Do emergency nurses and doctors agree in their triage assessment of dyspneic patients?

OBJECTIVES: This study investigated the inter-observer agreement (IOA) between doctors and nurses on triaging adult ED dyspneic patients. METHODS: This was a prospective observational study comparing eight trained ED nurses with doctors. Each patient was assessed by a nurse and two doctors (1 and 2) who decided on four-point Patient Acuity Category (PAC) and triage management steps. The primary outcome was the proportion of resuscitation room escalations from consult. Secondary outcomes included proportions and IOA of assigned PAC and steps in triage management. The investigators reported IOA as the k statistic (95% CIs) and percent agreement. DATA/RESULTS: There were 22/302 (7.3%) escalations; one from clinical deterioration. Proportions of assigned PAC status by nurses, Drs 1 and 2 were: PAC 1: 20.2-24.2%; PAC 2: 71.5-72.8%; PAC 3: 4.3-7.0%; PAC 4: 0.0-0.7%. The IOA was at least fair to moderate [k: 0.33 (0.22-0.43) to 1.00] in all steps of management except for electrocardiogram [k: 0.19 (0.10-0.27) to 0.45 (0.35-0.55)] ordering. The percent agreement ranged from 81 to 100% for all management steps except for chest Xray (66-73%) and electrocardiogram (61-71%) ordering. CONCLUSION: Trained ED nurses were safe and managed adult dyspneic patients as well as doctors at triage.

Survey of factors affecting health care workers' perception towards institutional and individual disaster preparedness.

INTRODUCTION: Health care institutions constantly must be prepared for disaster response. However, there are deficiencies in the current level of preparedness. The aim of this study was to investigate the factors affecting the perception of health care workers (HCWs) towards individual and institutional preparedness for a disaster. METHODS: A survey on disaster incident preparedness was conducted among doctors, nurses, and allied health workers over a period of two months in 2010. The survey investigated perceptions of disaster preparedness at the individual and institutional level. Responses were measured using a five-point Likert scale. The primary outcomes were factors affecting HCWs' perception of institution and individual preparedness. Secondary outcomes were the proportions of staff willing to participate and to place importance on disaster response training and their knowledge of access to such training. Data was analyzed using descriptive statistics. Logistic regression was performed to determine the factors that influenced the HCWs' perception of their individual and institutional readiness. Odd ratios (ORs) of such factors were reported with their 95% confidence intervals (CIs). RESULTS: Of 1700 HCWs, 1534 (90.2%) completed the survey. 75.3% (1155/1534) felt that the institution was ready for a disaster incident, but only 36.4% (558/1534) felt that they (as individuals) were prepared. Some important factors associated with a positive perception of institution preparedness were leadership preparedness (OR = 13.19; 95% CI, 9.93-17.51), peer preparedness (OR = 6.11; 95% CI, 4.27-8.73) and availability of training opportunities (OR = 4.76; 95% CI, 3.65-6.22). Some important factors associated with a positive perception of individual preparedness were prior experience in disaster response (OR = 2.80; 95% CI, 1.99-3.93), institution preparedness (OR = 3.71; 95% CI, 2.68-5.14), peer preparedness (OR = 3.49; 95% CI, 2.75-4.26), previous training in disaster response (OR = 3.48; 95% CI, 2.76-4.39) and family support (OR = 3.22; 95% CI, 2.54-4.07). Most (80.7%, 1238/1534) were willing to participate in future disaster incident response training, while 74.5% (1143/1534) felt that being able to respond to a disaster incident constitutes part of their professional competency. However, only 27.8% (426/1534) knew how to access these training opportunities. CONCLUSIONS: This study demonstrated that HCWs fare poorly in their perception of their individual preparedness. Important factors that might contribute to improving this perception at the individual and institution level have been identified. These factors could guide the review and implementation of future disaster incident response training in health care institutions.

Comparing triage evaluation of adult dyspneic patients between emergency nurses and doctors using simulated scenarios.

