The TriAGe + score for vertigo or dizziness: A validation study in a university hospital emergency department in Hong Kong.

OBJECTIVE: Patients with dizziness commonly present to Emergency Departments (ED) and 6% of these patients will be diagnosed with acute stroke. The TriAGe+ score comprises of eight clinical parameters and stratifies patients into four risk groups. The Japanese authors reported that the tool performed well, so our aim was to validate this diagnostic tool in our ED in Hong Kong. MATERIALS AND METHODS: A single-center retrospective observational study was conducted in the ED of our university hospital in Hong Kong. The primary outcome was the diagnosis of an acute cerebrovascular event. Receiver operator characteristic (ROC) analysis was performed to determine the best cut-off score. Secondary outcomes included univariable and multivariable analyses of stroke predictors. RESULTS: 455 patients aged 18 years or above with dizziness or vertigo at ED triage were recruited between 19 July and 30 September 2021. The overall prevalence of stroke was 11.9%. The median TriAGe+ score was 7 (IQR = 4-9). The AUC was 0.9. At a cut-off >5, sensitivity was 96.4% (95%CI: 87.3-99.5) and the negative likelihood ratio was 0.09 (95%CI: 0.02-0.3). At a cut-off >10, specificity was 99.8% (95%CI: 98.6-100.0), and the positive likelihood ratio was 237.6 (95%CI: 33.1-1704). On multivariable analyses, atrial fibrillation, blood pressure, gender, dizziness (not vertigo) and no history of dizziness, vertigo or labyrinth/vestibular disease were found to be positively associated with stroke outcomes significantly. CONCLUSION: The TriAGe+ score is an efficient stroke prediction score for patients presenting to the ED with dizziness.

Assessment of the patients' outcomes after implementation of South African triage scale in emergency department, Egypt.

PURPOSE: Overcrowding in emergency department (ED) is a concerning global problem and has been identified as a national crisis in some countries. Several emergency sorting systems designed successfully in the world. Launched in 2004, a group of branches in South African triage scale (SATS) developed. The effectiveness of the case sorting system of SATS was evaluated to reduce the patient's length of stay (LOS) and mortality rate within the ED at Suez Canal University Hospital. METHODS: The study was designed as an intervention study that included a systematic random sample of patients who presented to the ED in Suez Canal University Hospital. This study was implemented in three phases: pre-intervention phase, 115 patients were assessed by the traditional protocols; intervention phase, a structured training program was provided to the ED staff, including a workshop and lectures; and post-intervention phase, 230 patients were assessed by SATS. All the patients were retriaged 2 h later, calculating the LOS per patient and the mortality. Data was collected and entered using Microsoft Excel software. Collected data from the triage sheet were analyzed using the SPSS software program version 22.0. RESULTS: The LOS in the ED was about 183.78 min before the intervention; while after the training program and the application of SATS, it was reduced to 51.39 min. About 15.7% of the patients died before the intervention; however, after the intervention the ratio decreased to 10.7% deaths. CONCLUSION: SATS is better at assessing patients without missing important data. Additionally, it resulted in a decrease in the LOS and reduction in the mortality rate compared to the traditional protocol.

Suicide prevention during COVID-19: identification of groups with reduced presentations to emergency departments.

OBJECTIVE: Reductions in suicidal and self-harm presentations to emergency departments (EDs) since COVID-19 indicate changes in help-seeking behaviours, but it is unknown if hospital avoidance equally affects all population groups. METHOD: Socio-demographic and clinical information relating to suicidal and self-harm presentations to EDs in Queensland, Australia, were compared for the period before (March-August 2019) and since the COVID-19 outbreak (March-August 2020). RESULTS: Since COVID, Indigenous Australians and persons with less severe suicidal and self-harm presentations had significantly reduced presentations, while persons younger than 18 years had more presentations. Less suicidal presentations resulted in an admission to inpatient care. CONCLUSIONS: Patterns of reduced attendance to ED in some groups suggest the need for innovative and community-based models of care to help prevent suicides during the pandemic.

