scholarly journals LO75: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score in 7 emergency departments

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S54
Author(s):  
S.L. McLeod ◽  
J. McCarron ◽  
K. Stein ◽  
S. Scott ◽  
H.J. Ovens ◽  
...  
Keyword(s):  
Emergency Departments ◽  
Clinical Decision Making ◽  
Weighted Kappa ◽  
Clinical Decision ◽  
Primary Objective ◽  
Interrater Agreement ◽  
Kappa Statistics ◽  
Care Requirements ◽  
Research Assistants ◽  
Triage Time

Introduction: The Canadian Triage and Acuity Scale (CTAS) is the standard used in all Canadian (and many international) emergency departments (EDs) for establishing the priority by which patients should be assessed. In addition to its clinical utility, CTAS has become an important administrative metric used by governments to estimate patient care requirements, ED funding and workload models. Despite its importance, the process by which CTAS scores are derived is highly variable. Emphasis on ED wait times has also drawn attention to the length of time the triage process takes. The primary objective of this study was to determine the interrater agreement of CTAS in current clinical practice. The secondary objective was to determine the time it takes to triage in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 738 consecutive patient CTAS assessments were audited over 21 seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients. Using the auditor’s CTAS score as the reference standard, on-duty triage nurses over-triaged 89 (12.1%) and under-triaged 95 (12.9%) patients. Interrater agreement was “good” with an unweighted kappa of 0.63 (95% CI: 0.58, 0.67) and quadratic-weighted kappa of 0.79 (95% CI: 0.67, 0.90). Research assistants captured triage time for 3808 patients over 69 shifts at 7 different EDs. Median (IQR) triage time was 5.2 (3.8, 7.3) minutes and ranged from 3.9 (3.1, 4.8) minutes to 7.5 (5.8, 10.8) minutes. Conclusion: Variability in the accuracy, and length of time taken to perform CTAS assessments suggest that a standardized approach to performing CTAS assessments would improve both clinical decision making, and administrative data accuracy.

scholarly journals LO81: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score pre and post implementation of eCTAS

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S37
Author(s):  
S. McLeod ◽  
J. McCarron ◽  
T. Ahmed ◽  
S. Scott ◽  
H. Ovens ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Improve Patient Safety ◽  
Weighted Kappa ◽  
Clinical Decision ◽  
Interrater Agreement ◽  
Kappa Statistics ◽  
Support Tool ◽  
Number Of Patients ◽  
Research Assistants ◽  
Triage Time

Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, emergency department (ED) funding and workload models. The electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes that application of national triage guidelines across Ontario. The objective of this study was to evaluate triage times and score agreement in ED settings where eCTAS has been implemented. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1491 (752 pre-eCTAS, 739 post-implementation) individual patient CTAS assessments were audited over 42 (21 pre-eCTAS, 21 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 567 (75.4%) patients pre-eCTAS, compared to 685 (92.7%) patients triaged with eCTAS. Using the auditor's CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.0% vs. 5.1%; Δ 6.9, 95% CI: 4.0, 9.7) and under-triaged (12.6% vs. 2.2%; Δ 10.4, 95% CI: 7.9, 13.2). Interrater agreement was higher with eCTAS (unweighted kappa 0.89 vs 0.63; quadratic-weighted kappa 0.91 vs. 0.71). Research assistants captured triage time for 3808 patients pre-eCTAS and 3489 post implementation of eCTAS. Median triage time was 312 seconds pre-eCTAS and 347 seconds with eCTAS (Δ 35 seconds, 95% CI: 29, 40 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.

scholarly journals LO70: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score pre and post implementation of eCTAS

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S31-S32
Author(s):  
S. McLeod ◽  
J. McCarron ◽  
T. Ahmed ◽  
S. Scott ◽  
H. Ovens ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Improve Patient Safety ◽  
Weighted Kappa ◽  
Clinical Decision ◽  
Interrater Agreement ◽  
Kappa Statistics ◽  
Support Tool ◽  
Number Of Patients ◽  
Research Assistants ◽  
Triage Time

Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, ED funding and workload models. The Electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes the application of national triage guidelines (CTAS) across Ontario. The objective of this study was to evaluate the implementation of eCTAS in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1200 (738 pre-eCTAS, 462 post-implementation) individual patient CTAS assessments were audited over 33 (21 pre-eCTAS, 11 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients pre-eCTAS, compared to 429 (93.0%) patients triaged with eCTAS. Using the auditors CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.1% vs. 3.2%; 8.9, 95% CI: 5.7, 11.7) and under-triaged (12.9% vs. 3.9%; 9.0, 95% CI: 5.9, 12.0). Interrater agreement was higher with eCTAS (unweighted kappa 0.90 vs 0.63; quadratic-weighted kappa 0.79 vs. 0.94). Research assistants captured triage time for 4403 patients pre-eCTAS and 1849 post implementation of eCTAS. Median triage time was 304 seconds pre-eCTAS and 329 seconds with eCTAS ( 25 seconds, 95% CI: 18, 32 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.

