A Comparison Between Computer-Assisted Self-Triage by Patients and Triage Performed by Nurses in the Emergency Department.

Background and objective Emergency departments (EDs) often find the number of arriving patients exceeding their capacity and find it difficult to triage them in a timely manner. The potential risk to the safety of patients awaiting assessment by a triage professional has led some hospitals to consider implementing patient self-triage, such as using kiosks. Published studies about patient self-triage are scarce and information about patients' ability to accurately assess the acuity of their condition or predict their need to be hospitalized is limited. In this study, we aimed to compare computer-assisted patient self-triage scores versus the scores assigned by the dedicated ED triage nurse (TN). Methods This pilot study enrolled patients presenting to a tertiary care hospital ED without ambulance transport. They were asked a short series of simple questions based on an algorithm, which then generated a triage score. Patients were asked whether they were likely to be admitted to the hospital. Patients then entered the usual ED system of triage. The algorithm-generated triage score was then compared with the Canadian Triage and Acuity Scale (CTAS) score assigned by the TN. Whether the patients actually required hospital admission was determined by checking their medical records. Results Among the 492 patients enrolled, agreement of triage scores was observed in 27%. Acuity was overestimated by 65% of patients. Underestimation of acuity occurred in 8%. Among patients predicting hospitalization, 17% were admitted, but the odds ratio (OR) for admission was 3.4. Half of the patients with cardiorespiratory complaints were correct in predicting the need for hospitalization. Conclusion  The use of a short questionnaire by patients to self-triage showed limited accuracy, but sensitivity was high for some serious medical conditions. The prediction of hospitalization was more accurate with regard to cardiorespiratory complaints.

The POCUS Pulse Check: A Case Series on a Novel Method for Determining the Presence of a Pulse Using Point-of-Care Ultrasound.

BACKGROUND: During cardiopulmonary resuscitation, pulse checks must be rapid and accurate. Despite the importance placed on the detection of a pulse, several studies have shown that health care providers have poor accuracy for detection of central pulses by palpation. To date, the use of point-of-care ultrasound (POCUS) in cardiac arrest has focused on the presence of cardiac standstill and diagnosing reversible causes of the arrest. OBJECTIVE: This case series highlights a simple, novel approach to determine whether pulses are present or absent by using POCUS compression of the central arteries. DISCUSSION: Using this technique, we found that a POCUS pulse check can be consistently performed in < 5 s and is clearly determinate, even when palpation yields indeterminate results. CONCLUSIONS: In this case series, the POCUS pulse check was a valuable adjunct that helped to change management for critically ill patients. Future prospective studies are required to determine the accuracy of this technique and the impact on patient outcomes in a larger cohort.

Point-of-Care Ultrasound for Jugular Venous Pressure Assessment: Live and Online Learning Compared.

INTRODUCTION: Point-of-care ultrasound (POCUS) is a novel technique for the assessment of jugular venous pressure. Distance education may allow for efficient dissemination of this technique. We compared online learning to a live course for teaching ultrasonography jugular venous pressure (u-JVP) to determine if these teaching methods yielded different levels of comfort with and use of u-JVP. METHODS: This was an interventional trial of Canadian emergency physicians who had taken a basic POCUS course. The participants were in one of three Groups: online learning (Group OL), live teaching (Group LT), control (Group C). Group LT participants also took an advanced course prior to the study that included instruction in u-JVP. The participants who took the basic course were randomized to Group OL or Group C. Group OL was subject to the intervention, online learning. Group C only received an article citation regarding u-JVP. Questionnaires were completed before and after the intervention. The primary outcome was physician self-reported use and comfort with the technique of u-JVP after online learning compared to live teaching. RESULTS: Of the 287 advanced course participants, 42 completed the questionnaires (Group LT). Of the 3303 basic course participants, 47 who were assigned to Group OL completed the questionnaires and 47 from Group C completed the questionnaires. Use of u-JVP increased significantly in Group OL (from 15% to 55%) and Group C (from 21% to 47%) with the intervention. The comfort with use did not differ between Group LT and Group OL (p=0.14). The frequency of use remained higher in Group LT than Group OL (p=0.07). CONCLUSION: Online learning increases the use and comfort with performing u-JVP for emergency physicians with prior POCUS experience. Although the comfort with use of u-JVP was similar in Groups LT and OL, online learning appears to yield levels of use that are less than those of a live course.

A determination of emergency department pre-triage times in patients not arriving by ambulance compared to widely used guideline recommendations.

OBJECTIVES: Emergency department (ED) lengths of stay are measured from the time of patient registration or triage. The time that patients wait in line prior to registration and triage has not been well described. We sought to characterize pre-triage wait times and compare them to recommended physician response times, as per the Canadian Triage and Acuity Scale (CTAS). METHODS: This observational study documented the time that consenting patients entered the ED and the time that they were formally registered and triaged. Participants' CTAS scores were collected from the electronic record. Patients arriving to the ED by ambulance were excluded. RESULTS: A total of 536 participants were timed over 13 separate intervals. Of these, 11 left without being triaged. Participants who scored either CTAS 1 or 2 (n=53) waited a median time of 3.1 (interquartile range [IQR]: 0.43, 11.1) minutes. Patients triaged as CTAS 3 (n=187) waited a median of 11.4 (IQR: 1.6, 24.9) minutes, CTAS 4 (n=139) a median of 16.6 (IQR: 6.0, 29.7) minutes, and CTAS 5 (n=146) a median of 17.5 (IQR: 6.8, 37.3) minutes. Of patients subsequently categorized as CTAS 1 or 2, 20.8% waited longer than the recommended time-to-physician of 15 minutes to be triaged. CONCLUSIONS: All urban EDs closely follow patients' wait times, often stratified according to triage category, which are assumed to be time-stamped upon a patient's arrival in the ED. We note that pre-triage times exceed the CTAS recommended time-to-physician in a possibly significant proportion of patients. EDs should consider documenting times to treatment from the moment of patient arrival rather than registration.