Electronic cardiac arrest triage score best predicts mortality after intervention in patients with massive and submassive pulmonary embolism.

OBJECTIVE: To determine if the cardiac arrest triage (CART) Score would better predict poor outcomes after pharmacomechanical therapy (PMT) for massive and submassive pulmonary embolism (PE) than traditional risk scores BACKGROUND: PMT for massive and submassive PE allows for clot lysis with minimal doses of fibrinolytics. Although PMT results in improved right ventricular function, and reduced pulmonary pressures and thrombus burden, predictors of poor outcome are not well-studied. METHODS: We conducted a retrospective analysis of all patients who underwent PMT for massive or submassive PE at a single institution from 2010 to 2016. The CART score and electronic CART (eCART) score, derived previously as early warning scores for hospitalized patients, were compared to pulmonary embolism severity index (PESI) comparing the area under the receiver-operator characteristic curve (AUC) for predicting 30-day mortality. RESULTS: We studied 61 patients (56 ±17 years, 44.0% male, 29.5% massive PE, mean PESI 114.6 ± 42.7, mean CART 13.5 ± 1.39, mean eCART 108.5 ± 28.6). Thirty-day mortality was 24.6%. Treatments included rheolytic thrombectomy (32.7%), catheter-directed thrombolysis (50.8%), ultrasound-assisted thrombolysis (32.7%), and mechanical thrombectomy (4.9%). There were no differences in outcome based on technique. The eCART and CART scores had higher AUCs compared to PESI in predicting 30-day mortality (0.84 vs 0.72 vs 0.69, P = .010). We found troponin I and pro-BNP were higher in higher eCART tertiles, however AUCs were 0.51 and 0.63, respectively for 30-day mortality when used as stand-alone predictors. CONCLUSION: Compared to PESI score, CART and eCART scores better predict mortality in massive or submassive PE patients undergoing PMT.

Retrospective evaluation of traumatic pneumomediastinum in dogs and cats (2005-2022): 52 cases.

OBJECTIVE: To describe the incidence, etiology, clinical signs, diagnostics, treatments, and outcome of noniatrogenic traumatic pneumomediastinum (TPM) in dogs and cats. DESIGN: Retrospective study of cases (2005-2022). SETTING: University veterinary teaching hospital. ANIMALS: Fifty-two patients (29 dogs, 23 cats). MEASUREMENTS AND MAIN RESULTS: Data collected from the medical records included signalment, physical examination findings, animal trauma triage (ATT) score, clinicopathological data, imaging data, surgical intervention, length of hospitalization, supportive care, complications, and outcome. Most dogs presented with tachycardia and tachypnea, while cats presented with hypothermia and tachypnea. Subcutaneous emphysema, pneumothorax, and dyspnea were the most common clinical signs for both species. The median calculated ATT score was 3.5 in dogs and 4 in cats. The most common radiographic abnormalities other than pneumomediastinum were pneumothorax and lung contusions. The overall mortality rate was 18%, with a significantly higher survival rate in dogs (26/28 dogs [93%], 15/22 cats (68%); P = 0.03). Outcome was unknown in 1 dog and 1 cat. The only significant difference in treatment between survivors and nonsurvivors was the requirement in dogs for positive pressure ventilation. The median hospitalization period was 2 days for both species, with a shorter hospitalization in the nonsurvivors (0.6 vs 2 days, respectively; P = 0.006). CONCLUSIONS: TPM is an infrequent pathology in veterinary medicine and may be seen without an externally obvious injury. The most common causes for TPM in dogs were vehicular trauma and bite wounds, while high-rise syndrome was the most common cause in cats. Most of the cases have concurrent pneumothorax and require thoracocentesis; however, direct intervention to treat TPM is not usually required. The vast majority of cases did not undergo surgery to treat TPM. The prognosis for dogs with TPM was good but was guarded for cats.

Evaluation of outcome associated with feline trauma: A Veterinary Committee on Trauma registry study.

