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Prospective comparison of AMB, GAP AND START scores and triage nurse clinical judgement for predicting admission from an ED: a single-centre prospective study
  1. Mauro Salvato1,
  2. Monica Solbiati1,2,
  3. Paola Bosco1,3,
  4. Giovanni Casazza2,
  5. Filippo Binda3,
  6. Marco Iotti4,
  7. Jessica Calegari1,
  8. Dario Laquintana3,
  9. Giorgio Costantino1,2
  1. 1UOC Pronto Soccorso e Medicina d’Urgenza, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
  2. 2Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
  3. 3UOC Direzione delle Professioni Sanitarie, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
  4. 4UO Comparto Operatorio, Columbus Clinic Center, Milan, Italy
  1. Correspondence to Dr Mauro Salvato, UOC Pronto Soccorso e Medicina d’Urgenza, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; mauro.salvato{at}policlinico.mi.it

Abstract

Background It is postulated that early determination of the need for admission can improve flow through EDs. There are several scoring systems which have been developed for predicting patient admission at triage, although they have not been directly compared. In addition, it is not known if these scoring systems perform better than clinical judgement. Therefore, the aim of this study was to validate existing tools in predicting hospital admission during triage and then compare them with the clinical judgement of triage nurses.

Methods To conduct this prospective, single-centre observational study, we enrolled consecutive adult patients who presented between 30 September 2019 and 25 October 2019 at the ED of a large teaching hospital in Milan, Italy. For each patient, triage nurses recorded all of the variables needed to perform Ambulatory (AMB), Glasgow Admission Prediction (GAP) and Sydney Triage to Admission Risk Tool (START) scoring. The probability of admission was estimated by the triage nurses using clinical judgement and expressed as a percentage from 0 to 100 with intervals of 5. Nurse estimates were dichotomised for analysis, with ≥50% likelihood being a prediction of admission. Receiver operating characteristic curves were generated for accuracy of the predictions. Area under the curve (AUC) with 95% CI for each of the scores and for the nursing judgements was also calculated.

Results A total of 1710 patients (844 men; median age, 54 years (IQR: 34–75)) and 35 nurses (15 men; median age, 37 years (IQR: 33–48)) were included in this study. Among these patients, 310 (18%) were admitted to hospital from the ED. AUC values for AMB, GAP and START scores were 0.77 (95% CI: 0.74 to 0.79), 0.72 (95% CI: 0.69 to 0.75) and 0.61 (95% CI: 0.58 to 0.64), respectively. The AUC for nurse clinical judgement was 0.86 (95% CI: 0.84 to 0.89).

Conclusion AMB, GAP and START scores provided moderate accuracy in predicting patient admission. However, all of the scores were significantly worse than the clinical judgement of the triage nurses.

  • triage
  • emergency nursing
  • emergency department
  • hospitalisations

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplemental information. All the de-identified participant data and the statistical analysis plan will be available to researchers who will provide a methodologically sound proposal to the corresponding author.

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Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplemental information. All the de-identified participant data and the statistical analysis plan will be available to researchers who will provide a methodologically sound proposal to the corresponding author.

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Footnotes

  • Handling editor Ellen J Weber

  • Contributors MSa, MSo, GCa and GCo designed the study. MSa, JC and FB collected the data. MSa, MSo and GCa analysed and interpreted the data. MSo, MSa and GCo drafted the manuscript. All the authors critically revised the manuscript for important intellectual content. GCa provided statistical expertise. MSa is responsible for the overall content as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.