Accuracy of ED triage of psychiatric patients

The study objective was to determine the accuracy of initial triage assessment (ITA) in directing behavioral emergency patients to appropriate medical or psychiatric care, and to identify variables that enhance triage accuracy. A cohort study of 436 adult patients with 1 of 10 behavioral-related complaints was conducted. ITA compared with the final ED diagnosis, both of which were classified as either "medical" or "psychiatric." Patient triage characteristics correlated with the final ED diagnosis using logistic regression. Sensitivity of ITA for predicting a medical final ED diagnosis was 70% (95% CI 60.1, 78.5) and specificity 85% (95% CI 80.6, 88.7). ITA agreed with final ED diagnosis in 344 (81.3%) and these patients had a significantly shorter ED length of stay (4.50 v 5.90 hours, p=0.03). Dementia, past psychiatric history, family history of psychiatric illness, and ITA were significant predictors of final ED diagnosis. ITA is a fair predictor of the final ED diagnosis, but could be enhanced by screening for dementia and past psychiatric history. Improved triage accuracy could reduce length of stay for such patients.     

ED triage of patients with acute myocardial infarction: predictors of low acuity triage

Objective

Virtually all emergency department (ED) patients receive an ED triage assessment that determines their priority to be seen by a physician. Previous research found that half of patients who are having an acute myocardial infarction (AMI) are given a low priority triage score, which is associated with delays in electrocardiogram (ECG) acquisition and reperfusion therapy. We sought to determine some of the reasons why ED triage is failing in these patients.

Methods

We conducted a retrospective cohort analysis of a population-based cohort of AMI patients admitted to 102 acute care hospitals in Ontario, Canada, from July 2000 to March 2001. We examined 10 potential patient- and hospital-level predictors of low acuity triage: age, sex, number of comorbidities, arrival mode, socioeconomic status, time of day, day of week, ED AMI volume, hospital type, and department use of triage ECGs.

Results

Mean age of the 3088 patients was 67.5 (SD, 14.0), and 65% were men. In adjusted quantile regression analyses, low acuity triage was independently associated with ED AMI volume (odds ratio [OR], 0.44 at very high volume centers), arrival mode (OR, 0.60 for ambulance arrival), sex (OR, 0.80 for males), age (OR, 1.1 per 10 years of age), and a low number of comorbidities (OR, 0.92 for every cardiac co-morbidity).

Conclusions

Low acuity ED triage of AMI patients may be predicted by several patient- and hospital-level characteristics. Focusing future interventions on these factors may improve ED triage and, subsequently, time to initial ECG and reperfusion, in this patient group.     

Modification and Initial Psychometric Evaluation of the Physical Health Attitude Scale for Use in the Canadian Mental Health and Addictions Context

Introduction: The Physical Health Attitude Scale (PHASe) tool was developed to better understand mental health nurses’ attitudes towards their involvement and confidence in physical health care. This tool has been used in the United Kingdom and Australia; however, it has not been used in Canada.

Aim: This study aims to modify and provide an initial psychometric evaluation of the PHASe tool for use in a Canadian mental health and addictions context.

Methods: In Phase 1, clinical experts (n?=?8) were consulted to provide feedback on the content and face validity of the PHASe tool. In Phase 2, the PHASe tool was piloted with nurses at a large urban mental health and addiction organization in Ontario, Canada (n?=?77).

Results: In Phase 1, 4 items were added and 5 items were removed from the tool based on feedback provided by experts. In Phase 2, 12 poorly correlated items were removed. A two-factor solution was identified, with subscales “confidence” and “barriers and attitudes”.

Discussion: Initial psychometric evaluation suggests that a revised 15-item version of the PHASe tool is valid and reliable in a Canadian mental health and addictions context; however, more testing is recommended in larger, more diverse samples.     

Mental capacity of psychiatric patients

Nearly every society maintains legal norms that define those members of society qualified to participate in social affairs. Mental capacity and legal competence are deemed necessary conditions for legal actions to have legal validity. On Nov. 23, 2009, newly revised adult guardianship provisions came into effect in Taiwan. However, there has been lack of discussion with regard to how assessments of mental capacity and legal competence should be conducted on psychiatric patients. This paper reviewed relevant overseas literature on this subject and followed common practice in separating legal mental capacity into causal and functional components. The causal component predicates the diseases and illnesses that render the disability, while the functional component represents legally substantial impairments in terms of cognition, emotion and behavior. The paper explored functional component contents, including finance management, individual health care, independence in daily life, interpersonal relationships and communing. Findings pointed out that in setting up competence standards, a trade-off between respect for autonomy and beneficence is unavoidable. As Taiwan does not have rich empirical data on competence assessments and decisions, collaboration between the legal and psychiatric professions is recommended to engage in relevant research to enhance legal consistencies and the science of competence assessment.     

A simple and useful coma scale for patients with neurologic emergencies: the Emergency Coma Scale

Objectives

The Emergency Coma Scale (ECS) was developed in Japan in 2003. We planned a multicenter study to evaluate the utility of the ECS by comparison of the ECS and the Glasgow Coma Scale (GCS).

Methods

Ten medical facilities, including 4 university hospitals in Japan, participated in this study. We evaluated and recorded the level of consciousness, using the ECS and GCS, of all patients transported to these medical facilities by ambulance. We then performed a statistical analysis of the level of rater agreement of each scale using the average weighted κ coefficient according to the types of diagnosis at time of discharge and the occupations of the raters. We then evaluated the relationship between outcome of patients and their scores on the ECS and GCS by logistic regression analysis.

