Use of the Korean Triage and Acuity Scale for poor outcome prediction among emergency department patients with suspected infection

Objective@#The Korean Triage and Acuity Scale (KTAS) is a triage tool for patients in the emergency department (ED). This study aimed to evaluate the ability of the KTAS to predict poor outcomes in South Korean ED patients with a suspected infection. We also compared the effectiveness of KTAS with that of the National Early Warning Score (NEWS) and Modified Early Warning Score (MEWS) in predicting poor outcomes. @*Methods@#We conducted a single-center retrospective study that included adult patients with a suspected infection who were admitted to the ED between January 2019 and December 2019. Patients who received a prescription for antibiotics and associated culture tests in the ED were considered to have an infection. Poor outcomes were evaluated by in-hospital mortality, general ward admission, and intensive care unit (ICU) admission. A receiver operating characteristics (ROC) curve analysis was performed to evaluate and compare KTAS, NEWS, and MEWS. @*Results@#Of the 4,127 patients in the study, in-hospital mortality was reported in 154 (3.7%) patients. The median KTAS was lower in the non-survivors than in the survivors (2.51 vs. 3.35). Multivariate logistic regression analysis showed that the KTAS was associated with in-hospital mortality, ward admission, and ICU admission. The area under the ROC curve (AUROC) values for predicting in-hospital mortality associated with the KTAS, NEWS, and MEWS were 0.776 (95% confidence interval, 0.747-0.803), 0.829 (0.759-0.811) and 0.739 (0.694-0.786), respectively. @*Conclusion@#Our results showed that the KTAS was associated with in-hospital mortality, ward admissions, and ICU admissions among ED patients with a suspected infection. Thus, KTAS may be reliable in predicting a poor outcome in ED patients with a suspected infection.

Identifying characteristics of frequent and highly frequent users of the emergency department: a retrospective cross-sectional observational study

Objective@#Since the characteristics of frequent emergency department (ED) users are heterogeneous, it is impossible to mitigate overcrowding of the ED without basic data of diagnoses and risk factors of frequent ED users. Instead of selecting for a limited disease group, our study included all ED patients, thereby providing invaluable information to help predict patient demand for medical resources. @*Methods@#Frequent ED users are defined as patients who visit an ED between 7-17 times per calendar year, and highly frequent ED users are patients who visit an ED 18 times or more during the same period. Our study developed two logistic regression models comparing frequent users with less frequent users, and highly frequent users with frequent users. @*Results@#Although 98.98% of all patients were determined as less frequent ED users, they encompassed only 92.27% of all ED visits. Frequent ED users were most strongly identified as wound dressing follow-up visits and liver diseases (standardized βvalue of 3.29 and 2.31, respectively). However, considering the different disease categories, no differences were obtained between highly frequent ED and frequent ED users. @*Conclusion@#The diagnoses and risk factors related to frequent ED visits in Korea identified in this study, will provide important reference for future research aimed at reducing ED overcrowding. By further analyzing the risk factors associated with frequent ED use, non-emergency administrative systems or medical facilities can be utilized to reduce the ED overload.

Characteristics and effects of high-flow nasal cannula oxygen therapy in patients with heart failure admitted to the emergency department

Objective@#This study aimed to compare the effects of high-flow nasal cannula (HFNC) treatment and conventional oxygen therapy (COT) in patients with heart failure (HF) admitted to the emergency department (ED). @*Methods@#This study was a single-center, retrospective, observational study. The subjects were divided into HFNC and COT groups. The characteristics were compared, and vital signs and arterial blood gas (ABG) results were analyzed. In addition, mortality, intubation rate, intensive care unit (ICU) admission, and length of stay (LOS) were analyzed for clinical outcome. @*Results@#Among 252 patients, 91 and 161 were treated with HFNC and COT. Two groups showed differences in vital signs, ABG results, and pulmonary edema. The HFNC group showed no difference in mortality and LOS, but more intubation and ICU admission were observed (P=0.005, P<0.001). Due to the changes in vital signs and ABG results, the HFNC group reduced blood pressure, heart rate and respiratory rate, improved SpO2, increased pH, and decreased PaCO2. @*Conclusion@#HFNC therapy effectively improved vital signs and ventilation when administered to relatively unstable patients with HF admitted to the ED.

