Assessing the utility of frailty scores in triage: a comparative study of validated scales.

Currently, there is conflicting evidence regarding the efficacy of frailty scales and their ability to enhance or support triage operations. This study aimed to assess the utility of three common frailty scales (CFS, PRISMA-7, ISAR) and determine their utility in the triage setting. This prospective observational monocentric study was conducted at Merano Hospital's Emergency Department (ED) from June 1st to December 31st, 2023. All patients attending this ED during the 80-day study period were included, and frailty scores were correlated with three outcomes: hospitalization, 30-day mortality, and severity of condition as assessed by ED physicians. Patients were categorized by age, and analyses were performed for the entire study population, patients aged 18-64, and those aged 65 or older. Univariate analysis was followed by multivariable analysis to evaluate whether frailty scores were independently associated with the outcomes. In multivariable analysis, none of the frailty scores were found to be associated with the study outcomes, except for the CFS, which was associated with an increased risk of 30-day mortality, with an odds ratio of 1.752 (95% CI 1.148-2.674; p = 0.009) in the general population and 1.708 (95% CI 1.044-2.793; p = 0.033) in the population aged ≥ 65. Presently, available frailty scores do not appear to be useful in the triage context. Future research should consider developing new systems for accurate frailty assessment to support risk prediction in the triage assessment.

Enhancing triage accuracy: The influence of nursing education on risk prediction.

AIM: This study aimed to compare the performance in risk prediction of various outcomes between specially trained triage nurses and the Manchester Triage System (MTS). DESIGN: Prospective observational study. METHODS: The study was conducted from June 1st to December 31st, 2023, at the Emergency Department of Merano Hospital. Triage nurses underwent continuous training through dedicated courses and daily audits. We compared the risk stratification performed by expert nurses with that of MTS on various outcomes such as mortality, hospitalisation, and urgency defined by the physicians. Comparisons were made using the Areas Under the Receiver Operating Characteristic curve (AUROC). RESULTS: The agreement in code classification between the MTS and the expert nurse was very low. The AUROC curve analysis showed that the expert nurse outperformed the MTS in all outcomes. The triage nurse's experience led to statistically significant better stratification in admission rates, ICU admissions, and all outcomes based on the physician's assessment. CONCLUSIONS: The continuous training of nurses enables them to achieve better risk prediction compared to standardized triage systems like MTS, emphasizing the utility and necessity of implementing continuous training pathways for these highly specialised personnel.

Development and validation of a nomogram for assessing comorbidity and frailty in triage: a multicentre observational study.

Assessing patient frailty in the Emergency Department (ED) is crucial; however, triage frailty and comorbidity assessment scores developed in recent years are unsatisfactory. The underlying causes of this phenomenon could reside in the nature of the tools used, which were not designed specifically for the emergency context and, thus, are difficult to adapt to the emergency environment. The objective of this study was to create and internally validate a nomogram for identifying different levels of patient frailty during triage. Multicenter, prospective, observational exploratory study conducted in two ED. The study was conducted from April 1 to October 31, 2022. Following the triage assessment, the nurse collected variables related to the patient's comorbidities and chronic conditions using a predefined form. The primary outcome was the 90-day mortality rate. A total of 1345 patients were enrolled in this study; 6% died within 90 days. In the multivariate analysis, the Charlson Comorbidity Index, an altered motor condition, an altered cognitive condition, an autonomous chronic condition, arrival in an ambulance, and a previous hospitalization within 90 days were independently associated with death. The internal validation of the nomogram reported an area under the receiver operating characteristic of 0.91 (95% CI 0.884-0.937). A nomogram was created for assessing comorbidity and frailty during triage and was demonstrated to be capable of determining comorbidity and frailty in the ED setting. Integrating a tool capable of identifying frail patients at the first triage assessment could improve patient stratification.

Prognostic Role of Serum Albumin in Predicting 30-Day Mortality in Patients with Infections in Emergency Department: A Prospective Study.

