In a resource poor setting with poverty, a high burden of disease and critically low medical staff numbers, triage could potentially improve the long waiting times experienced at South African public hospital emergency departments (ED) and render timely emergency care to those in most need.
To evaluate the impact of introducing nurse triage (using the Cape Triage Score (CTS)) on waiting times for patients presenting to a South African public hospital ED.
Pre-triage waiting times were collected retrospectively through accessing hospital records of four randomly chosen months of the preceding year. This was compared with data collected prospectively over a 3 month period using nurse triage and the CTS triage tool. Captured data included CTS priority category, time of nurse triage and time of attendance by ED doctor.
Waiting times were significantly reduced in all but the lowest priority category. The introduction of nurse triage, using the CTS, resulted in an overall reduction in waiting time from 237 min to 146 min (p<0.001). Patients triaged "red" (highest priority) demonstrated a mean reduction in waiting time from 216 min to 38 min (p<0.001).
The results demonstrate that use of the CTS, as implemented by trained nurses, dramatically reduced the waiting time of patients attending a busy public hospital ED in South Africa.
Until recently South Africa had no triage system for emergency department (ED) use. The Cape triage group developed a triage scale called the Cape triage score (CTS). This system consists of a basic physiology score, mobility score and a short list of important discriminators that cannot be accurately triaged on a physiological score alone. Highest priority is given to a red colour code, followed by orange, yellow and green.
The purpose was to evaluate the components of the CTS and identify amendments that would improve the quality of the scale in terms of its accuracy to identify patients more likely to require admission or at high risk of death in the ED.
Data were prospectively collected over a 4-month period. Data captured included the parameters of a basic physiological score (respiratory rate, pulse rate, systolic blood pressure, temperature and a simplified score measuring level of consciousness), mobility, a list of selected clinical conditions (discriminator list), final clinical diagnosis and final outcome in the ED (admission to hospital or death).
798 patients were triaged and analyzed. The CTS undertriaged 24% (overtriage 25%) of cases who required admission. By altering the colour code parameters, amending the discriminator list as well as the addition of a trauma factor, undertriage was reduced to 12% (with an overtriage of 45%).
The amended CTS has an acceptably low undertriage rate and is capable of predicting patient disposal over a wide spectrum of ED presentations.
Thrombolytic therapy with intravenous recombinant tissue plasminogen activator (rt-PA) improves outcome in patients with ischaemic stroke treated within 3 h of symptom onset, but its extended implementation is limited. A pilot study was designed to verify whether evaluation of patients with acute ischaemic stroke and their treatment with intravenous rt-PA in the emergency department (ED), followed by transportation to a semi-intensive stroke care unit, offers a safe and effective organisational solution to provide intravenous thrombolysis to acute stroke patients when a stroke unit (SU) is not available.
After checking for inclusion and exclusion criteria, ED doctors contacted the stroke team with a single page, located family members and urgently obtained computed tomography scan and laboratory tests. A stroke team investigator clinically assessed the patient, obtained written informed consent and supervised intravenous rt-PA in the ED. After treatment, the patient was transferred to the SU for rehabilitation and treatment of complications, under supervision of the same stroke team investigator.
52 patients were treated with intravenous rt-PA within 3 h of symptom onset. 20 patients (38%) improved neurologically after 24 h, the number increased to 30 (58%) after one week. At 3 months 22 patients had a favourable outcome (43%). The 3-month mortality rate was 12%. Symptomatic cerebral haemorrhage was observed in two patients (4%).
Intravenous rt-PA administration in the ED is an effective organisational solution for acute ischaemic stroke when an SU is not established.
To determine interobserver variability between an emergency medicine consultant and nurse practitioners for the use of the Wells score in the assessment of deep vein thrombosis (DVT) in the emergency department.
A prospective cohort study was undertaken in a population of 100 cases of suspected DVT. The Wells score reading from the consultant was compared with the reading of the nurse practitioners. Consultant and nurses were blinded to each other’s assessments. The nurse practitioners were trained in interpreting the Wells score by assessing 100 patients together with the consultant before the start of the study.