scholarly journals Development of a stepwise tool to aide primary health care professionals in the process of deprescribing in older persons

2020 ◽  
Vol 18 (4) ◽  
pp. 2033
Author(s):  
Roxana De las Salas ◽  
Javier Eslava-Schmalbach ◽  
Claudia Vaca-González ◽  
Dolores Rodríguez ◽  
Albert Figueras
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Health Care Professionals ◽  
Older Persons ◽  
Clinical Decision Making ◽  
Inappropriate Medication ◽  
Clinical Decision ◽  
Potentially Inappropriate Medication ◽  
Kappa Statistics ◽  
Primary Health

Objective: The aim of this study was to develop and validate a stepwise tool to aid primary health care professionals in the process of deprescribing potentially inappropriate medication in older persons. Methods: We carried out a systematic review to identify previously published tools. A composite proposal of algorithm was made by following the steps from clinical experience to deprescribe medications. A 2-round electronic Delphi method was conducted to establish consensus. Eighteen experts from different countries (Colombia, Spain and Argentina) accepted to be part of the panel representing geriatricians, internists, endocrinologist, general practitioners, pharmacologists, clinical pharmacists, family physicians and nurses. Panel members were asked to mark a Likert Scale from 1 to 9 points (1= strongly disagree, 9= strongly agree). The content validity‏ ratio, item-level content validity, and Fleiss’ Kappa statistics was measured to establish reliability. The same voting method was used for round 2. Results: A 7-question algorithm was proposed. Each question was part of a domain and conduct into a decision. In round 1, a consensus was not reached but statements were grouped and organized. In round 2, the tool met consensus. The inter-rater reliability was between substantial and almost perfect for questions with Kappa=0.77 (95% CI 0.60-0.93), for domains with Kappa= 0.73 (95%CI 0.60-0.86) and for decisions with Kappa= 0.97 (95%CI 0.90-1.00). Conclusions: This is a novel tool that captures and supports healthcare professionals in clinical decision-making for deprescribing potentially inappropriate medication. This includes patient’s and caregiver’s preferences about medication. This tool will help to standardize care and provide guidance on the prescribing/deprescribing process of older persons’ medications. Also, it provides a holistic way to reduce polypharmacy and inappropriate medications in clinical practice.

scholarly journals A realist review of brief interventions for alcohol misuse delivered in emergency departments

2021 ◽  
Author(s):  
Caitlin J Davey ◽  
Meredith SH Landy ◽  
Amanda Pecora ◽  
David Quintero ◽  
Kelly E McShane
Keyword(s):  
Alcohol Use ◽  
Emergency Departments ◽  
Clinical Decision Making ◽  
Alcohol Misuse ◽  
Realist Review ◽  
Clinical Decision ◽  
Brief Interventions ◽  
Future Research ◽  
Healthcare Settings ◽  
Favorable Conditions

Background: Brief interventions (BIs) involve screening for alcohol misuse and providing feedback to patients about their use, with the aim of reducing alcohol consumption and related consequences. BIs have been implemented in various healthcare settings, including emergency departments (ED), where they have been found to contribute mixed results in their ability to address alcohol misuse among adults. Mechanisms through which BIs work and contextual factors impacting BI effectiveness are not clear. The purpose of this review was to understand how, for whom, and under what circumstances BIs work for adults misusing alcohol and who have been admitted to an ED. A realist review was chosen to answer these questions as realist reviews create context-mechanism-outcome configurations, leading to the development of comprehensive and detailed theories; in this case explaining how and for whom BIs work. Methods: Databases including PsycINFO, Healthstar, CINAHL, Medline, and Nursing and Allied Health were searched for articles published until December 2013. The search strategy focused on studies examining BIs that targeted alcohol misuse among adults admitted into the ED. The search identified 145 relevant abstracts, of which 36 were included in the review. The literature was synthesized qualitatively (immersion/crystallization). Results: Four mechanisms were found within reviewed studies, including engagement in/retention of BI materials, resolving ambivalence, increased awareness/insight into consequences of drinking, and increased self-efficacy/empowerment to use skills for change. The following contexts were found to impact mechanisms: emotional state, injury attributed to alcohol use, severity of alcohol use, and baseline stage of change. Conclusions: This realist review provides advances in theories regarding which mechanisms to target during a BI and which contexts create the most favorable conditions for these mechanisms to occur, ultimately leading to optimal BI outcomes. These results can inform future clinical decision-making when delivering BIs in ED settings. Future research should conduct quantitative examination to confirm these findings. Systematic review registration: PROSPERO CRD42013006549

scholarly journals A71 RECOMMENDATION REVERSALS IN GASTROENTEROLOGY CLINICAL PRACTICE GUIDELINES

