanned care over the telephone (in addition to age). However, further elements such as appropriate operator training and feasibility of implementing more population-specific protocols must also be considered. This study presents a useful step towards identifying key items which must be targeted within the larger scope of providing non-urgent out-of-hours telephone triage services for older adults seeking non-urgent unplanned care.

Using a theory-based, customized video game as an educational tool to improve physicians' trauma triage decisions: study protocol for a randomized cluster trial.

BACKGROUND: Transfer of severely injured patients to trauma centers, either directly from the field or after evaluation at non-trauma centers, reduces preventable morbidity and mortality. Failure to transfer these patients appropriately (i.e., under-triage) remains common, and occurs in part because physicians at non-trauma centers make diagnostic errors when evaluating the severity of patients' injuries. We developed Night Shift, a theory-based adventure video game, to recalibrate physician heuristics (intuitive judgments) in trauma triage and established its efficacy in the laboratory. We plan a type 1 hybrid effectiveness-implementation trial to determine whether the game changes physician triage decisions in real-life and hypothesize that it will reduce the proportion of patients under-triaged. METHODS: We will recruit 800 physicians who work in the emergency departments (EDs) of non-trauma centers in the US and will randomize them to the game (intervention) or to usual education and training (control). We will ask those in the intervention group to play Night Shift for 2 h within 2 weeks of enrollment and again for 20 min at quarterly intervals. Those in the control group will receive only usual education (i.e., nothing supplemental). We will then assess physicians' triage practices for older, severely injured adults in the 1-year following enrollment, using Medicare claims, and will compare under-triage (primary outcome), 30-day mortality and re-admissions, functional independence, and over-triage between the two groups. We will evaluate contextual factors influencing reach, adoption, implementation, and maintenance with interviews of a subset of trial participants (n = 20) and of other key decision makers (e.g., patients, first responders, administrators [n = 100]). DISCUSSION: The results of the trial will inform future efforts to improve the implementation of clinical practice guidelines in trauma triage and will provide deeper understanding of effective strategies to reduce diagnostic errors during time-sensitive decision making. TRIAL REGISTRATION: ClinicalTrials.gov; NCT06063434 . Registered 26 September 2023.

RELATIONSHIP BETWEEN SHOCK INDEX, MODIFIED SHOCK INDEX, AND AGE SHOCK INDEX AND 28-DAY MORTALITY AMONG PATIENTS WITH PREHOSPITAL SEPTIC SHOCK.

BACKGROUND: A relative hypovolemia occurs during septic shock (SS); the early phase is clinically reflected by tachycardia and low blood pressure. In the prehospital setting, simple objective tools to assess hypovolemia severity are needed to optimize triaging. OBJECTIVE: The aim of this study was to evaluate the relationship between shock index (SI), diastolic SI (DSI), modified SI (MSI), and age SI (ASI) and 28-day mortality of patients with SS initially cared for in a prehospital setting of a mobile intensive care unit (MICU). METHODS: From April 6, 2016 through December 31, 2021, 530 patients with SS cared for at a prehospital MICU were analyzed retrospectively. Initial SI, MSI, DSI, and ASI values, that is, first measurement after MICU arrival to the scene were calculated. A propensity score analysis with inverse probability of treatment weighting (IPTW) method was used to assess the relationship between SI, DSI, MSI, and ASI and 28-day mortality. RESULTS: SS resulted mainly from pulmonary, digestive, and urinary infections in 44%, 25%, and 17% of patients. The 28-day overall mortality was 31%. IPTW propensity score analysis indicated a significant relationship between 28-day mortality and SI (adjusted odds ratio [aOR] 1.13; 95% CI 1.01-1.26; p = 0.04), DSI (aOR 1.16; 95% CI 1.06-1.34; p = 0.03), MSI (aOR 1.03; 95% CI 1.01-1.17; p = 0.03), and ASI (aOR 3.62; 95% CI 2.63-5.38; p < 10-6). CONCLUSIONS: SI, DSI, MSI, and ASI were significantly associated with 28-day mortality among patients with SS cared for at a prehospital MICU. Further studies are needed to confirm the usefulness of SI and SI derivates for prehospital SS optimal triaging.

The prehospital NEW score to assess septic shock in-hospital, 30-day and 90-day mortality.

BACKGROUND: The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). METHODS: Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports. RESULTS: Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39-3.95], 2.08 [1.33-3.25] and 2.22 [1.38-3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively. CONCLUSION: A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.

Factors related to changes in severity among adult and older adult patients at an internal medicine department clinic: an embedded mixed-method study.

The changes in aging plus the pathology of diseases can influence the changes in severity levels. This study aimed to examine the changes in levels of severity in patients while waiting to see a doctor. The study was conducted at an outpatient clinic in northeastern Thailand with a total of 421 patients who were assessed twice for levels of severity using the Emergency Severity Index. The 38 triage nurses screened patients, and 18 were interviewed when severity level changes were observed. Data were collected April 1-30, 2021. Quantitative data were analyzed by Chi-square test, Fisher's exact test, and logistic regression. Qualitative data were analyzed by content analysis. Most patients were female, between 18 and 59 years old. Most patients did not change their level of severity. However, increasing levels of severity were found in older adults. Factors related to the changes in severity levels were age group, chronic disease, chief complaint, educational level, the duration of travel to the outpatient clinic, type of vehicle, aging process and comorbidity, pathology of diseases, reassessment interval, nurse's experience, bypassing the patient triage process, patient's self-preparation, management of triage nurses, and assignment of direct healthcare staff until the end of the treatment. Increased severity was more frequently found in older adults, so closely monitored during waiting times at a clinic is needed. Setting rescreening as a policy and having sensitive screening guidelines and tools specific to older adults would contribute to early detection and immediate treatment of deteriorating symptoms and illness to help reduce complications and morbidity.Trial registration: https://osf.io/fp3j2 .

A novel scale for triage assessment of frailty in the emergency department (ED-FraS): a prospective videotaped study.

BACKGROUND: Rapid recognition of frailty in older patients in the ED is an important first step toward better geriatric care in the ED. We aimed to develop and validate a novel frailty assessment scale at ED triage, the Emergency Department Frailty Scale (ED-FraS). METHODS: We conducted a prospective cohort study enrolling adult patients aged 65 years or older who visited the ED at an academic medical center. The entire triage process was recorded, and triage data were collected, including the Taiwan Triage and Acuity Scale (TTAS). Five physician raters provided ED-FraS levels after reviewing videos. A modified TTAS (mTTAS) incorporating ED-FraS was also created. The primary outcome was hospital admission following the ED visit, and secondary outcomes included the ED length of stay (EDLOS) and total ED visit charges. RESULTS: A total of 256 patients were included. Twenty-seven percent of the patients were frail according to the ED-FraS. The majority of ED-FraS was level 2 (57%), while the majority of TTAS was level 3 (81%). There was a weak agreement between the ED-FraS and TTAS (kappa coefficient of 0.02). The hospital admission rate and charge were highest at ED-FraS level 5 (severely frail), whereas the EDLOS was longest at level 4 (moderately frail). The area under the Receiver Operating Characteristic curve (AUROC) in predicting hospital admission for the TTAS, ED-FraS, and mTTAS were 0.57, 0.62, and 0.63, respectively. The ED-FraS explained more variation in EDLOS (R2 = 0.096) compared with the other two methods. CONCLUSIONS: The ED-Fras tool is a simple and valid screening tool for identifying frail older adults in the ED. It also can complement and enhance ED triage systems. Further research is needed to test its real-time use at ED triage internationally.