Correlation of the Canadian Pediatric Emergency Triage and Acuity Scale to ED resource utilization

Objectives

The aim of this study was to find if there is a correlation between acuity measured by the Canadian Pediatric Emergency Triage and Acuity Scale (Ped-CTAS) and resource utilization in a large tertiary academic emergency department (ED). If correlation exists, it may indicate that resource allocation was done in accordance with needs (the more acute the patient, the more resources needed). This may also be the basis for future consideration regarding resource allocation decisions.

Methods

All pediatric patients (0-19 years of age) who were seen in the ED during 12 randomly selected days between May 1, 2005, and April 30, 2006, were included in the study. Detailed information regarding number and types of investigations ordered was collected. To look at the aggregate use of resources, we used the unit of cost. Resource utilization was calculated using standardized cost lists, and results were used to explore the correlation between different Ped-CTAS levels and resource utilization. A fixed cost model was used to predict the remainder of costs, other than diagnostic services.

Results

Of the 1661 patients presenting during the study period, 1618 (97.4%) were included in the study. The mean laboratory, microbiology, imaging, and total investigational costs increased with increasing acuity. This difference was insignificant between the semiurgent and the nonurgent categories of the Ped-CTAS.

Conclusions

The Ped-CTAS level correlates well with resource utilization for patient management in the ED. Further research should focus on measuring nursing and physician time use for each Ped-CTAS level to more accurately document ED resource utilization.     

Evaluation of the Paediatric Canadian Triage and Acuity Scale in a pediatric ED

The aim of this study was to compare the performance of the Paediatric Canadian Triage and Acuity Scale (Paed CTAS) to a previous triage tool with respect to the percentage of admissions, the diagnostic and therapeutic interventions, and the mean pediatric risk of admission (PRISA) score in a pediatric tertiary center emergency department. Data were prospectively collected for 4 months before the Paed CTAS introduction (PRE group) and for 4 months after its implementation (Paed CTAS group). Both groups were similar in chief complaints, distribution of triage levels, and mean PRISA score. In the Paed CTAS group, more patients were triaged in the higher acuity levels (53% vs 36%, P < .05), but the percentage of admission for these patients was comparatively lower (13% vs 27%, P<.05). The ability to predict admission was greater for the PRE tool as compared to the Paed CTAS tool (AUC: 0.82 vs 0.69, P=.001). The ability to predict requirements for interventions such as blood culture and intravenous fluid bolus was similar for both triage tools.     

Effectiveness of a 6-week online course in the Canadian Triage and Acuity Scale for emergency nurses.

INTRODUCTION: There is increasing interest in 5-level triage systems in emergency departments; however, the adoption of a new system places heavy training demands on ED department nurses and physicians. One emerging training option is online learning. The purpose of this study was to explore the effectiveness of an online course in the 5-level Canadian Triage and Acuity Scale (CTAS) on the clinical practice of the triage nurse. METHODS: Interviews were held with 23 emergency nurses from across Canada. A chart audit of triage codes from 367 charts from 6 hospitals was conducted. RESULTS: The most consistent finding was that the majority of RN staff enjoyed the online course and believed it had improved their triage practice. Nurses believed that their patient assessments were more thorough, accurate, and consistent throughout the department. Improved communication between staff and with patients and families was identified. Nurses reported using what they learned to improve triage assessment. Triage accuracy was high; the overall agreement between CTAS graduates and the chart auditor/expert within one CTAS level was 99.7%. Nurses also identified a number of organizational barriers to CTAS implementation after the course. DISCUSSION: The online format appears to be an effective, efficient, and convenient way to educate large numbers of ED staff in CTAS. Further research is needed regarding the use of multimedia and computer online chat options to further enhance the online learning experience for nurses.     

The Canadian Triage and Acuity Scale: A Canadian perspective on emergency department triage

The Canadian Triage and Acuity Scale has received widespread acceptance in Canada as a reliable and valid tool for emergency department triage. The importance of accurate triage becomes more apparent as emergency department volumes increase, and resources shrink. The need to ensure that those patients requiring more urgent care receive care first is the basis for all triage scales. Through the Canadian Triage and Acuity Scale National Working Group, the scale became the recommended triage tool for Canadian emergency departments. Work has been done on the interrater reliability of Canadian Triage and Acuity Scale among health care providers. There is a need to further assess the validity of the scale. This scale has now been applied in the out of hospital setting by paramedics and is being used in measurements of emergency physician workload. The future may see an electronic triage tool develop for emergency department use to reduce variability in its application. The Canadian Triage and Acuity Scale has become an integral component of Canadian emergency departments.     