OBJECTIVE: To evaluate outcome (survival to discharge) among trauma types (blunt, penetrating, both) in cats. Secondary objectives were to evaluate for associations between trauma type, injury severity, and the diagnostics and interventions selected by primary clinicians. DESIGN: Retrospective evaluation of veterinary trauma registry data. SETTING: Veterinary Committee on Trauma (VetCOT) veterinary trauma centers (VTCs). ANIMALS: A total of 3895 feline trauma patients entered in the VetCOT trauma registry from April 1, 2017 to December 31, 2019. INTERVENTIONS: Data collected included patient demographics, trauma type, Abdominal Fluid Score (AFS), Animal Trauma Triage (ATT) score, surgical intervention, glide sign on Thoracic Focused Assessment with Sonography for Trauma, Triage, and Tracking (TFAST), pleural effusion on TFAST, modified Glasgow Coma Scale (mGCS), and outcome (survival to discharge). MEASUREMENTS AND MAIN RESULTS: Data from 3895 cats were collected over a 30-month period. Incidence of trauma types was as follows: blunt, 58% (95% confidence interval [CI]: 56%-59%); penetrating, 35% (95% CI: 34%-37%); and combination, 7.4% (95% CI: 6.7%-8.3%). Differences in survival incidence among the trauma types were identified: blunt, 80% (95% CI: 78%-81%); penetrating, 90% (95% CI: 89%-92%); and combined, 68% (95% CI: 63%-74%) (P < 0.01). Cats in the penetrating trauma group had the lowest proportion of severe injuries (6%) and highest proportion of mGCS of 18 (89%); cats with combined trauma had the highest proportion of severe injuries (26%) and lowest proportion of mGCS of 18 (63%). Point-of-care ultrasound and surgery were not performed in the majority of cases. When surgery was performed, the majority of blunt cases' procedures occurred in the operating room (79%), and the majority of penetrating cases' procedures were performed in the emergency room (81%). CONCLUSIONS: Cats suffering from penetrating trauma had the best outcome (survival), lower ATT scores, and higher mGCS overall. Cats that sustained a component of blunt trauma had a lower survival rate, higher ATT scores, and the highest proportion of mGCS <18.

Pediatric trauma smackdown: PTS vs SIPA.

BACKGROUND: Different scoring tools aid prediction of pediatric trauma patients' prognosis but there's no consensus on when to apply each. Pediatric Trauma Score (PTS) was one of the first tools developed. Shock Index Pediatric Adjusted (SIPA) adapts Shock Index (SI) in predicting outcomes adjusted for age. It is unclear if either scoring tool is better at predicting outcomes. OBJECTIVE: To compare SIPA and PTS for level I and II pediatric traumas to determine if both are equally effective in predicting outcomes for pediatric trauma patients. DESIGN/METHODS: This is a retrospective review of patients 1-17 years with level 1 and 2 activated trauma (1/2013 - 11/2019). OUTCOMES OF INTEREST: disposition, length of stay, ventilator use, moderate/major spleen/liver lacerations, and Index Severity Score (ISS). Patient visits were scored using both scores and placed into high/low risk category as predefined by the individual scoring tools: High risk SIPA, low risk SIPA, high risk PTS, low risk PTS. RESULTS: There were 750 patients who met inclusion criteria, 35 visits scored high with both tools and 543 visits scored low. The odds ratio (OR) for each tool showed high risk scores were more likely to be associated with increased likelihood of outcomes. When both high-risk groups were compared, PTS had an increased OR for most outcomes. SIPA had an increased OR for receiving fluid bolus. CONCLUSION: This study externally validates both scoring tools for the same cohort. Both tools were reliable predictors, but PTS identifies more "high risk" visits. PTS requires more variables to calculate than SIPA. SIPA may be an effective way to triage when resources are scarce. However, there's still a need for a pediatric trauma triage score that can encompass the accuracy of PTS and the convenience of SIPA.

Performance of the South African triage score among HIV positive individuals presenting to an emergency department.