BACKGROUND: Infections in emergency departments (EDs) are insidious clinical conditions characterised by high rates of hospitalisation and mortality in the short-to-medium term. The serum albumin, recently demonstrated as a prognostic biomarker in septic patients in intensive care units, could be an early marker of severity upon arrival of infected patients in the ED. AIM: To confirm the possible prognostic role of the albumin concentration recorded upon arrival of patients with infection. METHODS: A prospective single-centre study was performed in the ED of the General Hospital of Merano, Italy, between 1 January 2021 and 31 December 2021. All enrolled patients with infection were tested for serum albumin concentration. The primary outcome measure was 30-day mortality. The predictive role of albumin was assessed by logistic regression and decision tree analysis adjusted for Charlson comorbidity index, national early warning score, and sequential organ failure assessment (SOFA) score. RESULTS: 962 patients with confirmed infection were enrolled. The median SOFA score was 1 (0-3) and the mean serum albumin level was 3.7 g/dL (SD 0.6). Moreover, 8.9% (86/962) of patients died within 30 days. Albumin was an independent risk factor for 30-day mortality with an adjusted hazard ratio of 3.767 (95% CI 2.192-6.437), p < 0.001. Decision tree analysis indicated that at low SOFA scores, albumin had a good predictive ability, indicating a progressive mortality risk reduction in concentrations above 2.75 g/dL (5.2%) and 3.52 g/dL (2%). CONCLUSIONS: Serum albumin levels at ED admission are predictive of 30-day mortality in infected patients, showing better predictive abilities in patients with low-to-medium SOFA scores.

Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms - A prospective observational study.

BACKGROUND: An immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms. METHODS: All patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient's ECG. The main study outcome was the diagnosis of an acute cardiovascular event. RESULTS: Of the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse-physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001). CONCLUSIONS: ECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.

Can triage nurses accurately interpret the electrocardiogram in the emergency department to predict acute cardiovascular events? A prospective observational study.

AIMS: The prompt recording of the electrocardiogram (ECG) and its correct interpretation is crucial to the management of patients who present to the emergency department (ED) with cardiovascular symptoms. Since triage nurses represent the first healthcare professionals evaluating the patient, improving their ability in interpreting the ECG could have a positive impact on clinical management. This real-world study investigates whether triage nurses can accurately interpret the ECG in patients presenting with cardiovascular symptoms. DESIGN: Prospective, single-centre observational study conducted in a general ED of General Hospital of Merano in Italy. METHODS: For all patients included, the triage nurses and the emergency physicians were asked to independently interpret and classify the ECGs answering to dichotomous questions. We correlated the interpretation of the ECG made by the triage nurses with the occurrence of acute cardiovascular events. The inter-rater agreement in ECG interpretation between physicians and triage nurses was evaluated with Cohen's kappa analysis. RESULTS: Four hundred and ninety-one patients were included. The inter-rater agreement between triage nurses and physicians in classifying an ECG as abnormal was good. Patients who developed an acute cardiovascular event were 10.6% (52/491), and in 84.6% (44/52) of them, the nurse accurately classified the ECG as abnormal, with a sensitivity of 84.6% and a specificity of 43.5%. CONCLUSION: Triage nurses have a moderate ability in identifying alterations in specific components of the ECG but a good ability in identifying patterns indicative of time-dependent conditions correlated with major acute cardiovascular events. IMPACT FOR NURSING: Triage nurses can accurately interpret the ECG in the ED to identify patients at high risk of acute cardiovascular events. REPORTING METHOD: The study was reported according to the STROBE guidelines. NO PATIENT OR PUBLIC CONTRIBUTION: The study did not involve any patients during its conduction.

The triage Nurse's ability in electrocardiogram interpretation in real clinical practice.

