Predictability of the emergency department triage system during the COVID-19 pandemic – ScienceOpen
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      Predictability of the emergency department triage system during the COVID-19 pandemic

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          Abstract

          Objective

          Emergency department (ED) triage systems are used to classify the severity and urgency of emergency patients, and Korean medical institutions use the Korean Triage and Acuity Scale (KTAS). During the COVID-19 pandemic, appropriate treatment for emergency patients was delayed due to various circumstances, such as overcrowding of EDs, lack of medical workforce resources, and increased workload on medical staff. The purpose of this study was to evaluate the accuracy of the KTAS in predicting the urgency of emergency patients during the COVID-19 pandemic.

          Methods

          This study retrospectively reviewed patients who were treated in the ED during the pandemic period from January 2020 to June 2021. Patients were divided into COVID-19–screening negative (SN) and COVID-19–screening positive (SP) groups. We compared the predictability of the KTAS for urgent patients between the two groups.

          Results

          From a total of 107,480 patients, 62,776 patients (58.4%) were included in the SN group and 44,704 (41.6%) were included in the SP group. The odds ratios for severity variables at each KTAS level revealed a more evident discriminatory power of the KTAS for severity variables in the SN group (P<0.001). The predictability of the KTAS for severity variables was higher in the SN group than in the SP group (area under the curve, P<0.001).

          Conclusion

          During the pandemic, the KTAS had low accuracy in predicting patients in critical condition in the ED. Therefore, in future pandemic periods, supplementation of the current ED triage system should be considered in order to accurately classify the severity of patients.

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          Most cited references31

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          Critically Ill patients with 2009 influenza A(H1N1) in Mexico.

          In March 2009, novel 2009 influenza A(H1N1) was first reported in the southwestern United States and Mexico. The population and health care system in Mexico City experienced the first and greatest early burden of critical illness. To describe baseline characteristics, treatment, and outcomes of consecutive critically ill patients in Mexico hospitals that treated the majority of such patients with confirmed, probable, or suspected 2009 influenza A(H1N1). Observational study of 58 critically ill patients with 2009 influenza A(H1N1) at 6 hospitals between March 24 and June 1, 2009. Demographic data, symptoms, comorbid conditions, illness progression, treatments, and clinical outcomes were collected using a piloted case report form. The primary outcome measure was mortality. Secondary outcomes included rate of 2009 influenza (A)H1N1-related critical illness and mechanical ventilation as well as intensive care unit (ICU) and hospital length of stay. Critical illness occurred in 58 of 899 patients (6.5%) admitted to the hospital with confirmed, probable, or suspected 2009 influenza (A)H1N1. Patients were young (median, 44.0 [range, 10-83] years); all presented with fever and all but 1 with respiratory symptoms. Few patients had comorbid respiratory disorders, but 21 (36%) were obese. Time from hospital to ICU admission was short (median, 1 day [interquartile range {IQR}, 0-3 days]), and all patients but 2 received mechanical ventilation for severe acute respiratory distress syndrome and refractory hypoxemia (median day 1 ratio of Pao(2) to fraction of inspired oxygen, 83 [IQR, 59-145] mm Hg). By 60 days, 24 patients had died (41.4%; 95% confidence interval, 28.9%-55.0%). Patients who died had greater initial severity of illness, worse hypoxemia, higher creatine kinase levels, higher creatinine levels, and ongoing organ dysfunction. After adjusting for a reduced opportunity of patients dying early to receive neuraminidase inhibitors, neuraminidase inhibitor treatment (vs no treatment) was associated with improved survival (odds ratio, 8.5; 95% confidence interval, 1.2-62.8). Critical illness from 2009 influenza A(H1N1) in Mexico occurred in young individuals, was associated with severe acute respiratory distress syndrome and shock, and had a high case-fatality rate.
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            Systematic review of emergency department crowding: causes, effects, and solutions.

            Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. We conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding. Two independent reviewers identified the relevant articles by consensus. We applied a 5-level quality assessment tool to grade the methodology of each study. From 4,271 abstracts and 188 full-text articles, the reviewers identified 93 articles meeting the inclusion criteria. A total of 33 articles studied causes, 27 articles studied effects, and 40 articles studied solutions of ED crowding. Commonly studied causes of crowding included nonurgent visits, "frequent-flyer" patients, influenza season, inadequate staffing, inpatient boarding, and hospital bed shortages. Commonly studied effects of crowding included patient mortality, transport delays, treatment delays, ambulance diversion, patient elopement, and financial effect. Commonly studied solutions of crowding included additional personnel, observation units, hospital bed access, nonurgent referrals, ambulance diversion, destination control, crowding measures, and queuing theory. The results illustrated the complex, multifaceted characteristics of the ED crowding problem. Additional high-quality studies may provide valuable contributions toward better understanding and alleviating the daily crisis. This structured overview of the literature may help to identify future directions for the crowding research agenda.
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              Therapeutic and triage strategies for 2019 novel coronavirus disease in fever clinics

              In December, 2019, numerous unexplained pneumonia cases occurred in Wuhan, China. This outbreak was confirmed to be caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), belonging to the same family of viruses responsible for severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). 1 The SARS epidemic in 2003 was controlled through numerous measures in China. One effective strategy was the establishment of fever clinics for triaging patients. Based on our first-hand experience in dealing with the present outbreak in Wuhan, we have established the following clinical strategies in adult fever clinics (figure ). Figure Flow chart for treatment of 2019 novel coronavirus disease in fever clinics in Wuhan China CRP=C-reactive protein. CAP=Community-acquired pneumonia. SARS-CoV-2=severe acute respiratory syndrome corona virus 2. Patients can be afebrile in the early stages of infection, with only chills and respiratory symptoms. High temperature is not a general presentation. Elevated C-reactive protein (CRP) is an important factor of 2019 novel coronavirus disease (COVID-19; formally known as 2019-nCoV) and impaired immunity, characterised by lymphopenia, is an essential characteristic. Therefore, in afebrile patients (temperature 65 years) and immunocompromised patients should be treated as moderate or severe cases in the initial assessment. Infections in pregnant women might progress rapidly and timely clinical decisions are crucial to provide pregnant women with options, such as induction, anaesthesia, and surgery. Consultation with an obstetric specialist is recommended and depending on the condition of the mother, termination of the pregnancy is a consideration. Home care and isolation can relieve the burden on health-care providers of fever clinics. We used this strategy in Wuhan in response to the large volume of patients arriving at health care centres but do not recommend it for other regions where each suspected case can be appropriately isolated and monitored in a health setting. Inappropriate home care can be life threatening for patients and be a detriment to public health. 5 Many factors contributed to developing our clinical algorithm in Wuhan during the early outbreak period. During this time, the influx of patients to fever clinics substantially outweighed the number of physicians. Inpatient care was unsafe due to potential cross-infection and supplementary resources were not ready. Applying and waiting for results of an SARS-CoV-2 test was time consuming just after the outbreak and did not aid clinical decision making. We made trade-offs between infection control and standard medical principles and adapted the protocol as more information and resources became available. We hope our experience will serve as guidance for other fever clinics and future cases.
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                Author and article information

                Journal
                Clin Exp Emerg Med
                Clin Exp Emerg Med
                CEEM
                Clinical and Experimental Emergency Medicine
                The Korean Society of Emergency Medicine
                2383-4625
                June 2024
                29 January 2024
                : 11
                : 2
                : 195-204
                Affiliations
                Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
                Author notes
                Correspondence to: Jinwoo Myung Department of Emergency Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Email: JWM1125@ 123456yuhs.ac
                Author information
                http://orcid.org/0000-0002-6908-9459
                http://orcid.org/0000-0003-1634-5209
                http://orcid.org/0000-0002-3098-2784
                http://orcid.org/0000-0001-6110-1495
                http://orcid.org/0000-0001-7033-766X
                http://orcid.org/0000-0002-5125-0881
                Article
                ceem-23-107
                10.15441/ceem.23.107
                11237259
                38286510
                1b5e2a33-e6cd-45e7-869f-4d3624228a88
                Copyright © 2024 The Korean Society of Emergency Medicine

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/).

                History
                : 7 August 2023
                : 6 October 2023
                : 6 October 2023
                Categories
                Original Article

                emergency departments,triage,covid-19
                emergency departments, triage, covid-19

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