Introduction: Over a quarter of patients presenting to South African Emergency Centres (EC) have concurrent human immunodeficiency virus (HIV), yet it is unclear how this impacts their presenting complaints, the severity of illness, and overall resource needs in the EC. The primary objective of this study was to compare the performance of the South African Triage Score (SATS) in people living with HIV (PLWH) compared to HIV-negative patients. Secondary objectives included comparing the presentation characteristics and resource utilisation of these populations. Methods: A prospective cross-sectional observational study was conducted in the Livingstone Hospital EC, Gqeberha, South Africa, to compare triage designation and clinical outcomes in PLWH and HIV-negative patients. In this six-week study, all eligible patients received point-of-care HIV testing and extensive data abstraction, including SATS designation and EC clinical course. Descriptive statistical analysis was completed, and a log-binomial model was used to examine the association between HIV status and clinical outcomes using crude (unadjPR) and adjusted prevalence ratios (adjPR). Results: During the study period, 755 adult patients who consented to a POC HIV test were enrolled, of which 193 (25.6%) were HIV positive. HIV-positive patients were significantly more likely to be admitted compared to their HIV-negative counterparts when triaged as low acuity (adjPR 1.48, 95% CI 1.14-1.92, (p=0.003)). HIV-positive patients were also significantly more likely to receive laboratory testing when triaged as low acuity (adjPR 1.31, 95% CI 1.08-1.59 (p=0.006)) and as high acuity (adjPR 1.38, 95% CI 1.08-1.59 (p=0.034)) compared to HIV negative patients of the same triage categories. Conclusion: In our study, PLWH, compared to HIV-negative patients in the same category, were more likely to be admitted and require more EC resources, thus alluding to possible under triage of HIV-positive patients under the current SATS algorithm.

Clinical parameters at time of admission as prognostic indicators in cats presented for trauma to an emergency centre in New Zealand: a retrospective analysis.

OBJECTIVES: The aims of this study were to describe the clinical features of cats presented for trauma in a first-opinion and referral teaching hospital in New Zealand, and to determine the relationship between those features and outcome. METHODS: The electronic medical records of cats presented for trauma to the Massey University Pet Emergency Centre between September 2013 and January 2019 were examined, from which the signalment, clinical parameters and patient outcomes were extracted. Cases were assigned an Animal Trauma Triage (ATT) score and Modified Glasgow Coma Scale (MGCS) score. Variables were selected for inclusion in a logistic regression model to predict survival, and backward elimination was used to find the minimal significant model. RESULTS: In total, 530 cats met the inclusion criteria. The cause of injury was not known in the majority of cases (38.0%). The most common location of injury was the hindlimbs/pelvis/tail (n = 247; 41%), and skin lacerations/abrasions were the most common specific injury. Multivariate analysis revealed altered mentation (odds ratio [OR] 0.31, P = 0.029), hypothermia (rectal temperature <37.8°C [<100.04°F]; OR 0.45, P = 0.015) and an ATT score ⩾5 (OR 0.13, P <0.001) to be statistically significantly associated with mortality. CONCLUSIONS AND RELEVANCE: Altered mentation and hypothermia are easily measurable perfusion parameter abnormalities associated with mortality in cats presenting with trauma. The ATT score appears to be an accurate prognostic indicator in cats presenting with trauma in New Zealand. These results highlight the importance of incorporating a hands-on triage examination in each cat that presents as an emergency after trauma.

The prognostic value of sepsis scores and dichotomized triage score in patients presenting to the emergency department with fever: A prospective, observational study.