AIMS AND OBJECTIVE: The study aimed to assess the triage nurse's skill in the recognition of abnormal electrocardiogram during actual clinical practice and to identify nurse- and patient-related factors associated with errors in electrocardiogram interpretation. BACKGROUND: The nurse's ability to interpret the electrocardiogram has only been evaluated in simulation settings and has reported conflicting results. DESIGN: A prospective single-centre observational study. METHODS: During the evaluation of a patient with a cardiovascular symptom, the triage nurses were asked to define whether the 12-lead electrocardiogram performed during the triage evaluation was pathological or non-pathological for the presenting symptom. Patient characteristics and some nurse-related variables were recorded. Inter-rater agreement between the physician and nurse in the electrocardiogram interpretation was considered the primary outcome, while the association of a major acute cardiovascular event related to patient access in the Emergency Department was the secondary outcome. We have followed the STROBE checklist for the preparation of this manuscript. RESULTS: Twenty nurses agreed to participate to the study and collect data. Of the 644 patients enrolled, 21.6% (139/644) reported a pathological electrocardiogram according to the ED Physician. The concordance between nurse and physician was modest with Cohen's Kappa of 0.666. An error in the electrocardiogram interpretation was present in 11% of the patients. Nurses who performed an electrocardiogram course within 1 year and studied electrocardiogram interpretation autonomously presented a lower error rate, while older patients and patients with more previous cardiovascular disease were found to be more associated with an error in electrocardiogram interpretation. CONCLUSIONS: The study demonstrates that triage nurses have a fair ability to interpret the electrocardiogram. RELEVANCE TO CLINICAL PRACTICE: Specific educational programmes for electrocardiogram interpretation could improve the skill of electrocardiogram interpretation by the nurse and enable this instrument to become an indispensable tool in triage assessment.

Analysis of Clinical and Laboratory Risk Factors of Post-Traumatic Intracranial Hemorrhage in Patients on Direct Oral Anticoagulants with Mild Traumatic Brain Injury: An Observational Multicenter Cohort.

BACKGROUND: Assessing the risk of intracranial hemorrhage (ICH) in patients with a mild traumatic brain injury (MTBI) who are taking direct oral anticoagulants (DOACs) is challenging. Currently, extensive use of computed tomography (CT) is routine in the emergency department (ED). OBJECTIVE: This study aims to investigate whether the clinical and laboratory characteristics presented at the ED evaluation can also estimate the risk of post-traumatic ICH in DOAC-treated patients with MTBI. METHODS: A retrospective observational study was conducted in three EDs in Italy from January 1, 2016 to March 15, 2020. All patients treated with DOACs who were evaluated for an MTBI in the ED were enrolled. The primary outcome of the study was the presence of post-traumatic ICH in the head CT performed in the ED. RESULTS: Of 930 patients on DOACs with MTBI who were enrolled, 6.8% (63 of 930) had a post-traumatic ICH and 1.5% (14 of 930) were treated with surgery or died as a result of the ICH. None of the laboratory factors were associated with an increased risk of ICH. On multivariate analysis, previous neurosurgical intervention, major trauma dynamic, post-traumatic loss of consciousness, post-traumatic amnesia, Glasgow Coma Scale score of 14, and evidence of trauma above the clavicles were associated with a higher risk of post-traumatic ICH. The net clinical benefit provided by risk factor assessment appears superior to the strategy of performing CT on all DOAC-treated patients. CONCLUSIONS: Assessment of the clinical characteristics presented at ED admission can help identify DOAC-treated patients with MTBI who are at risk of ICH.

Daily triage audit can improve nurses' triage stratification: A pre-post study.

AIMS: The objective was to evaluate whether the error rate in the application of the triage system decreased after the introduction of daily auditing, and it was also evaluated if the agreement rate between physician and nurse on triage priority levels increased after the introduction of daily auditing and if the error-related variables in the pre-intervention period changed in the post-intervention period. DESIGN: A quasi-experimental study was performed with a pre-post design, between June 2019 and June 2021 in one emergency department. METHODS: The accuracy and error rate of triage in the pre- and post-intervention period were compared. Univariate and multivariate logistic regression analyses were performed to explore the relationships between the variables related to the error. The comparison between the priority level assigned by the physician and the triage nurse was analysed using Cohen's K. RESULTS: Nine hundred four patients were enrolled in the pre-intervention period and 869 in the post-intervention period. The error rate in the pre-intervention period was 23.3% and in the post-intervention period was 9.7%. The concordance between the degree of priority expressed by the physician and the nurse varied from a quadratically weighted Cohen's K of 0.447 in the pre-intervention period to 0.881 in the post-intervention period. CONCLUSION: Daily auditing is a clinical procedure that improves the nurse's application of the triage system. Daily auditing has reduced errors by the nurse, improving performance and concordance with the physician. IMPACT: Triage systems are a key point for the stratification of the priority level of patients and it is therefore evident that they maintain high-quality standards. Through the practice of daily auditing, not only a reduction in the error rate, which ensures patient safety, but also an improvement in triage performance has been demonstrated. NO PATIENT OR PUBLIC CONTRIBUTION: The study did not involve any patients during its conduction.