Analysis on the ratio of emergency department visits by elderly and non-elderly patients based on disease and particulate matter concentration in South Korea: a multicenter cross-sectional observational study

Objective@#Many previous studies have reported relationships between particulate matter 80 μg/m3, and the PM10 values on the 5 following days were recorded. To assess the cumulative effects of PM10, we calculated relative risk (RR) by analyzing the cumulative effects over 6 days (lag days 0 to 5). @*Results@#Asthma, COPD, and ischemic stroke patients (< 65 years old) showed a positive correlation between PM10 (asthma on lag day 5: RR, 2.587; 95% confidence interval [CI], 2.001-3.344; COPD on lag day 4: RR, 3.727; 95% CI, 2.988-4.650; and ischemic stroke on lag day 4: RR, 1.573; 95% CI, 1.168-2.118). MI in those≥65 showed the highest RR on lag day 1 (RR, 1.471; 95% CI, 1.042-2.077). Hemorrhagic stroke was not found to be significantly correlated with PM10 in either age group. @*Conclusion@#An increase in PM10 is associated with ED visits by patients<65 years old with asthma, COPD, or ischemic stroke, and with MI for those≥65 years.

Identifying characteristics of frequent and highly frequent users of the emergency department: a retrospective cross-sectional observational study

Objective@#Since the characteristics of frequent emergency department (ED) users are heterogeneous, it is impossible to mitigate overcrowding of the ED without basic data of diagnoses and risk factors of frequent ED users. Instead of selecting for a limited disease group, our study included all ED patients, thereby providing invaluable information to help predict patient demand for medical resources. @*Methods@#Frequent ED users are defined as patients who visit an ED between 7-17 times per calendar year, and highly frequent ED users are patients who visit an ED 18 times or more during the same period. Our study developed two logistic regression models comparing frequent users with less frequent users, and highly frequent users with frequent users. @*Results@#Although 98.98% of all patients were determined as less frequent ED users, they encompassed only 92.27% of all ED visits. Frequent ED users were most strongly identified as wound dressing follow-up visits and liver diseases (standardized βvalue of 3.29 and 2.31, respectively). However, considering the different disease categories, no differences were obtained between highly frequent ED and frequent ED users. @*Conclusion@#The diagnoses and risk factors related to frequent ED visits in Korea identified in this study, will provide important reference for future research aimed at reducing ED overcrowding. By further analyzing the risk factors associated with frequent ED use, non-emergency administrative systems or medical facilities can be utilized to reduce the ED overload.

Validation of systemic inflammatory response syndrome criteria without white blood cell count in Korean Triage and Acuity Scale

OBJECTIVE: The systemic inflammatory response syndrome (SIRS) criteria used in the triage scale have been implemented incompletely without laboratory data, such as the white blood cell (WBC) count, so the validity of SIRS as a triage tool has been uncertain. This study assessed the validity of the Korean Triage and Acuity Scale (KTAS) in applying SIRS with or without a WBC count. METHODS: The KTAS level was simulated by the number of SIRS criteria. This new KTAS level that did not apply the WBC count was defined as the partial-simulated KTAS (PS-KTAS), and the KTAS level including the WBC count was called the total-simulated KTAS (TS-KTAS). The authors used the intensive care unit (ICU), overall admission rate, and use of emergent interventions as the primary outcomes. RESULTS: A total of 1,077 patients with a suspected infection were triaged using the SIRS in KTAS. Multivariable logistic regression analysis showed that the odds ratio for overall admission was greater with a higher KTAS level than with KTAS level 4 in both the PS-KTAS and TS-KTAS. All areas under the curve of the PS- and TS-KTAS for ICU admission and emergent intervention rate both showed very low discriminant powers. CONCLUSION: Compared to TS-KTAS, PS-KTAS showed a similar or partially better relationship between the KTAS level and the use of critical medical resource. Future research is recommended to improve the matching between the SIRS scoring and each KTAS level to better classify the patient severity status and develop or discover new infection assessment tools that can be applied to KTAS.