Results

The ECS showed the greater agreement among raters in patient scoring (0.802). In patients with traumatic brain injury and cerebrovascular disease, the ECS also yielded the higher agreement (0.846 and 0.779, respectively). The ECS score appears to be more strongly related than the GCS to patient outcome as measured by the Glasgow Outcome Scale (GOS).

Conclusions

Our results showed that the ECS is a simple and readily understandable coma scale for a wide range of professionals in the field of neurologic emergencies. Furthermore, ECS appears to be suitable for evaluating patients in neurologic emergency settings.     

Pediatric triage. A system to JumpSTART your triage of young patients at MCIs

No matter how well we plan and train, every MCI is an exercise in gaining control over chaos. Emotions can sometimes get in the way. An MCI with pediatric victims is an additional emotional challenge that must be met by using objective tools so we can avoid needless mistakes in medical judgment. JumpSTART, used in conjunction with an adult triage tool such as START, can help to ensure that we not only meet the needs of all our MCI victims, but also address our own needs to provide the very best care for the children we encounter.     

Evaluating an Alternative to the Emergency Department for Adults in Mental Health Crisis

Adults with mental health issues lack clinically indicated options when in crisis. Historically, the emergency department (ED) has been the primary source of intervention largely due to funding cuts and decreased community resources in the USA. The literature highlights drastic mental health funding cuts alongside an increased prevalence of mental illness. A community-based alternative for adults in mental health crises was subsequently developed as a model of crisis care. The program has demonstrated impressive short-term outcomes, typically avoiding ED admissions in over 95% of the clients. This number benefits both the consumers who otherwise rely on the ED and the State of Illinois in terms of cost savings for avoidable ED visits. The current deflection rate only reflects ED admissions deflected on the day of the visit to the crisis respite program. To establish the long-term outcomes for this model, follow-up phone calls were conducted to determine whether or not the individual required an ED visit for a psychiatric reason within 30 days of utilization of the program. The follow-up phone calls began in May and continued for eight weeks. At this time, the data collected were analyzed and the outcomes of the program were further evaluated. Based on the follow-up survey results, the positive long-term outcomes validate this model as a cost-saving and clinically indicated alternative to the ED. Establishing such outcomes was necessary to ensure continued funding and to support establishment of similar models of crisis care.     

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.     

急诊科护士心理健康状况的调查

目的了解医院急诊科护士的心理健康状况并分析其影响因素。方法 2014年6月,采用症状自评量表(symptom checklist 90,SCL-90)对哈尔滨市10所三级乙等和10所三级甲等医院的160名急诊科护士进行调查。结果女性护士身体不适、人际关系、恐怖等因子的得分高于男性护士(P0.05),未婚护士的焦虑及恐怖因子得分高于已婚护士(P0.05),工作年限10年的护士的强迫和恐怖因子得分高于工作年限10年的护士(P0.05);不同学历护士SCL-90量表的各因子得分各不相同,但差异无统计学意义(P0.05);三级甲等医院急诊科护士的身体不适、强迫因子得分高于三级乙等医院的急诊科护士,差异有统计学意义(P0.05);急诊科护士SCL-90量表各因子得分与常模比较,人际关系、躯体化、强迫、抑郁、焦虑、敌对性、恐怖、精神病性和附加项因子得分的差异有统计学意义(P0.05)。结论急诊科护士存在一定的情绪性心理问题倾,其与他们的情感、性格、工作环境及工作经验等因素有关,医院管理者应重视急诊科护士的心理健康状况,并给予针对性的指导和帮助。     

急诊科护士心理健康状况调查

目的：了解医院急诊科护士心理健康状况。方法：应用临床症状自评量表（SCL－90），对5所综合性医院的急诊科74名护士和普通病房72名护士进行了问卷调查，并进行对比分析。结果：急诊护士的总均分及阳性项目数与普通病房护士比较， 前者明显高于后者，统计学有明显差异；各因子分中躯体化、焦虑、抑郁、强迫及敌对因子得分，急诊护士均明显高于普通病房护士，其他因子得分无明显差异。结论：与普通病房护士比较，急诊护士显示出较多的心身问题，表现为临床症状自评量表上的总均分高、阳性项目数多、躯体化、焦虑、抑郁、强迫、敌对因子得分较高。导致急诊护士较多的心理问题的原因是多方面的，主要与急诊特定的工作性质、工作环境、工作对象有关。     

急诊科护士心理健康状况调查

目的了解医院急诊科护士心理健康状况.方法应用临床症状自评量表(SCL-90),对5所综合性医院的急诊科74名护士和普通病房72名护士进行了问卷调查,并进行对比分析.结果急诊护士的总均分及阳性项目数与普通病房护士比较,前者明显高于后者,统计学有明显差异;各因子分中躯体化、焦虑、抑郁、强迫及敌对因子得分,急诊护士均明显高于普通病房护士,其他因子得分无明显差异.结论与普通病房护士比较,急诊护士显示出较多的心身问题,表现为在临床症状自评量表上的总均分高、阳性项目数多、躯体化、焦虑、抑郁、强迫、敌对因子得分较高.导致急诊护士较多的心理问题的原因是多方面的,主要与急诊特定的工作性质、工作环境、工作对象有关.