Consultant and nurse practitioner assessments resulted in the same final Wells score in 81% of cases (simple agreement), with a kappa score of 0.74 (95% CI 0.63 to 0.84). If the nurse practitioner score had been followed in preference to the consultant assessment, this would have resulted in eight patients being assessed in a lower risk algorithm (8%).
There is good interobserver agreement between consultant and nurse practitioners for the use of the Wells score as part of a DVT assessment service within the emergency department. Pretest scoring is pivotal to integrated strategies for the exclusion of DVT. The Wells score is a robust and reliable tool for pretest scoring in the emergency department regardless of the grade of the assessor, provided there is adequate training in its use.
To investigate the clinical validity of a nurse practitioner emergency department-based service for investigating outpatients with suspected deep vein thrombosis.
A prospective management study was undertaken to investigate the safety of withholding anticoagulant treatment in patients who were negative for testing after application of an evidence-based protocol. The protocol involved a nurse assessment using the Wells pretest score followed by investigations tailored to the risk category (variable combinations of strain gauge plethysmography, D-dimer and ultrasound). The main outcome assessed was the venothromboembolic complication rate in patients deemed to have deep vein thrombosis excluded by the protocol.
A total of 625 consecutive patients were evaluated between March 2003 and January 2007. Of these, 435 were eligible and 190 were ineligible. Four patients in the negative cohort were confirmed to have venous thromboembolism on follow-up. The incidence of venous thromboembolism in the 6-month follow-up period was therefore 1.04% (95% CI 0.41% to 2.65%).
The evidence-based protocol used in this study can reliably exclude deep vein thrombosis in an outpatient population when applied as part of a nurse-based evaluation.
To identify the factors considered by parents to be most important in determining overall satisfaction with care in a children’s emergency department, and to assess whether these factors are influenced by the child’s age and triage category.
A prospective questionnaire-based study of parents attending a paediatric emergency department with their child.
Bristol Royal Hospital for Children, Bristol, UK.
The parent or next of kin adult accompanying a child to the emergency department during the study period.
The primary outcome measure was the response to the questionnaire. The secondary outcome analysed responses according to the child’s age and triage category.
During the sampling period questionnaires were distributed to the parent or accompanying adult of 247 children, of which 225 (91%) were completed. The most important factors were: a clear explanation of the child’s diagnosis and treatment plan; the ability of a parent to stay with their child at all times; rapid and adequate pain relief; and staff attitude. These factors significantly outranked waiting times and other process issues. The age and triage category of the child did not influence these preferences.
Despite recent emphasis on waiting times and emergency department throughput in the UK, parents still value the clinical interaction above process issues when their child visits an emergency department. Current efforts to reduce the time spent by children in an emergency department must not undermine the core service values that are most appreciated by parents, and which will lead to the greatest satisfaction.
To determine medical and nursing staffing levels in emergency departments in England and Wales.
A postal survey with an addressed return envelope was sent to all emergency departments in England and Wales enquiring about staffing levels and annual attendances.
Responses were received from 91/202 departments (45%). Great variability was seen in medical and nursing staffing levels across departments in England and Wales. The predominant members of the medical workforce were SHO grade doctors. The number of senior and middle grade doctors generally increased as departments became larger. Nursing levels were not as responsive to departmental size.
There is great variability in staffing numbers in similar-sized departments, and most departments are understaffed in comparison with the recommendations of the British Association for Emergency Medicine to achieve the 4 h target at the 90% level.
Emergency department (ED) attendances and subsequent hospital admissions are rising in the United Kingdom. The reasons for this are unclear but may relate to recent changes in primary care and public perception. The actions taken by patients or their relatives before emergency hospital admission, the reasons for these actions and their outcome were determined.
Adult patients admitted to an inner city teaching hospital with a medical or surgical illness were interviewed using a semistructured questionnaire. Data were collected and analyzed regarding the actions taken before arrival at hospital, the reasons for taking these actions, their outcome and future intentions. 200 patients were interviewed.