BACKGROUND: The performance of the Quick Sequential Organ Failure Assessment (qSOFA) score needs to be explored further in the emergency triage room. This study aims to explore the performance of triage (tqSOFA) versus the dichotomized triage score (DTS) in patients admitted to the emergency room triage with fever. METHODS: This research was designed as a prospective, observational study within a six-month period, including patients who presented to the emergency room triage with infrared fever ≥ 37.5 °C. RESULTS: 771 patients were analyzed.The highest sensitivity for predicting overall hospitalization and intensive care admission was seen for DTS (95.4 %, 100 %; p < 0.0001, p < 0.0001, respectively) (AUC:0.697, 95 % CI 0.663 to 0.730; AUC:0.684, 95 % CI 0.650 to 0.717, respectively). The highest sensitivity for predicting 1st week and 1st month mortality was found for DTS (100 %, 96.3 %; p < 0.0001, p < 0.0001, respectively). However, the highest specificity for predicting 1st week and 1st month mortality was observed in tqSOFA (94.1 %, 95.16; p = 0.0845, p < 0.0001, respectively) (AUC:0.658, 95 % CI 0.623 to 0.691; AUC:0.698, 95 % CI 0.664 to 0.730, respectively). CONCLUSION: We found DTS to be as effective as tqSOFA and SIRS in determining all hospitalization times and mortality.

Evaluation of a modified South African Triage Score as a predictor of patient disposition at a tertiary hospital in Rwanda.

BACKGROUND: Triage is essential for efficient and effective delivery of care in emergency centers (ECs) where numerous patients present simultaneously with varying acuity of conditions. Implementing EC triage systems provides a method of recognizing which patients may require admission and are at higher risks for poor health outcomes. Rwanda is experiencing increased demand for emergency care; however, triage has not been well-studied. The University Teaching Hospital of Kigali (UTH-K) is an urban tertiary care health center utilizing a locally modified South African Triage Score (mSATS) that classifies patients into five color categories. Our study evaluated the utility of the mSATS tool at UTH-K. METHODS: UTH-K implemented mSATS in April 2013. All patients aged 15 years or older from August 2015 to July 2016 were eligible for inclusion in the database. Variables of interest included demographic information, mSATS category, patient case type (trauma or medical), disposition from the ED and mortality. RESULTS: 1438 cases were randomly sampled; the majority were male (61.9%) and median age was 35 years. Injuries accounted for 56.7% of the cases while medical conditions affected 43.3%. Admission likelihood significantly increased with higher triage color category for medical patients (OR: Yellow = 3.61, p < .001 to Red (with alarm) = 7.80, p < .01). Likelihood for trauma patients, however, was not significantly increased (OR: Yellow = .84, p = .75 to Red (with alarm) = 1.50, p = .65). Mortality rates increased with increasing triage category with the red with alarm category having the highest mortality (7.7%, OR 18.91). CONCLUSION: The mSATS tool accurately predicted patient disposition and mortality for the overall ED population. The mSATS tool provided useful clinical guidance on the need for hospital admission for medical patients but did not accurately predict patient disposition for injured patients. Further trauma-specific triage studies are needed to improve emergency care in Rwanda.

A proposed ABCD scoring system for better triage of patients with COVID-19: Use of clinical features and radiopathological findings.

BACKGROUND AND AIMS: Currently there are limited tools available for triage of patients with COVID -19. We propose a new ABCD scoring system for patients who have been tested positive for COVID-19. METHODS: The ABCD score is for patients who have been tested positive for COVID-19 and admitted in a hospital. This score includes age of the patient, blood tests included leukopenia, lymphocytopenia, CRP level, LDH level,D-Dimer, Chest radiograph and CT Scan, Comorbidities and Dyspnea. RESULTS: The triage score had letters from alphabets which included A, B, C, D. The score was developed using these variables which outputs a value from 0 to 1. We had used the code according to traffic signal system; green(mild), yellow moderate) and red(severe). The suggestions for mild (green)category: symptomatic treatment in ward, in moderate (yellow) category: active treatment, semi critical care and oxygen supplementation, in severe (red) category: critical care and intensive care. CONCLUSIONS: This study is, to our knowledge, is the first scoring tool that has been prepared by Indian health care processional's and used alphabets A, B,C,D as variables for evaluation of admitted patients with COVID-19. This triage tool will be helpful in better management of patients with COVID-19. This score component includes clinical and radiopathological findings.A multi-centre study is required to validate all available scoring systems.