Impact of tourists on emergency department in a high-tourism alpin area: An observational study.

BACKGROUND: The exponential growth of tourism worldwide could have consequences for healthcare services in tourist locations. The impact of the tourist population on access to emergency departments (EDs) is currently unknown. AIM: To describe the characteristics of tourist access in an ED of an alpine tourist area in a period prior to the COVID-19 pandemic. METHODS: All patients evaluated at the ED of the Merano Hospital from January 1, 2017, to December 31, 2019, were considered and divided into two study groups: locals and tourists. Analyses were conducted to assess the impact of tourists in terms of weighted ED admissions and differences in admission characteristics. Finally, for tourist patients only, an analysis of severity according to their type of healthcare system of provenance was performed. RESULTS: A total of 208,875 ED presentations were considered, of which 90.7% (189,406) were by local patients and 9.3% (19,469) were by tourists. The median ED admission rate was 1.65 admissions per 1000 overnight stays for locals versus 0.90 admissions per 1000 overnight stays for tourists. The time series analysis revealed a greater seasonal variation in accesses by tourists than by resident patients. A higher proportion of accesses with a severe code was found among tourist patients, while the local population exhibited a higher proportion of patients with a non-urgent code. In the tourist population, patients from a country with a free-market healthcare system had a higher number of ED presentations for severe conditions or that required hospitalisation than tourists from countries with Bismarck or Beveridge healthcare systems. CONCLUSIONS: The tourist population can have an important impact on EDs in high-impact tourist areas. The seasonality of the tourist population indicates the need for health policies that focus on educating the tourist population on the correct use of the ED.

The impact of COVID-19 pandemic on the urgency of patients admitted to the emergency department.

BACKGROUND: The COVID-19 pandemic brought important changes in access to the Emergency Department (ED). At present, an analysis of how the COVID-19 pandemic has changed not only the number but also the nature of the urgency of ED access is not available. This study aimed to verify the effect of the COVID-19 pandemic on the urgency of patients admitted to the ED utilizing timebased analyses. METHODS: A quasi-experimental interrupted time series analysis based on a retrospective review of data from all ED admissions occurring at the Merano Hospital (Italy) from 1 January 2015 to 30 June 2021 was conducted. RESULTS: From January 2015 to June 2021, 416,560 patients were admitted to the ED. Since the pandemic outbreak, the trend of urgent patients (classified as orange and red by triage) remained unchanged compared to the pre-pandemic period (p = 0.095, p = 0.155). In contrast, patients classified as blue (non-urgent) increased exponentially since the outbreak of the pandemic (p < 0.001). CONCLUSION: The present study reported stability in urgent codes (orange and red) since the pandemic outbreak while a dramatic increase in non-urgent codes (blue and green) is reported. The results of the study may indicate the need to find health policy solutions to manage this large increase in nonurgent patients requiring assessment in EDs since the outbreak of the pandemic.

The impact of COVID-19 pandemic on temporal trends of workplace violence against healthcare workers in the emergency department.

BACKGROUND: It is known that there has been an increase over the years in attacks by patients admitted to the emergency department (ED) on healthcare workers; it is unclear what effect the COVID-19 pandemic has on these attacks. AIM: to verify through a long-term time analysis the effect of COVID-19 on ED attacks on healthcare workers. MOTHODS: a quasi-experimental interrupted time-series analysis on attacks on healthcare workers was performed from January 2017 to August 2021. The main outcome was the monthly rate of attacks on healthcare workers per 1000 general accesses. The pandemic outbreak was used as an intervention point. RESULTS: 1002 attacks on healthcare workers in the ED were recorded. The rate of monthly attacks on total accesses increased from an average of 13.5 (SD 6.6) in the pre-COVID-19 era to 27.2 (SD 9.8) in the pandemic months, p < 0.001. The pandemic outbreak led to a significant increase in attacks on healthcare workers from 0.05/1000 attacks per month (p = 0.018), to 4.3/1000 attacks per month (p = 0.005). CONCLUSIONS: The COVID-19 pandemic has led to a significant increase in attacks on healthcare workers in the ED. Trends compared to pre-pandemic months do not seem to indicate a return to normality. Health institutions and policymakers should develop strategies to improve the safety of the working environment in hospitals and EDs.