Direct attendance at the ED was more common when help was sought by bystanders or persons known only slightly to the patient (p = 0.03). 57 patients (28.5%) attended the ED directly, 45 of whom dialled 999 for an emergency ambulance. Most patients who attended the ED directly did so as a result of the perceived severity or urgency of their condition and there was incomplete awareness of the out-of-hours GP service.
The majority of adult patients who are admitted to hospital with an acute illness seek professional help from primary care in the first instance. Those who attend the ED generally perceive their problem as more urgent or severe, or have an ambulance called on their behalf. The shift towards ED care appears partly driven by changes in general practice and unfamiliarity with the new arrangements for out-of-hours primary care provision.
To determine the feasibility of screening asymptomatic young men for genital Chlamydia trachomatis infection in a suburban emergency department setting.
Prospective observational study.
Chase Farm Hospital Emergency Department in Enfield, North London.
Asymptomatic sexually active men aged 16–24 years.
A convenience sample of men aged 16–24 years attending the emergency department was offered urine-based screening for Chlamydia at triage. Verbal consent was obtained and first pass urine specimens were tested using the strand displacement amplification technique. Participants were traced by their preferred method of contact in order to be offered treatment within 2 weeks of attendance at the emergency department.
67 men participated, 64 of whom were tested, 3 returning positive tests. The prevalence of Chlamydia in asymptomatic men attending the emergency department was 4.7%.
Urine testing for genital C trachomatis in the emergency department can identify asymptomatic men in the community who may otherwise remain undetected. It is suggested that this is a worthwhile screening test to offer in the emergency department, providing follow-up for treatment can be arranged locally. There is no requirement for increased emergency department input into these patients over and above introducing them to the screening programme.
To assess the reliability and validity of the Manchester Triage System (MTS) in a general emergency department patient population.
A prospective evaluation study was conducted in two general hospitals in the Netherlands. Emergency department nurses from both hospitals triaged 50 patient vignettes into one of five triage categories in the MTS. Triage ratings were compared with the ratings of two Dutch MTS experts to measure inter-rater reliability. Nineteen days after triaging the patient vignettes, triage nurses were asked to rate the same vignettes again to measure test-retest reliability. Reliability in relation to the work experience of emergency department nurses was also studied. Validity was assessed by calculating percentages for overtriage, undertriage, sensitivity and specificity.
Inter-rater reliability was "substantial" (weighted kappa 0.62 (95% CI 0.60 to 0.65)) and test-retest reliability was high (intraclass correlation coefficient 0.75 (95% CI 0.72 to 0.77)). No significant association was found between the experience of emergency department nurses and the reliability score (kappa). Undertriage occurred more frequently than overtriage, especially in elderly patients (25.3% vs 7.6%). Sensitivity for urgent patients in the MTS was 53.2% and specificity was 95.1%. The patient vignettes representing children aged <16 years revealed a higher sensitivity (83.3%).
Inter-rater reliability is "moderate" to "substantial" and test-retest reliability is high. The reliability of the MTS is not influenced by nurses’ work experience. Undertriage mainly occurs in the MTS categories orange and yellow. The MTS is more sensitive for children who need immediate or urgent care than for other patients in the emergency department.
To determine whether daily board rounds in the emergency department (ED) alter patient management and whether they provide educational opportunities.
A prospective observational study of board rounds conducted in a small to medium-sized ED in the United Kingdom. Data were collected on changes made and educational events that took place.
Data were collected on 120 board rounds (984 patients). 5.8% of patients had a clinical change made. 12% of board rounds led to a significant change in at least one of investigation, treatment or disposition. 2% of board rounds led to a change in diagnosis. In 30% of board rounds teaching events took place.
Regular conduct of board rounds in a medium-sized UK ED is worthwhile and provides an additional teaching opportunity for juniors.
Preclinical actions in the primary assessment of victims of blunt trauma may prolong the time to definitive clinical care. The aim of this study was to examine the duration of performed interventions and to study the effect of on-scene time (OST) and interventions performed before admission to hospital on hospital resuscitation time.
147 consecutive patients with high-energy blunt trauma aged >=15 years were studied prospectively. Prehospital time intervals and interventions were documented and compared with hospital data collected from continuous digital video registration. Analyses were performed with correction for injury severity and type of prehospital medical assistance (emergency medical services (EMS) versus physician-staffed helicopter emergency medical services (HEMS)).