Validity Analysis of Korean Triage and Acuity Scale

PURPOSE: The Korean Triage and Acuity Scale (KTAS), which was developed in 2012 due to the need for a single triage tool for emergency patients in Korea, has since become nationalized. Although five years has passed, there has been limited evidence of its validation. Therefore, this study was conducted to analyze the validity of the new triage system. METHODS: We conducted a multicenter prospective study. Data were collected from seven hospitals and 42,187 patients were classified using the KTAS from April 1, 2013 to July 6, 2014. We analyzed whether the indirect severity variables showed meaningful differences according to KTAS levels. The variables consisted of disposition from emergency room, length of stay, numbers of consultations, examination of computed tomography, emergency room costs, and performance of emergent interventions. RESULTS: From KTAS level 1 to 5, a decreasing trend in the length of stay in emergency room, frequency of consultation with other departments, admission, computed tomography rate, emergency intervention rate, and emergency room costs was observed. Upon binominal logistic regression, disposition from emergency room and emergent intervention rate showed the highest odds ratio with statistical significance. CONCLUSION: The results of this study demonstrated that KTAS is a valid emergency triage tool that reflects the severity of the patient with indirect indicators. The results of this study will be useful as a reference for quality control of KTAS.

Korean Triage and Acuity Scale (KTAS)

The number of patients visiting the emergency room (ER) is increasing every year. The Korean Triage and Acuity Scale (KTAS) was developed in Korea in 2012 to help reduce the congestion of the ER at the hospital level and improve the safety of patients. From January 2016, KTAS has been implemented in emergency medical (EM) centers. KTAS evaluates patients who visit the ER by the following process: impression evaluation, infection confirmation, primary symptom selection, and primary/secondary considerations. KTAS prioritizes patients according to the level, and if necessary, sets a time for which the patient can wait safely with the aim to see a doctor within that time. KTAS has the characteristics of both severity and acuity, so there can be some discrepancy between the KTAS level and disposition. All EM centers conducted the KTAS classification from March to November, 2016. An analysis of the results of the KTAS classification showed no distortion in the classification from the beginning of KTAS introduction. In the near future, it is hoped to develop a KTAS-based transport protocol reflecting the regional medical resources and cultures at the pre-hospital stage, and establish an effective EM system, including medical basis and policy consideration.

Analysis on Workforce and Workload of Korean Emergency Physicians

PURPOSE: The purpose of this study is to understand the workforce and the workload of emergency physicians based depending on their experiences. METHODS: This study analyzed the results of the 2015 Korean Emergency Physician Survey performed between August and October 2015. RESULTS: Of the total 1,418 emergency physicians, 437 (30.8%) answered the questionnaire. One thousand one hundred twenty emergency physicians currently work in the emergency room and 415 (37.1%) of them responded to the questionnaire. There were 29,324 annual visitors to the emergency rooms in which the emergency physicians who responded to the questionnaire work, of which, 5,693 (19.4%) were hospitalized. Full time equivalent (FTE) per institution was 4.29, assuming that only one emergency physician was on duty in the each emergency room at any given time of day. Currently, the average number of physicians per institution is 4.3; therefore, the ratio of FTE to emergency physicians is about 1. However, according to the Korean Emergency Medicine Association, one emergency physician should treat 2.5 patients per hour. Based on this, the corrected FTE value should be 5.79, and the ratio of FTE to emergency physicians needs to be 0.74. CONCLUSION: Based on this research, it is expected that emergency physicians will have a strategy for proper manpower supply.