2021 ◽  
Vol 4 (Supplement_1) ◽  
pp. 34-37
Author(s):  
R Gholami ◽  
N Gimpaya ◽  
R Khan ◽  
M A Scaffidi ◽  
R Bansal ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Clinical Decision Making ◽  
Epidemiologic Study ◽  
Clinical Decision ◽  
Primary Objective ◽  
Accepted Practice ◽  
Meta Analyses ◽  
Quality Evidence

Abstract Background Clinical practice guidelines are evidence-based resources designed to inform clinical decision making. Often, superior evidence will support the inclusion of novel procedures and practices to replace older recommendations. Recommendation reversals occur when (a) superior quality evidence emerges to suggest the harm or non-beneficence of prior recommendations, and (b) that recommendation is not supplanted by a newer one. Aims The primary objective of this study was to describe the content, frequency and rationale for recommendation reversals in CPGs published by gastroenterological societies. Methods For this meta-epidemiologic study, we considered two criteria to define a recommendation reversal: (a) the more recent CPG makes a recommendation that contradicts a previously accepted practice; and (b) the prior recommendation is not replaced by any novel intervention. We searched CPGs published by 20 major GI societies from 1991- 2019. Guidelines were included if had at least two iterations with the same title and used a valid evidence rating system (such as GRADE). Explicit recommendations which reported definite levels of evidence and strength of recommendation were extracted. Results We identified 1022 clinical guidelines from GI societies over 28 years. 292 CPGs were included for data synthesis. 5985 explicit statements were extracted. 12 reversals were confirmed and are summarized in the Table. Six reversals (50.0%) occurred due to studies reporting non-beneficence and 3 (25.0%) occrred due to studies reporting harm. Three recommendations (25.0%) were reversed due to new clinical trials; 3 (25.0%) due to systematic reviews or meta-analyses; and 2 to conform with CPGs of other societies (16.7%). Conclusions We describe recommendation reversals made in gastroenterology CPGs, and the reasons thereof. Investigation of recommendation reversals allows for the identification of low-value medical practices. This reinforces the need for GI CPG committees to (1) iteratively review guidelines to re-evaluate recommendations made on low-quality evidence and; (2) refrain from making recommendations when evidence for the same is weak. Funding Agencies None

scholarly journals Pilot Study of a Web-based Decision Tool on Post-operative Use of Radioactive Iodine

2017 ◽  
Vol 13 (01) ◽  
pp. 26
Author(s):  
Shrujal S Baxi ◽  
Rachel Kurtzman ◽  
Anne Eaton ◽  
Eliza Dewey ◽  
Craig Bickford ◽  
...  
Keyword(s):  
Thyroid Cancer ◽  
Pilot Study ◽  
High Risk ◽  
Radioactive Iodine ◽  
Clinical Decision Making ◽  
Weighted Kappa ◽  
Clinical Decision ◽  
Risk Level ◽  
Lymph Node Staging ◽  
Web Based

Background: The Thyroid Cancer Care Collaborative developed a web-based clinical decision-making module (CDMM) to inform riskadjusted decisions on post-thyroidectomy radioactive iodine (RAI) use in papillary thyroid cancer (PTC). Methods: In a pilot study, we evaluated the CDMM in 19 PTC cases representing low- (five), intermediate- (seven) and high-risk (seven) disease. Two PTC experts and 10 PTC physicians reviewed cases and assigned risk level and RAI recommendation. The experts used a standard approach while the others used the CDMM. We assessed agreement between responses using a weighted Kappa. Results: Between experts, risk-assignment was concordant in 100%, 57% and 86% of low-, intermediate- and high-risk cases, respectively. Between CDMM users, risk-assignment was concordant in 100%, 29% and 14% in low-, intermediate- and high-risk cases, respectively (p=0.01). CDMM-assigned risk agreed with the expert-assigned risk in 100%, 25% and 0% of low-, intermediate- and high-risk cases, respectively (Kappa=0.69). For RAI use, the experts agreed in 15 cases while CDMM users agreed in eight. On further analysis, interpretation of extrathyroidal extension and lymph node staging led to discrepancies with the CDMM. Conclusions

scholarly journals Predictors of pandemic influenza infection in adults presenting to two urban emergency departments, Toronto, 2009