Predicting clinical deterioration with Q-ADDS compared to NEWS, Between the Flags, and eCART track and trigger tools.

BACKGROUND: Early warning tools have been widely implemented without evidence to guide (a) recognition and (b) response team expertise optimisation. With growing databases from MET-calls and digital hospitals, we now have access to guiding information. The Queensland Adult-Deterioration-Detection-System (Q-ADDS) is widely used and requires validation. AIM: Compare the accuracy of Q-ADDS to National Early Warning Score (NEWS), Between-the-Flags (BTF) and the electronic Cardiac Arrest Risk Triage Score (eCART)). METHODS: Data from the Chicago University hospital database were used. Clinical deterioration was defined as unplanned admission to ICU or death. Currently used NEWS, BTF and eCART trigger thresholds were compared with a clinically endorsed Q-ADDS variant. RESULTS: Of 224,912 admissions, 11,706 (5%) experienced clinical deterioration. Q-ADDS (AUC 0.71) and NEWS (AUC 0.72) had similar predictive accuracy, BTF (AUC 0.64) had the lowest, and eCART (AUC 0.76) the highest. Early warning alert (advising ward MO review) had similar NPV (99.2-99.3%), for all the four tools however sensitivity varied (%: Q-ADDS = 47/NEWS = 49/BTF = 66/eCART = 40), as did alerting rate (% vitals sets: Q-ADDS = 1.4/NEWS = 3.5/BTF = 4.1/eCART = 3.4). MET alert (advising MET/critical-care review) had similar NPV for all the four tools (99.1-99.2%), however sensitivity varied (%: Q-ADDS = 14/NEWS = 24/BTF = 19/eCART = 29), as did MET alerting rate (%: Q-ADDS = 1.4/NEWS = 3.5/BTF = 4.1/eCART = 3.4). High-severity alert (advising advanced ward review, Q-ADDS only): NPV = 99.1%, sensitivity = 26%, alerting rate = 3.5%. CONCLUSION: The accuracy of Q-ADDS is comparable to NEWS, and higher than BTF, with eCART being the most accurate. Q-ADDS provides an additional high-severity ward alert, and generated significantly fewer MET alerts. Impacts of increased ward awareness and fewer MET alerts on actual MET call numbers and patient outcomes requires further evaluation.

Retrospective evaluation of factors influencing transfusion requirements and outcome in cats with pelvic injury (2009-2014): 122 cases.

OBJECTIVE: To characterize a population of cats with pelvic trauma and evaluate factors influencing transfusion requirement and outcome. DESIGN: Retrospective case series (2009-2014). SETTING: University teaching hospital. ANIMALS: One hundred twelve client-owned cats with pelvic trauma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twenty-one (18.8%) cats received a transfusion. Most cats required only 1 fresh whole blood transfusion (85.8%). Packed cell volume at admission was significantly lower in cats that required transfusion but was not associated with hospitalization time or survival to discharge. Increasing Animal Trauma Triage (ATT) score at admission was significantly associated with transfusion requirement (P = 0.0001) and nonsurvival to discharge (P = 0.03). Number of pelvic fractures was not associated with transfusion requirement but cats with sacroiliac luxations and pubic fractures were more likely to require a transfusion (P = 0.0015 and P = 0.0026, respectively). However, fracture type was not associated with survival to discharge. Most cats (86%) required a surgical procedure and half of transfusions were administered preoperatively. No surgical comorbidities were associated with transfusion requirement or survival. Transfusion requirement was associated with longer length of hospitalization but not survival to discharge. CONCLUSIONS: Transfusion requirement in this population of cats with pelvic fractures was fairly high. Transfusion requirement was associated with lower packed cell volume, higher ATT score at admission, longer length of hospitalization, and certain types of pelvic fractures. Transfusion requirement was not associated with surgical comorbidities, surgical intervention, or survival to discharge. Lower ATT score at admission was associated with survival to discharge.