A Case of Kommerell's Diverticulum with Aortic Dissection

In 1936, a German radiologist, Burckhard Kommerell, reported a rare variant of thoracic aortic aneurysm named Kommerell's diverticulum which may be accompanied by an aberrant origin of the right subclavian artery. The most common type of Kommerell's diverticulum is the right-sided aortic arch, with the aberrant left subclavian artery. Kommerell's diverticulum is associated with a high risk of early rupture, and 20% is accompanied with aortic dissection. However, because Kommerell's diverticulum is rare, it is highly probably for emergency physicians to overlook the abnormal findings from a chest X-ray or dismiss the potential risk of early rupture and aortic dissection. Symptoms of Kommerell's diverticulum are not specific, like chest pain, dyspnea, swallowing difficulty, and so on. Therefore, it is necessary for emergency physicians to detect Kommerell's diverticulum and avoid premature discharge without consulting a thoracic surgeon for further treatment.

Validity of iPad for Remote Diagnosis of Rib Fracture

PURPOSE: In elderly and patients with underlying diseases, mortality rate is increased when compared to rib fractures which occurred in other patients. Because there is a shortage of emergency physicians or real-time consultation with radiologists in many countries, it is necessary to receive a formal image reading remotely from an expert. We suggested the use of iPad in X-ray reading and compared the diagnostic validity of iPad, which was highly portable, with that of liquid crystal display (LCD) monitor. METHODS: Fifty four X-ray cases of rib fracture and 54 cases without rib fracture were randomized and reviewed by 10 emergency physicians. A total of 108 cases were divided 1st to 54th and 55th to 108th. Two sessions were separated with a four-week interval. If the reviewer interpreted the 1st to 54th with iPad, they did 55th to 108th with LCD monitor. Reviewers reported the presence of rib fracture, the number of fractured ribs, and diagnostic confidence of 5-scale. RESULTS: The interobserver agreement among reviewers in LCD and iPad was 0.551, 0.524 in Fleiss-kappa value. The intraobserver agreement between tools for each reviewer was 0.410-0.859 (Mean=0.628+/-0.150). Reviewers showed sensitivity over 0.810 regardless of the tool; 0.810- 0.966 (Mean=0.879+/- 0.054) in LCD, 0.828-1.000 (Mean=0.898+/-0.052) in iPad. The specificity was 0.520- 0.860 (Mean=0.750+/-0.117) in LCD and 0.560-0.880 (Mean=0.708+/-0.111) in iPad. Therefore, remote consultation of X-ray by iPad with a specialist was possible with minimized temporal and spatial limits in the emergency room. CONCLUSION: In our study, there was no statistical difference in the diagnosis of rib fracture by X-ray via iPad or LCD. Therefore, remote consultation of X-ray by iPad with a specialist in the emergency room was possible, with temporal and spatial limits by iPad.

A Nationwide Survey of Korean Emergency Department Triage Systems and Scales; A First Step Towards Reform of the Emergency Medical Service System

PURPOSE: As a first step towards reform of the emergency medical service system, we aimed to assess the current status of our emergency department triage systems and illustrated the current status and problems of the Korean emergency department triage system. METHODS: We conducted e-mail and telephone surveys of the triage officers of all 136 emergency medical centers in Korea. RESULTS: All 136 emergency departments responded to the survey. In Korea, a triage scale derived from the 'emergency symptoms based on the requirements of the Emergency Medical Service Act' is the most-used triage scale. We identified factors showing significant association with use of verified triage vs. unverified scales, including level of triage scale, type of hospital, type of emergency department, perception of problems regarding the triage scale, educational performance, and number of annual visits. CONCLUSION: Results of our survey showed that in Korea various kinds of triage scale are in use and the reliability and validity of more than half of them are unverified. Reform of the Korean national triage system is in progress and our survey findings should be helpful in guiding reorganization of the national triage systems of many countries.