Impact of a Disaster Drill on Waiting Times in a Pediatric Emergency Department

Objective: Emergency departments should improve their preparedness for mass casualty incidents (MCIs) through periodic drills. These exercises are conducted while maintaining regular care. The aim of this study was to determine the impact of a disaster drill in a pediatric emergency department (PED) on real patients’ waiting times. Methods: On September 10, 2019, a 4-h disaster drill was conducted in the PED of a tertiary pediatric hospital, with minimal staff reinforcement (2 nurses). Cases were real patients that came to the PED during the drill. The patients that visited the PED the day before were the control group. Variables analyzed were: age, sex, destination, triage level, time-to-triage, time-to-physician, length of PED stay, and percentage of patients visited within the optimal time according to triage level. Results: Sixty-eight patients (case group) and 63 patients (control group) were analyzed; both groups were comparable except for the median age. There were no differences in time-to-triage, time-to-physician, and length of PED stay between the 2 groups. The percentage of patients visited within optimal time according to triage level was higher in the case group. Conclusions: Conducting an MCI drill in the PED, with minimal staff reinforcement, was not detrimental to real patients’ waiting times.

Utility and acceptability of the EXCEEDS algorithm for oncology stakeholders: Results of a Delphi study.

e13538 Background: The Exercise in Cancer Decision Support (EXCEEDS) algorithm is an evidence-based, risk stratified framework. This framework allows for enhanced decision making for exercise pre-participation medical clearance and triage to cancer rehabilitation or exercise services across the cancer continuum. We conducted a Delphi study to examine utility and acceptability of the EXCEEDS algorithm for oncology stakeholders. Methods: Delphi study participants were randomized to two case studies, then made pre-participation medical clearance (yes/no) and intervention triage recommendations (cancer rehabilitation, clinically-supervised exercise, cancer-specific community-based exercise, and unsupervised exercise) in two conditions: independent (IND) and using EXCEEDS. Immediately following, participants rated algorithm acceptability in four domains using 4-point Likert scales (1- strongly disagree, to 4- strongly agree). We dichotomously coded accuracy (correct/incorrect) for each medical clearance and triage recommendation, then calculated the proportion of correct answers for each case to determine accuracy. We compared triage decision time (seconds) between conditions (IND vs. EXCEEDS) using paired-samples t-tests. We calculated the proportion of participants who ‘agreed’ (i.e., score ≥3) with each acceptability domain. Results: Oncology stakeholders (N=33) were mostly female (69.7%), 35-44 years old (42.4%), located in the United States (60.6%), and had at least 10 years of experience (60.6%). When using EXCEEDS, accuracy for medical clearance decisions improved in 3 of 4 cases (75%), triage decision accuracy improved in 4 of 4 (100%) cases, and triage time (seconds) improved significantly in 3 of 4 cases (75%, p<.05). Table shows average improvement in decision accuracy and triage time for each case study. Most participants agreed that the algorithm was acceptable in each domain: “meets my approval” (n=21, 63.6%), “is appealing” (n=29, 87.9%), “enjoyable to use” (n=19, 57.6%), and “welcomed in my discipline or practice” (n=24, 72.7%). Conclusions: Accuracy and efficiency of decision-making for medical clearance and triage to cancer rehabilitation or exercise services was enhanced when using the EXEECDS algorithm. Most participants agreed the algorithm was acceptable. Future research is needed to validate the tool and explore avenues for dissemination and clinical implementation. % difference between EXCEEDS and Individual condition (EXCEEDS – IND) for medical clearance decision, triage decision and mean (M) and standard deviation (SD) of triage decision time.[Table: see text]

Smart Check - COVID-19 triage system: evaluation of the impact on the screening time and identification of clinical manifestations of SARS-CoV-2 infection in a public health service.