Estimating the attributes of urban trees using terrestrial photogrammetry.

Today, different methods are used to measure two-dimensional (2D) and three-dimensional (3D) attributes of trees. One of these methods, which is considered in recent years is using point clouds and a 3D model extracted from terrestrial photogrammetry (TP). This study aims to estimate the 2D and 3D attributes of urban trees at three levels of seedlings, single trees and sample plot using TP. Structure-from-Motion with Multi-View Stereo-photogrammetry (SfM-MVS) method was used to derive the point clouds and the 3D model. Comparing estimated values of diameter at the middle of trunk of seedlings and diameter at breast height (DBH) of trees, using TP with measured values showed that the values of RMSE% were < 2% at three levels of seedlings, single trees and sample plot. Furthermore, validation of the estimated values of total height and crown height attributes of seedlings and trees at three levels showed that the RMSE% did not exceed 4% and 5%, respectively. Considering the overlap of tree crowns with each other in the sample plot, the average diameter of the crown attribute was estimated only in seedlings and single tree levels with RMSE% = 6.51% and 9.34%, respectively. The validation of estimated values of stem volume of seedlings and trees at three levels showed that the lowest errors were returned from trees within a sample plot with RMSE% = 14.37%, whereas the highest rates of errors were achieved for seedlings with RMSE% = 20.99%. As an alternative to approaches such as employing laser scanners, this method is quick, inexpensive, non-destructive, and does not need specialized equipment.

"Effect of the SARS-COV-2 pandemic outbreak on the emergency department admission for an acute psychiatric condition".

Preliminary evidence seems to suggest a reduction in absolute terms of Emergency Department (ED) admissions for an acute psychiatric condition during the first months of the pandemic. The study aimed to test through a long-term time analysis the effect of COVID-19 on changes in ED visits for an acute psychiatric condition. A quasi-experimental interrupted time series analysis of admissions for acute psychiatric conditions to the Emergency Department of the Merano Hospital (Italy) was performed from January 2017 to August 2021. The main outcome was the monthly rate of ED accesses for an acute psychiatric condition reported per 1000 general admissions. The pandemic outbreak was used as an intervention point. 4398 ED admissions for an acute psychiatric condition were registered. The rate of monthly admissions over total admissions increased from a mean of March 17, 1000 (SD 2.9) admissions per month in the pre-COVID-19 era to September 22, 1000 (SD 4.5) in the pandemic months, p < 0.001. In March 2020, the pandemic outbreak led to a significant increase in ED visits for an acute psychiatric condition (p = 0.013) and suicide attempts (p = 0.029), and to an increased need for pharmacological sedation in ED (p = 0.001). During the pandemic, although admissions and hospitalizations showed a non-significant decreasing trend, suicide attempts increased steadily and significantly. The outbreak of the COVID-19 pandemic caused a major increase in rates of admission to the ED for an acute psychiatric condition.

"Decision tree analysis for assessing the risk of post-traumatic haemorrhage after mild traumatic brain injury in patients on oral anticoagulant therapy".

BACKGROUND: The presence of oral anticoagulant therapy (OAT) alone, regardless of patient condition, is an indication for CT imaging in patients with mild traumatic brain injury (MTBI). Currently, no specific clinical decision rules are available for OAT patients. The aim of the study was to identify which clinical risk factors easily identifiable at first ED evaluation may be associated with an increased risk of post-traumatic intracranial haemorrhage (ICH) in OAT patients who suffered an MTBI. METHODS: Three thousand fifty-four patients in OAT with MTBI from four Italian centers were retrospectively considered. A decision tree analysis using the classification and regression tree (CART) method was conducted to evaluate both the pre- and post-traumatic clinical risk factors most associated with the presence of post-traumatic ICH after MTBI and their possible role in determining the patient's risk. The decision tree analysis used all clinical risk factors identified at the first ED evaluation as input predictor variables. RESULTS: ICH following MTBI was present in 9.5% of patients (290/3054). The CART model created a decision tree using 5 risk factors, post-traumatic amnesia, post-traumatic transitory loss of consciousness, greater trauma dynamic, GCS less than 15, evidence of trauma above the clavicles, capable of stratifying patients into different increasing levels of ICH risk (from 2.5 to 61.4%). The absence of concussion and neurological alteration at admission appears to significantly reduce the possible presence of ICH. CONCLUSIONS: The machine-learning-based CART model identified distinct prognostic groups of patients with distinct outcomes according to on clinical risk factors. Decision trees can be useful as guidance in patient selection and risk stratification of patients in OAT with MTBI.