Primary survey and initial treatment were initiated and completed within 1 h of arrival of the EMS. 83% of this "golden hour" elapsed out of hospital and 81% (n = 224) of all interventions (n = 275) were carried out before admission to hospital. An increase in the number of prehospital interventions was associated with an increased OST (p<0.001). Subanalyses showed no such correlation in the HEMS group. The HEMS group had a longer mean OST than the EMS group (p<0.001) with relatively more prehospital interventions (p<0.001) and a shorter mean in-hospital primary survey time with fewer in-hospital interventions. Overall, OST and the number of prehospital interventions were not related to in-hospital primary survey time and interventions.
For most trauma patients the initial life- and limb-saving care is achieved within the "golden hour". Prehospital treatment occupies most of the golden hour. More prehospital interventions were performed with HEMS than with EMS only, but the higher number of interventions did not result in a longer OST with HEMS. Although the numbers of subsequent in-hospital interventions may be lower, no reduction in time in hospital may be expected from the interventions performed before hospital admission.
Although widely acknowledged, few data exist on the scope of general practice involvement in the management of prehospital emergencies. A study was undertaken to explore the frequency and types of emergencies dealt with and the interventions undertaken by GPs who had completed Immediate Care training.
All participants in Immediate Care courses in Ireland in 2002, 2003 and 2004 were invited to complete an anonymised questionnaire in which they estimated their experience of emergencies since completing a course. Sections dealt with personal/practice information, types of emergencies, interventions used and follow-up training.
448 participants completed courses, 408 were available to participate in the study and 259 (63.5%) responded; 66.6% of GPs responded. The mean reporting period was 29.4 months (range 18–53). Participants included many younger female GPs at the start of their general practice careers. Although most emergencies dealt with were medical, few other patterns emerged in the timing or setting of emergencies. 88% of GPs had called an ambulance in an emergency at least once in the preceding year. 84% of GPs had managed a suspected acute myocardial infarction at least once during the reporting period; seizures, serious injuries, paediatric emergencies and hypoglycaemia were dealt with by up to half of all GPs. Interventions used included intravenous access in a medical emergency (69%), intravenous fluid administration (51%), intravenous morphine (54%), cardiopulmonary resuscitation (37%), defibrillation (21%), use of airway adjuncts (28%) and use of advanced life support drugs in cardiac arrest (24%).
GPs make frequent use of a wide range of interventions in prehospital emergencies. Issues relating to tailored training, adequate equipment, collaboration with the emergency services and skills maintenance are highlighted by these data.
Litigation claims against the NHS are increasing. Society is less tolerant of mistakes or inadequate service and litigation claims are now becoming increasingly accepted.
All claims registered with the NHS litigation authority, both closed and still open, were collated from all the ambulance trusts across England in the past 10 years. All incidents notified between 19 December 1995 and 19 April 2005 were included. The data were then analysed according to time, description of the incident, cause of the incident and type of damage incurred. Cases were also described according to the total claim. Potential actions and further work are discussed.
Between 19 December 1995 and 19 April 2005 there were 272 cases of litigation conducted through the NHS litigation authority against ambulance services across the United Kingdom. The greatest proportion of claims was as a result of lack of assistance or care, which was alleged in 75 cases. Another significant proportion of cases related to a "failure/delay in treatment" or "diagnosis" accounting for 36 and 34 cases, respectively. The most common type of injury was a fatality in 69 cases and unnecessary pain in a further 56 claims. 17 claims were for sums of over £1 million; however, most of these cases were still ongoing. These cases are described in more detail; the type of outcome tended to be brain damage or significant spinal injury rather than a fatality, reflecting the higher cost of continuing long-term care of a chronically injured person.
This study suggests that the key clinical areas that need to be addressed are obstetric care, spinal injury recognition and the decision not to convey a person to hospital. The first two of these have been addressed in the recent release of the Joint Royal Colleges Ambulance Liaison Committee guidelines. The major areas of organisation relate to reducing delays and providing the safe transfer of patients.