Introduction: Most patients with COVID-19 have mild or moderate manifestations, however, there is a wide spectrum of clinical presentations and even more severe repercussions that require high diagnostic suspicion. Vital sign acquisition and monitoring are crucial for detecting and responding to patients with COVID-19. Objective: Thus, we conducted this study to demonstrate the impact of using a tool called Smart Check on the triage time of patients with suspected COVID-19 and to identify the main initial clinical manifestations in these cases. Methodology: We assessed triage times before and after the use of Smart Check in 11,466 patients. In this group, we identified 211 patients for the identification of COVID-19 clinical manifestations in a case-control analysis. Results: Smart Check was able to decrease the triage time by 33 seconds on average, with 75% of the exams being performed within 5 minutes, whereas with the usual protocol these steps were performed within 6 minutes. A range of clinical presentations made up the COVID-19 initial manifestations. Those with the highest frequency were dry cough (46.8%), fever (41.3%), dyspnea (35.8%), and headache (32.1%). Loss of appetite, fever, and ageusia were the manifestations that had a statistically significant association with the SARS-CoV-2 presence. Conclusions: Smart Check, a simple clinical evaluation tool, along with the targeted use of rapid PCR testing, can optimize triage time for patients with and without COVID-19. In triage centers, a number of initial signs and symptoms should be cause for SARS-CoV-2 infection suspicion, in particular the association of respiratory, neurological, and gastrointestinal manifestations. Keywords: new coronavirus, COVID-19, triage, clinical manifestations

Conversion to an electronic missing medication request system at an academic medical center

Missing medications can negatively contribute to the financial and operational workflows of pharmacy departments and add medication safety challenges. The missing medication request (MMR) system at the study institution converted to entirely electronic in June 2018 from a hybrid electronic system. This study evaluated 4-week periods pre- and post-conversion. The objective of this study was to evaluate the impact of conversion to an electronic MMR system on the quantity of requests received at an academic medical center. The average daily number of MMR’s decreased from the pre-conversion group to the post-conversion group (1.77 (±0.16) vs 1.48 (±0.17), p < 0.001). During post-conversion, the median triage time was 8 min [3 min–19 min], pharmacists triaged 62.4% of requests, and 29.6% of requests were declined. Conversion to an electronic MMR system represents one solution to decreasing missing medications. Future studies are needed to evaluate the financial, operational, and medication safety impact of conversion.

P027: Development of a physician assistant lead stroke protocol to provide timely and equitable access to hyperacute stroke care in a telestroke community hospital

Background: The Brant Community Healthcare System (BCHS) has consistently been well above the recommended 30 minute benchmark for door-to-needle (DTN) for eligible acute stroke patients. As a large community hospital with no neurologists, and like many other hospitals internationally, we rely on telestroke support for every stroke case. This is a time-consuming process that requires a multitude of phone calls, and pulls physicians from other acutely ill patients. We sought to develop a system that would streamline our approach and care for hyperacute stroke patients by targeting improvements in DTN. Aim Statement: We will decrease the door-to-needle (DTN) time for stroke patients arriving at the BCHS Emergency Department (ED) who are eligible for tissue plasminogen activator (tPA) by 25% from a median of 87 minutes to 50 minutes by March 31, 2018 and maintain that standard. Measures & Design: Outcome Measures: Door-to-needle time for acute stroke patients receiving tPA Process Measures: Door-to-triage time, Door-to-CT time, Door-to-CTA time; INR collection-to-verification time, telestroke callback time Balancing Measures: Number of stroke protocol patients per month Model Design: We simultaneously designed and implemented a robust program to train physician assistants in hyperacute stroke care. Evaluation/Results: Through vast stakeholder engagement and implementing a multitude of change ideas, by March of 2018 we had achieved an average DTN of 53 minutes. Our door-to-triage time went from an average of 7 minutes to 3 minutes. Our door-to-CT time decreased from 17 minutes to 7 minutes and our time between CT and CTA from an average of 13 minutes to 3 minutes. One and a half years later, our average DTN is maintained at 55 minutes and physician assistants continue to effectively lead and liaise with telestroke neurologists and stroke patients. Discussion/Impact: Prior to this program, acute stroke care was a very contentious topic at our local community hospital. Creating a program that streamlined the care and standardized the work has proven successful, and not only allowed for improved DTN times but also freed up physicians to better simultaneously care for other acutely ill patients.