A comparison of a formal triage scoring system and a quick-look triage approach.

BACKGROUND: Emergency Department (ED) triage systems have become increasingly comprehensive over time, requiring ever more resources such as nursing time and computer support. There are very few studies that have looked at whether this increased complexity results in improved performance. OBJECTIVES: This study looked at one aspect of performance, comparing reliability of triage nurses' (TNs) triage scores utilizing a simple quick-look method with a commonly used, resource-intense, five-level triage system. METHODS: This observational study of TNs was carried out in two urban tertiary-care hospital EDs, in real time, assessing patients arriving consecutively. Immediately upon patients' arrival, TNs were asked to assign triage scores based simply on their observation of the patient and the chief complaint. The patient was then triaged in the department's usual way, utilizing a computer-assisted five-level triage system [Canadian Triage and Acuity Scale (CTAS)]. Agreement between scores was quantified. κ scores were calculated, and weighted by the CTAS score. RESULTS: A total of 496 triage assessments were included. Percent agreement between the quick-look method and the standard CTAS method was 84.5%. κ scores were moderately high. Fourteen patients (2.6%), ultimately classified as CTAS 1 or 2, initially received lower scores from TNs using the quick-look method. No comparison of validity was assessed. CONCLUSION: TNs assigning triage scores to ED patients on arrival, using only chief complaint and observation, were statistically comparable to scores assigned utilizing a resource-intense, comprehensive triage system, but clinically significant discrepancies were identified.

A comparison of the supraclavicular and infraclavicular views for imaging the subclavian vein with ultrasound.

INTRODUCTION: Ultrasound guidance for central line placement in the subclavian vein (SCV) is more efficient and safer than landmark-based technique. The supraclavicular (SC) approach is an alternative to the infraclavicular (IC) approach, but the research is sparse. The objective was to determine which approach provides the best view. METHODS: This was a prospective anatomical survey of voluntary normovolemic patients. Four experienced emergency physicians and 1 resident scanned the right and left SCVs from SC and IC approaches. They assigned a score for the views obtained on a 5-point Likert scale. RESULTS: Ninety-eight patients were enrolled. Mean Likert scores for the 4 views were: right SC, 4.06 (95% confidence interval [CI], 0.22); right IC, 3.07 (95% CI, 0.25); left SC, 3.82 (95% CI, 0.23); left IC, 3.12 (95% CI, 0.25). When combining data from right and left, the mean score for the SC view was significantly higher than the mean score for the IC view: 3.94 (95% CI, 0.16) vs 3.10 (95% CI, 0.18). The following ratings were obtained: right SC view was good or excellent in 71.5%; left SC view was good or excellent in 66.3%; right IC view was good or excellent in 37.8%; and left IC view was good or excellent in 38.8%. CONCLUSION: The SC approach allows for a better view of the SCV on ultrasound than the IC approach. Future research should determine if this translates to a greater success rate when placing central lines in the SCV.

A prospective study of students' and instructors' opinions on Advanced Cardiac Life Support course teaching methods.

INTRODUCTION: The American Heart Association (AHA) revises the Advanced Cardiac Life Support (ACLS) course approximately every 5 years, citing the scientific literature for any changes to content and management recommendations. With ACLS 2005, the AHA also revised the methods used to teach course content. The AHA cited no evidence in making these changes. The ACLS 2005 course, distributed in early 2007, makes greater use of videos to teach students. This prospective study surveyed opinions of both students and instructors in an effort to determine the level of satisfaction with this method of teaching. METHODS: During 16 consecutive ACLS courses, all students and instructors were asked to complete a questionnaire. The students provided demographic information, but completed the survey anonymously. Four questions probed the participants' opinions about the effectiveness of videos in learning ACLS skills. Experienced participants were asked to compare the new teaching methods with previous courses. Opinions were compared among several subgroups based on sex, occupation and previous experience. RESULTS: Of the 180 students who participated, 71% felt the videos were unequivocally useful for teaching ACLS skills. Fewer first-time students were unequivocally positive (59%) compared with those who had taken 2 or more previous courses (84%). A small proportion of students (13%) desired more hands-on practice time. Of the 16 instructors who participated, 31% felt that the videos were useful for teaching ACLS skills. No differences were found between doctors and nurses, or between men and women. CONCLUSION: The use of standardized videos in ACLS courses was felt by the majority of students and a minority of instructors to be unequivocally useful. First-time students had more doubts about the effectiveness of videos.

'Fever phobia' in the emergency department: a survey of children's caregivers.

OBJECTIVES: To investigate children's caregivers' attitudes towards fever in an emergency department setting. METHODS: A 25-item questionnaire was formulated, on the basis of similar previous published surveys, for administration to a convenience sample of caregivers. It was administered by a medical translator after triage, before assessment by a physician. Most questions were multiple choice, a few open-ended. RESULTS: Three hundred questionnaires were administered to caregivers and 264 were analyzed. A high proportion (82%) of caregivers professed to be 'very worried' about fever. Temperatures that were felt to require treatment were relatively low (one-third treating <37.9 degrees C), but many respondents measured body temperature at the axilla. Similar to previously published studies, the main specific concerns were possible central nervous system damage (24%), seizures (19%) and death (5%), although worries about discomfort and signs of serious illness were also expressed by a significant number of respondents (11%). Similar to older surveys, home treatment of fever was worrisome, with too-frequent dosing (acetaminophen