Reliability of a Computerized Version of the Pediatric Canadian Triage and Acuity Scale

Background: The use of a standardized triage tool allows better comparison of the patients; a computerized version could theoretically improve its reliability.
Objectives: To compare the interrater agreement of the Pediatric Canadian Triage and Acuity Scale (PedCTAS) and a computerized version (Staturg).
Methods: A two-phase experimental study was conducted to compare the interrater agreement between nurses assigning triage level to written case scenarios using either traditional PedCTAS or Staturg. Participants were nurses with at least one year of experience in pediatric emergency medicine and trained at triage. Each of the 54 scenarios was evaluated first by all nurses using either one of the strategies. Four weeks later, they evaluated the same scenarios using the other tool. The primary outcome was the interrater agreement measured using κ score.
Results: Eighteen of the 29 eligible nurses participated in the study. The computerized triage tool showed a better interrater agreement, with a Staturg κ score of 0.55 (95% confidence interval = 0.53 to 0.57) versus a PedCTAS κ score of 0.51 (95% confidence interval = 0.49 to 0.53). The computerized version was also associated with higher agreements for scenarios describing patients with the highest severity of triage (κ score of 0.72 vs. 0.55 for level 1; κ score of 0.70 vs. 0.51 for level 2).
Conclusions: A computerized version of the PedCTAS showed a statistically significant improvement in the interrater agreement for nurses evaluating the triage level of 54 clinical scenarios, but this difference has probably small clinical significance.     

Interrater Agreement between Nurses for the Pediatric Canadian Triage and Acuity Scale in a Tertiary Care Center

Objectives: The objective was to measure the interrater agreement between nurses assigning triage levels to children visiting a pediatric emergency departments (EDs) assisted by a computerized version of the Pediatric Canadian Triage and Acuity Scale (PedCTAS). Methods: This was a prospective cohort study evaluating children triaged from Level 2 (emergent) to Level 5 (nonurgent). A convenience sample of patients triaged during 38 shifts from April to September 2007 in a tertiary care pediatric ED was evaluated. All patients were initially triaged by regular triage nurses using a computerized version of the PedCTAS. Research nurses performed a second evaluation blinded to the first evaluation using the same triage tool. These research nurses were regular ED nurses performing extra hours for research purposes exclusively. The primary outcome measure was the interrater agreement between the two nurses as measured by the linear weighted kappa score. Secondary outcomes included the proportion of patient for which nurses did not apply the triage level suggested by Staturg (override) and agreement for these overrides. Results: A total of 499 patients were recruited. The overall interrater agreement was moderate (linear weighted kappa score of 0.55 [95% confidence interval {CI} = 0.48 to 0.61] and quadratic weighted kappa score of 0.61 [95% CI = 0.42 to 0.80]). There was a discrepancy of more than one level in only 10 patients (2% of the study population). Overrides occurred in 23.2 and 21.8% for regular and research triage nurses, respectively. These overrides were equally distributed between increase and decrease in triage level. Conclusions: Nurses using Staturg, which is a computerized version of the PedCTAS, demonstrated moderate interrater agreement for assignment of triage level to children presenting to a pediatric ED.     

Implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in an Urgent Care Center in Saudi Arabia

Objectives

The objectives of the study is to review and assess the implementation of the applied modified five-level triage and acuity scale triage system in AL-Yarmook Urgent Care Center (UCC), King Abdulaziz Residential City, Riyadh, Saudi Arabia.

Method

An observational cross-sectional study was conducted, where a data collection sheet was designed and distributed to triage nurses. The data collection was done during the triage process and was directly observed by the co-investigator. The triage system was reviewed by measuring three time intervals as quality indicators: time before triage (TBT), time before being seen by physician (TBP), and total length of stay (TLS) taking in consideration the timing of presentation and the level of triage.

Results

A total of 187 patients visiting the UCC during December 2014 were included. There was an almost equal distribution of males 98 (52 %) and females 89 (48 %) with most of the patients being in the age group of 14 years and younger (n?=?85, 46 %). The visits of the patients were classified according to the level of triage from patients to be seen immediately by the physician to those who had been triaged out. Overall, 173 patients (92.5 %) were seen by the physician in a timely manner according to triage guidelines, while 14 patients (7.5 %) were not. The mean time was 5.36 min in TBT, 22.6 min in TBP, and 59 min in TLS. The median time to be seen by the physician was significantly greater (p?=?0.001) for the urgent cases on the weekends (25 min; IQR, 21,30) as compared to the weekdays (17 min; IQR, 14,21). Generally, the results did not show significant increases in TBT, TBP, the number of patients not seen at the proper time, or referral and admission rates during weekends.

Conclusion

The Canadian Emergency Department Triage and Acuity Scale (CTAS) is adaptable to countries beyond Canada and can be implemented successfully. The applied CTAS triage system in Al-Yarmouk UCC in Riyadh, Saudi Arabia, is considered to be well applied. Overall, urgent cases have been seen by physicians in a timely manner according to the triage system, and there was no delay in the management of critical cases which need prompt attention.