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

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.

MP28: Reigniting improvements in emergency departments – New approaches to resolving unsolvable problems

Background: In 2016 The Fraser Health Authority's Emergency Network established a priority to standardize patient access and flow through their 13 emergency departments (ED). A Model of Care (MOC) was developed after an extensive review of the literature and current practices across BC. Aim Statement: The ED Model of Care (MOC) specifies best practice expectations with respect to emergency patient access and flow. Rather than a ‘top-down’ mandate of expected practices, the MOC provided the opportunity for site-based teams to promote solutions that were ‘locally actioned and regionally enabled’. Measures &amp; Design: ED Quality Improvement (QI) teams were developed at all sites. The ED Network developed a “QI Bootcamp”, a one-day course focused on imparting tools to drive improvements, providing a baseline understanding of how to launch and sustain local QI initiatives. Using Prosci's change approach, an emphasis was placed on using local ingenuity to implement plans, analyze feedback and diagnose gaps. This approach measured utilization of the changes to tangibly link initiatives and change to specific outcomes. As part of this strategy, an online scorecard was created to measure local results against best practice outcomes. The scorecard tracked quantitative access metrics such as ED Length of Stay (EDLOS), Left Without Being Seen rate, and triage time. Measures such as forming a QI team, identifying a QI project and completing a PDSA cycle were included in the scorecard Evaluation/Results: The MOC change management strategy was launched in May of 2018. By December 2018 all 13 EDs had formed a local QI team and identified a project. Twelve sites had completed at least one PDSA cycle and 10 sites had at least 75% of their members attend the QI Bootcamp. The scorecard displayed improvements in flow metrics. Highlights include the average arrival to triage time decreasing by 36% at one site, EDLOS for moderately ill patients decreased from 4.8 to 3.4 hours at another, and a community hospital had low acuity patient EDLOS decrease from 3.52 to 2.37 hours. Discussion/Impact: A standardized approach to patient access and flow in the ED (MOC), combined with the engaging grass roots approach to inspiring local innovation, allied with a concrete change management approach demonstrated significant results for patients accessing and moving through EDs. This pattern that is more likely to sustain itself because the results are felt and locally owned.

Multicenter survey on emergency nurses’ perception of Numerical Rating Scale reliability at triage time in adult Emergency Department patients

Since pain perception is highly subjective and culturally mediated, its objective evaluation remains difficult. Nevertheless, pain measurement should ideally be a part of the assessment of patients in order to plan adequate pain relief. Several scales have been proposed for pain measurement, being the numerical rating scale (NRS) the most widely used, often at triage time. NRS have demonstrated acceptable reliability and validity, in post-operative medicine and in oncologic pain, but data in the Emergency Departments (EDs) are poor. The aim of this study is to evaluate the Emergency Nurses’ (ENs) perception about the reliability of NRS in the triage process. A questionnaire based on 11 items was designed and subsequently administered to a large number of ENs in several EDs in Northern and Central Italy. 301 questionnaires were filled out and returned. The majority declares using NRS scale to measure pain (item 2, mode = 4, mean = 3.8), and attributing priority code based on NRS value (item 3, mode = 4, mean = 3.4). In general, triage nurses believe that NRS is only indicative and that their judgement matters (item 4, mode = 4, mean = 3.2). The vast majority of triage nurses do believe that the patients will indicate a fake higher NRS value with the aim to get a more urgent code (item 5, mode = 5, mean = 4), while only a small minority expects that patients would underestimate their NRS for fear of penalizing more urgent patients. Very few believe that such scale underestimates the patients’ condition, while the majority is ambivalent about whether such scale overestimates it. In conclusion, NRS confirms to be a potentially valuable tool for pain evaluation at triage time, but many nurses express some doubts on its reliability, and will attribute the triage code mainly basing on their own judgement.