Provider-in-triage prediction of hospital admission after brief patient interaction.

BACKGROUND AND OBJECTIVES: We sought to determine if emergency physician providers working in the triage area (PIT) of the ED could accurately predict the likelihood of admission for patients at the time of triage. Such predictions, if accurate, could decrease the time spent in the ED for patients who are admitted to the hospital by hastening downstream workflow. METHODS: This is a prospective cohort study of PIT providers at a large urban hospital. Physicians were asked to predict the likelihood of admission and confidence of prediction for patients after evaluating them in triage. Measures of predictive accuracy were calculated, including sensitivity, specificity, and area under the receiver operator characteristic (AUROC). RESULTS: 36 physicians (20 attendings, 16 residents) evaluated 340 patients and made predictions. The average patient age was 48 (range 18-94) and 52% were female. Seventy-three patients (21%) were admitted (5% observation, 85% general care/telemetry, 7% progressive care, 3% ICU). The sensitivity of determining admission for the entire cohort was 74%, the specificity was 84%, and the AUROC was 0.81. When physicians were at least 80% confident in their predictions, the predictions improved to sensitivity of 93%, specificity of 96%, and AUROC 0.95 (Graph 1). CONCLUSION: The accuracy of physician providers-in-triage of predicting hospital admission was very good when those predictions were made with higher degrees of confidence. These results indicate that while general predictions of admission are likely inadequate to guide downstream workflow, predictions in which the physician is confident could provide utility.

Quick cuts: A comparative study of two tools for ring tourniquet removal.

BACKGROUND: Ring tourniquet occurs when a ring becomes entrapped due to swelling or trauma. As the finger expands the blood flow restriction causes additional swelling, which can lead to nerve damage and other complications. Ring tourniquet can be an emergency that requires rapid ring removal. Standard devices for ring removal have been described but rarely tested. We conducted a randomized study to compare removal time, user and participant satisfaction and complications between a motorized diamond disc ring cutter (MDDRC) and a ring cutter attached to trauma shears (TS). METHODS: In pairs, emergency medicine providers removed rings using both devices and wore randomized rings to be removed (silver or steel). Each effort was timed from initiation to removal. After each effort both user and subject rated their satisfaction with the device, using a visual analog scale and reported any complications. Median and interquartile ranges were generated for the primary and secondary outcomes with 95% confidence intervals where applicable. Wilcoxon Rank Sum tests were calculated with a = 0.05 to compare removal time and secondary outcomes between the two tools. RESULTS: Thirty subjects completed the study. Median time to ring removal was significantly lower with the TS compared to the MDDRC (7.7 vs 67.0 s, p < .0001). Device user satisfaction (9.7/10 vs 3.8/10, p < .0001) and participant satisfaction (9.7/10 vs 6.8/10, p < .0001) were significantly higher with the TS, while participant discomfort was significantly lower with the TS (0.0/10 vs 2.2/10, p < .0001). CONCLUSION: This study is the first to compare efficacy, satisfaction and complications of two standard tools for removal of ring tourniquets. The TS took significantly less time than the GEM MDDRC and demonstrated significantly better satisfaction for both the ring wearer and ring remover.