CJEM ◽  
2011 ◽  
Vol 13 (01) ◽  
pp. 7-12 ◽  
Author(s):  
Todd C. Lee ◽  
Linda R. Taggart ◽  
Barbara Mater ◽  
Kevin Katz ◽  
Allison McGeer
Keyword(s):  
Blood Cell ◽  
White Blood Cell ◽  
Pandemic Influenza ◽  
Emergency Departments ◽  
Clinical Decision Making ◽  
Influenza Infection ◽  
Clinical Decision ◽  
H1n1 Influenza ◽  
Influenza Activity ◽  
Wbc Count

ABSTRACT Objective: Identifying features that differentiate patients with H1N1 influenza infection from those with other conditions may assist clinical decision making during waves of pandemic influenza activity. Methods: From April 27 to June 15, 2009, nasopharyngeal swabs were obtained from all adults presenting to two urban emergency departments (EDs) with illness including fever or respiratory symptoms. H1N1 infection was detected by reverse transcriptase–polymerase chain reaction. Chart review was performed to compare cases of H1N1 influenza (n = 117) to matched controls. Results: The median age of cases was 35 years versus 50 years for controls (p < .001). In those with pre-existing conditions, asthma was present in 31% of cases versus 14% of controls (OR 2.6, 95% CI 1.3–5.4). Cough (OR 7.8, 95% CI 3.2–19), fever (OR 3.0, 95% CI 1.7–5.4), headache (OR 2.0, 95% CI 1.2–3.2), and myalgias (OR 1.9, 95% CI 1.2–3.1) were significantly more common in H1N1 cases. The median white blood cell count was 5.7 × 109/mL versus 10.9 × 109/mL (p < .001). The combination of fever and cough had an OR of 5.3. Fever, cough, low white blood cell (WBC) count, and tachycardia had the highest OR at 11. The absence of both fever and cough had a negative predictive value of 99%, but this occurred in only 8% of controls. Conclusion: In patients presenting to the ED, the combination of fever, cough, tachycardia, and WBC count < 10 × 109/mL was suggestive of H1N1 influenza infection. However, clinical features could not reliably distinguish influenza from other acute respiratory illnesses in adult ED patients.

The Manchester Triage System (MTS): a score for emergency management of patients with acute gastrointestinal bleeding

2018 ◽  
Vol 56 (05) ◽  
pp. 479-487 ◽  
Author(s):  
Constantin Cornelius ◽  
Arthur Hoffman ◽  
Achim Tresch ◽  
Joerg Krey ◽  
Ralf Kiesslich ◽  
...  
Keyword(s):  
Emergency Department ◽  
Emergency Departments ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Initial Assessment ◽  
Gi Bleeding ◽  
Tertiary Referral Hospital ◽  
Triage System ◽  
Manchester Triage System ◽  
Level 3

Abstract Background Suspected gastrointestinal (GI) bleeding is a common initial diagnosis in emergency departments. Despite existing endoscopic scores to estimate the risk of GI bleeding, the primary clinical assessment of urgency can remain challenging. The 5-step Manchester Triage System (MTS) is a validated score that is often applied for the initial assessment of patients presenting in emergency departments. Methods All computer-based records of patients who were admitted between January 2014 and December 2014 to our emergency department in a tertiary referral hospital were analyzed retrospectively. The aim of our retrospective analysis was to determine if patient triage using the MTS is associated with rates of endoscopy and with presence of active GI bleeding. Results In summary, 5689 patients with a GI condition were treated at our emergency department. Two hundred eighty-four patients (4.9 %) presented with suspected GI bleeding, and 165 patients (58 %) received endoscopic diagnostic. Endoscopic intervention for hemostasis was needed in 34 patients (21 %). In patients who underwent emergency endoscopy, triage into MTS categories with higher urgency was associated with higher rates of endoscopic confirmation of suspected GI bleeding (79 % of patients with MTS priority levels 1 or 2, 53 % in level 3 patients, and 40 % in levels 4 or 5 patients; p = 0.024). Conclusions The MTS is an established tool for triage in emergency departments and could have a potential to guide early clinical decision-making with regards to urgency of endoscopic evaluation in patients with suspected GI bleeding.

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