Historic Timber Roof Structure Reconstruction through Automated Analysis of Point Clouds.

We present a set of methods to improve the automation of the parametric 3D modeling of historic roof structures using terrestrial laser scanning (TLS) point clouds. The final product of the TLS point clouds consist of 3D representation of all objects, which were visible during the scanning, including structural elements, wooden walking ways and rails, roof cover and the ground; thus, a new method was applied to detect and exclude the roof cover points. On the interior roof points, a region-growing segmentation-based beam side face searching approach was extended with an additional method that splits complex segments into linear sub-segments. The presented workflow was conducted on an entire historic roof structure. The main target is to increase the automation of the modeling in the context of completeness. The number of manually counted beams served as reference to define a completeness ratio for results of automatically modeling beams. The analysis shows that this approach could increase the quantitative completeness of the full automatically generated 3D model of the roof structure from 29% to 63%.

The Manchester Triage System's performance in clinical risk prioritisation of patients presenting with headache in emergency department: A retrospective observational study.

OBJECTIVE: Non-traumatic headache is a frequent reason for visits to the emergency department (ED). We evaluated the performance of the Manchester Triage System (MTS) in prioritising patients presenting to the ED with non-traumatic headache. METHODS: In this single-centre observational retrospective study, we compared the association of MTS priority classification codes with a final diagnosis of a severe neurological condition requiring timely management (ischaemic or haemorrhagic stroke, subarachnoid haemorrhage, cerebral sinus venous thrombosis, central nervous system infection or brain tumour). The study was conducted and reported according to the STROBE statement. The overall prioritisation accuracy of MTS was estimated by the area under the receiver operating characteristic (ROC) curve. The correctness of triage prediction was estimated based on the "very urgent" MTS grouping. An undertriage was defined as a patient with an urgent and severe neurological who received a low priority/urgency MTS code (green/yellow). RESULTS: Over 30 months, 3002 triage evaluations of non-traumatic headache occurred (1.7% of ED visits). Of these, 2.3% (68/3002) were eventually diagnosed with an urgent and severe neurological condition. The MTS had an acceptable prioritisation accuracy, with an area under the ROC curve of 0.734 (95% CI 0.668-0.799). The sensitivity of the MTS for urgent codes (yellow, orange and red) was 79.4% (95% CI 74.5-84.3), with a specificity of 54.1% (95% CI 52.9-55.3). The triage prediction was incorrect in only 6.3% (190/3002) of patients with headache. CONCLUSION: The MTS is a safe and accurate tool for prioritising patients with non-traumatic headache in the ED. However, MTS may need further specific tools for evaluating the more complicated symptoms and for correctly identifying patients with urgent and severe underlying pathologies. RELEVANCE TO CLINICAL PRACTICE: The triage nurse using MTS may need additional tools to improve the assessment of patients with headache, although MTS provides a good safety profile.

Triage assessment of transitory loss of consciousness in the emergency department-A retrospective observational study.