Validation of the Pediatric Physiological and Anatomical Triage Score in Injured Pediatric Patients.

INTRODUCTION: Triaging plays an important role in providing suitable care to a large number of casualties in a disaster setting. A Pediatric Physiological and Anatomical Triage Score (PPATS) was developed as a new secondary triage method. This study aimed to validate the accuracy of the PPATS in identifying injured pediatric patients who are admitted at a high frequency and require immediate treatment in a disaster setting. The PPATS method was also compared with the current triage methods, such as the Triage Revised Trauma Score (TRTS). METHODS: A retrospective review of pediatric patients aged ≤15 years, registered in the Japan Trauma Data Bank (JTDB) from 2012 through 2016, was conducted and PPATS was performed. The PPATS method graded patients from zero to 22, and was calculated based on vital signs, anatomical abnormalities, and the need for life-saving interventions. It categorized patients based on their priority, and the intensive care unit (ICU)-indicated patients were assigned a PPATS ≥six. The accuracy of PPATS and TRTS in predicting the outcome of ICU-indicated patients was compared. RESULTS: Of 2,005 pediatric patients, 1,002 (50%) were admitted to the ICU. The median age of the patients was nine years (interquartile range [IQR]: 6-13 years). The sensitivity and specificity of PPATS were 78.6% and 43.7%, respectively. The area under the receiver-operating characteristic (ROC) curve (AUC) was larger for PPATS (0.61; 95% confidence interval [CI], 0.59-0.63) than for TRTS (0.57; 95% CI, 0.56-0.59; P <.01). Regression analysis showed a significant correlation between PPATS and the Injury Severity Score (ISS; r2 = 0.353; P <.001), predicted survival rate (r2 = 0.396; P <.001), and duration of hospital stay (r2 = 0.252; P <.001). CONCLUSION: The accuracy of PPATS for injured pediatric patients was superior to that of current secondary triage methods. The PPATS method is useful not only for identifying high-priority patients, but also for determining the priority ranking for medical treatments and evacuation.

Triage in Complex, Coordinated Terrorist Attacks.

INTRODUCTION: Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed. METHODS: Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs). DISCUSSION: Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and "tactical triage." CONCLUSION: Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.

Introduction of Pediatric Physiological and Anatomical Triage Score in Mass-Casualty Incident.

BACKGROUND: Triage has an important role in providing suitable care to the largest number of casualties in a disaster setting, but there are no secondary triage methods suitable for children. This study developed a new secondary triage method named the Pediatric Physiological and Anatomical Triage Score (PPATS) and compared its accuracy with current triage methods. METHODS: A retrospective chart review of pediatric patients under 16 years old transferred to an emergency center from 2014 to 2016 was performed. The PPATS categorized the patients, defined the intensive care unit (ICU)-indicated patients if the category was highest, and compared the accuracy of prediction of ICU-indicated patients among PPATS, Physiological and Anatomical Triage (PAT), and Triage Revised Trauma Score (TRTS). RESULTS: Among 137 patients, 24 (17.5%) were admitted to ICU. The median PPATS score of these patients was significantly higher than that of patients not admitted to ICU (11 [IQR: 9-13] versus three [IQR: 2-4]; P<.001). The optimal cut-off value of the PPTAS was six, yielding a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 95.8%, 86.7%, 60.5%, and 99.0%. The area under the receiver-operating characteristic curve (AUC) was larger for PPTAS than for PAT or TRTS (0.95 [95% CI, 0.87-1.00] versus 0.65 [95% CI, 0.58-0.72]; P<.001 and 0.79 [95% CI, 0.69-0.89]; P=.003, respectively). Regression analysis showed a significant association between the PPATS and the predicted mortality rate (r2=0.139; P<.001), ventilation time (r2=0.320; P<.001), ICU stay (r2=0.362; P<.001), and hospital stay (r2=0.308; P<.001). CONCLUSIONS: The accuracy of PPATS was superior to other methods for secondary triage of children. Toida C , Muguruma T , Abe T , Shinohara M , Gakumazawa M , Yogo N , Shirasawa A , Morimura N . Introduction of pediatric physiological and anatomical triage score in mass-casualty incident. Prehosp Disaster Med. 2018;33(2):147-152.