     

Preparing new nurses with complexity science and problem-based learning

Successful nurses function effectively with adaptability, improvability, and interconnectedness, and can see emerging and unpredictable complex problems. Preparing new nurses for complexity requires a significant change in prevalent but dated nursing education models for rising graduates. The science of complexity coupled with problem-based learning and peer review contributes a feasible framework for a constructivist learning environment to examine real-time systems data; explore uncertainty, inherent patterns, and ambiguity; and develop skills for unstructured problem solving. This article describes a pilot study of a problem-based learning strategy guided by principles of complexity science in a community clinical nursing course. Thirty-five senior nursing students participated during a 3-year period. Assessments included peer review, a final project paper, reflection, and a satisfaction survey. Results were higher than expected levels of student satisfaction, increased breadth and analysis of complex data, acknowledgment of community as complex adaptive systems, and overall higher level thinking skills than in previous years.     

Validity of the Japan Acuity and Triage Scale in elderly patients: A cohort study

BackgroundIn developed nations, the age of patients in emergency departments (ED) continues to increase. Many emergency triage systems, such as the Canadian Triage and Acuity Scale (CTAS), triage patients as a homogenous group, regardless of age. However, older adults have multiple comorbidities and a higher risk of undertriage. The Japan Acuity and Triage Scale (JTAS) was developed based on the CTAS and has been validated for overall adults. We assessed the validity of the JTAS for use in elderly ED patients.MethodsThis was a secondary analysis of a cohort study that previously validated the JTAS in self-presenting adults of all ages in the ED of a Japanese tertiary-care hospital. We included non-transferred patients who were ≥65 years old and triaged between June 2013 and May 2014. Our primary outcome measures were overall admission and ED length of stay. Our secondary outcomes included admission to the intensive care units (ICUs) and in-hospital mortality. We examined the association between the triage level and patient outcomes with multivariable logistic regression analysis (overall and ICU admission and in-hospital mortality) and the Kruskal-Wallis rank-sum test (ED length of stay).ResultsWe included a total of 11,087 elderly patients in our study. Higher odds ratios for overall and ICU admission and in-hospital mortality corresponded to higher acuity levels. ED length of stay was significantly longer in patients with a higher JTAS level (p < 0.001). Twenty-nine percent of admissions who were triaged as lower acuity levels were related to non-acute diseases including malignancy-related events.ConclusionOur study suggests an association between the JTAS triage level and clinical outcomes in self-presenting elderly patients, thereby demonstrating the validity of the JTAS in these patients. However, admission due to chronic diseases including malignancy was common in patients who were rated as low acuity level.     

Triage nurses order x-rays for patients with isolated distal limb injuries: A 12-month ED study.

OBJECTIVES: To determine whether triage nurses could safely, accurately, and appropriately order x-rays for patients with distal limb injuries. METHODS: All adult patients presenting to the emergency department of a tertiary teaching hospital for 12 months with distal limb injuries were eligible for the study. Patients with severe pain or evidence of acute neurovascular compromise were excluded. Triage nurses who had completed a training workshop offered patients the option of having an x-ray obtained before seeing a physician. Data were collected regarding the number and type of x-rays ordered, the number of positive x-ray findings on radiologic review, and violations of x-ray ordering guidelines. All ED distal limb x-rays ordered during the 12-month study period were analyzed for type, frequency, and abnormality. To determine the impact of the project on practice, all triage nurses were given the opportunity to complete a questionnaire, patient satisfaction surveys were conducted, and structured interviews were conducted with senior ED medical and radiography personnel. RESULTS: During the 12-month study, triage nurses ordered 876 x-rays (49%), whereas physicians ordered 930 x-rays (51%). Medical staff and triage nurses ordered equal proportions of upper and lower limb x-rays. The abnormality rate in the total study group was 699 (39%). The abnormality rate for x-rays when comparing nursing and medical staff was 43% (390) and 33% (309), respectively (x(2) = 23.4; P <.0001). The triage x-ray abnormality rate for the upper limb was 51%, compared with 31% for the lower limb. Data indicated that all staff believed that this new triage practice had increased patient satisfaction and improved patient flow and waiting times. CONCLUSION: With structured education, triage nurses at one institution safely assessed patients and ordered appropriate distal limb x-rays prior to physician assessment.     

Preparing nurses to use microcomputers for the work of management

Communications and information systems are expanding rapidly in health care organizations today. That nurses must not only be computer literate but also consumers of information technologies emerges as a professional imperative. This is especially true for nurses in management and administration. Therefore, exposing them to current technologies becomes crucial in their academic experience. Educating students to use business software applications and to understand their output will yield a leading edge to those preparing for management decision-making.