AIM: To establish how the Manchester Triage System can correctly prioritize patients admitted to the emergency department for transitory loss of consciousness in relation to their risk of presenting severe acute disease. DESIGN: A observational retrospective study. METHODS: A total of 2291 patients who required a triage evaluation for a transitory loss of consciousness at the emergency department of Merano Hospital between 1 January 2017 and 30 June 2019 were considered. Transitory loss of consciousness was classified according to European Society of Cardiology guidelines. The baseline characteristics of the patients were collected and divided according to the priority level assigned at triage into two different study groups: high priority (red/orange) and low priority (blue/green/yellow). The composite outcome of the study was defined as the diagnosis of a severe acute disease. RESULTS: Of the patients enrolled, 17% (390/2291) had a high-priority code and 83% (1901/2291) received a low-priority code. Overall, a severe acute disease was present in 16.9% of patients (387/2291). The Manchester Triage System had a sensitivity of 42.4%, a specificity of 88.1% and an accuracy of 80.4% for predicting severe acute disease. The discriminatory ability had an area under the receiver operating characteristic curve of 0.651 (CI 95%: 0.618-0.685). CONCLUSIONS: Despite the good specificity, the low sensitivity does not currently allow the Manchester Triage System to completely exclude patients with a severe acute disease who presented in the emergency department for a transitory loss of consciousness. Therefore, it is important to develop precise nursing tools or assessments that can improve triage performance. IMPACT: The assessment of a complex symptom can create difficulties in the stratification of patients in triage, assigning low-priority codes to patients with a severe disease. Additional tools are needed to allow the correct triage assessment of patients presenting with transitory loss of consciousness.

Severity of SARS-CoV-2 infection and albumin levels recorded at the first emergency department evaluation: a multicentre retrospective observational study.

BACKGROUND: The aim of this study was to investigate the association between serum albumin levels in the ED and the severity of SARS-CoV-2 infection. METHODS: This is a retrospective observational study conducted from 15 March 2020 to 5 April 2020 at the EDs of three different hospitals in Italy. Data from 296 patients suffering from COVID-19 consecutively evaluated at EDs at which serum albumin levels were routinely measured on patients' arrival in the ED were analysed. Albumin levels were measured, and whether these levels were associated with the presence of severe SARS-CoV-2 infection or 30-day survival was determined. Generalised estimating equation models were used to assess the relationship between albumin and study outcomes, and restricted cubic spline (RCS) regression was used to plot the adjusted dose-effect relationship for possible clinical confounding factors. RESULTS: The mean albumin level recorded on entry was lower in patients with severe SARS-CoV-2 infection than in those whose infections were not severe (3.5 g/dL (SD 0.3) vs 4 g/dL (SD 0.5)) and in patients who had died at 30 days post-ED arrival compared with those who were alive at this time point (3.3 g/dL (SD 0.3) vs 3.8 g/dL (SD 0.4)). Albumin <3.5 g/dL was an independent risk factor for both severe infection and death at 30 days, with adjusted odd ratios of 2.924 (1.509-5.664) and 2.615 (1.131-6.051), respectively. RCS analysis indicated that there was an adjusted dose-response association between the albumin values recorded on ED and the risk of severe infection and death. CONCLUSION: Albumin levels measured on presentation to the ED may identify patients with SARS-CoV-2 infection in whom inflammatory processes are occurring and serve as a potentially useful marker of disease severity and prognosis.

Rapid antigen test to identify COVID-19 infected patients with and without symptoms admitted to the Emergency Department.

PURPOSE: Early detection of SARS-CoV-2 patients is essential to contain the pandemic and keep the hospital secure. The rapid antigen test seems to be a quick and easy diagnostic test to identify patients infected with SARS-CoV-2. To assess the possible role of the antigen test in the Emergency Department (ED) assessment of potential SARS-CoV-2 infection in both symptomatic and asymptomatic patients. METHODS: Between 1 July 2020 and 10 December 2020, all patients consecutively assessed in the ED for suspected COVID-19 symptoms or who required hospitalisation for a condition not associated with COVID-19 were subjected to a rapid antigen test and RT-PCR swab. The diagnostic accuracy of the antigen test was determined in comparison to the SARS-CoV-2 PCR test using contingency tables. The possible clinical benefit of the antigen test was globally evaluated through decision curve analysis (DCA). RESULTS: A total of 3899 patients were subjected to antigen tests and PCR swabs. The sensitivity, specificity and accuracy of the antigen test were 82.9%, 99.1% and 97.4% (Cohen's K = 0.854, 95% CI 0.826-0.882, p < 0.001), respectively. In symptomatic patients, sensitivity was found to be 89.8%, while in asymptomatic patients, sensitivity was 63.1%. DCA appears to confirm a net clinical benefit for the preliminary use of antigen tests. CONCLUSIONS: The antigen test performed in the ED, though not ideal, can improve the overall identification of infected patients. While it appears to perform well in symptomatic patients, in asymptomatic patients, although it improves their management, it seems not to be definitive.