Using age, triage score, and disposition data from emergency department electronic records to improve Influenza-like illness surveillance.

OBJECTIVE: Markers of illness severity are increasingly captured in emergency department (ED) electronic systems, but their value for surveillance is not known. We assessed the value of age, triage score, and disposition data from ED electronic records for predicting influenza-related hospitalizations. MATERIALS AND METHODS: From June 2006 to January 2011, weekly counts of pneumonia and influenza (P&I) hospitalizations from five Montreal hospitals were modeled using negative binomial regression. Over lead times of 0-5 weeks, we assessed the predictive ability of weekly counts of 1) total ED visits, 2) ED visits with influenza-like illness (ILI), and 3) ED visits with ILI stratified by age, triage score, or disposition. Models were adjusted for secular trends, seasonality, and autocorrelation. Model fit was assessed using Akaike information criterion, and predictive accuracy using the mean absolute scaled error (MASE). RESULTS: Predictive accuracy for P&I hospitalizations during non-pandemic years was improved when models included visits from patients ≥65 years old and visits resulting in admission/transfer/death (MASE of 0.64, 95% confidence interval (95% CI) 0.54-0.80) compared to overall ILI visits (0.89, 95% CI 0.69-1.10). During the H1N1 pandemic year, including visits from patients <18 years old, visits with high priority triage scores, or visits resulting in admission/transfer/death resulted in the best model fit. DISCUSSION: Age and disposition data improved model fit and moderately reduced the prediction error for P&I hospitalizations; triage score improved model fit only during the pandemic year. CONCLUSION: Incorporation of age and severity measures available in ED records can improve ILI surveillance algorithms.

Validation of the Calgary Spine Severity Score.

BACKGROUND CONTEXT: The Calgary Spine Severity Score (CSSS) is a published triage score reported in the Spine Journal in 2010. It separates spine referrals into four time categories of urgency. It stratifies patients according to clinical, radiologic, and pathologic findings. The CSSS however still requires external validation at another institution and in an unselected sample of patients. PURPOSE: The aim was to validate the CSSS. STUDY DESIGN/SETTING: This was a validation study. PATIENT SAMPLE: The sample included a total of 316 consecutive patients undergoing spinal surgery between April 2014 and September 2014 at a tertiary care hospital in Canada. OUTCOME MEASURES: The outcome was validity of the CSSS via its predicted time to operating room (OR) to predict actual time to OR. METHODS: We applied the CSSS to an unselected sample of consecutive patients from a tertiary care hospital between April 2014 and September 2014. Demographic and clinical data were collected. The CSSS was determined. We compared the time with OR predicted by the CSSS in one of four categories (routine>6 months=CSSS 3-5, priority<6 months=CSSS 6-8, urgent<1 month=CSSS 9-11, and emergent<1 week=CSSS 12-15) with the actual time to OR. We used Kaplan-Meier survival analysis to assess the CSSS predictive ability. Cox proportional hazard models were built and compared via analysis of variance to determine whether the models differed in their ability to fit the data. RESULTS: Three hundred sixteen patients were eligible. Two hundred eighty-nine had sufficient data. One hundred eighteen were a mismatch with the actual time to OR yielding an accuracy of 63%. The CSSS overestimated the urgency in 68 cases and underestimated it in 50 cases. Notably, seven cauda equina syndrome cases were classified as priority (<6 months) instead of emergent. The concordance was 0.70 and the R-square 0.33. We proposed several adjustments to the CSSS to increase its accuracy. The modified CSSS had an accuracy of 96%, overestimating nine cases and underestimating one case. The concordance was 0.77, and the R-square 0.70. CONCLUSIONS: The modified CSSS is an easy-to-use triage score, which represents a substantial improvement as compared with the original CSSS. It now requires further external validation.