OBJECTIVE: Although registered nurses frequently perform triaging in many emergency departments (EDs), little is known regarding the agreement between nurses and doctors in triaging dyspneic patients. The aim of our study was to compare the effectiveness of trained ED nurses with doctors in the evaluation of dyspneic patients at triage using the SimMan 3G simulator. METHODS: We compared eight nurses who underwent a structured training/accreditation program with eight doctors. Two assessors evaluated them through seven common and/or important cardiorespiratory simulated scenarios. Each scenario had an evaluation instrument that scored participants on triage assessment and management. Each nurse was also surveyed over a six-point Likert scale (0-5) on their confidence in triaging dyspneic patients after the study. Data was analyzed using descriptive statistics with statistical significance set at p<0.05. DATA/RESULTS: There were no statistically significant differences between the mean assessment or management scores across all scenarios between doctors versus nurses (p ranging from 0.070 to 0.798). Six nurses felt they could evaluate ED dyspneic patients alone (score of 4) and the remainder with supervision (score of 2-3). CONCLUSION: Trained ED nurses; when compared to doctors; could triage and evaluate dyspneic patients effectively on a simulator.

Identifying predictors of an abnormal computed tomographic scan among patients with a head injury and a Glasgow Coma Scale of 15.

AIM: The aim of this study was to determine the proportions of patients with a head injury and a Glasgow Coma Scale of 15 with an abnormal computed tomographic (CT) head scan and to explore its predictors. METHODS: We conducted a retrospective study on adult patients with such injuries. Patients were risk stratified to undergo a head CT and subsequently discharged or admitted to a neurosurgical (NS) intensive care unit (ICU)/high-dependency (HD) NS or general ward (GW) and observation ward [Emergency Diagnostic and Therapeutic Centre (EDTC)]. The primary outcomes were proportions of abnormal CT results and NS interventions. The secondary outcomes included rates of disposition status, and the distribution and predictors of abnormal CT results. Data were analysed using descriptive statistics. We identified predictors of an abnormal head CT using logistic regression and reported their odds ratios (ORs) and 95% confidence intervals. RESULTS: We reviewed 2038 complete records. A total of 1088 scans were performed; 115 (10.6%) were abnormal. There were 962 (47.2%) discharges and 1076 (52.8%) admissions; six (0.6%) required NS interventions and ICU/HD admission. The proportions of GW admissions (n=1070) were as follows: EDTC 78.0%; NS 18.0%; and medical 4.0%. The proportions of abnormal CT results among these disposition statuses were as follows: NS ICU/HD 6/6 (100%); EDTC 59/835 (7.1%); NS GW 47/188 (25.0%); and medical GW 3/33 (9.1%). We identified three predictors, namely, vomiting [OR 2.23 (1.39-3.58)]; loss of consciousness [OR 1.56 (1.03-2.36)]; and amnesia [OR 2.08 (1.30-3.31)]. CONCLUSION: Abnormal CT and NS interventions were infrequent in patients with a head injury and a Glasgow Coma Scale of 15. We identified three predictors of abnormal head CTs.

Identifying adult asthmatic patients with an abnormal chest radiograph in the emergency department.

OBJECTIVES: The Global Initiative for Asthma (GINA) guidelines classify asthmatic exacerbations into mild, moderate, severe episodes and those with imminent respiratory arrest. We aimed to identify proportions of adult asthmatic patients in different subgroups with abnormal chest radiograph (CR) results and to explore predictors of them. METHODS: In this prospective study, we recruited consecutive adult patients with asthmatic exacerbation over 7 months. Primary outcomes were rates of abnormal CR results among the subgroups. Secondary outcomes included predictors of CR abnormalities, rates of disposition status, and their distribution of abnormal CR results. Logistic regression was applied to identify predictors of an abnormal CR result. RESULTS: We recruited 201 patients; CR was carried out in 84.6%. Rates of abnormal CR results were 8.1% (nine of 111), 17.6% (nine of 51), 20% (one of five), and 0% (zero of three) in the mild, moderate, severe, and imminent respiratory arrest subgroups. No statistically significant differences existed when the rate of CR abnormalities in each subgroup was compared with the combined rate of the other three subgroups (P values: 0.186-0.943). There were 92 (45.8%) planned discharges, 14 (7%) discharges against medical advice, and 95 (47.2%) admissions. The rates of abnormal CR results in the planned discharged group versus the rest (discharges against medical advice+ admissions) were 3% (two of 67) versus 16.5% (17 of 103) (P=0.006). Logistic regression revealed the female sex to be associated with an abnormal CR result [odds ratio 10.1 (95% confidence interval: 2.2-45.8)]. CONCLUSION: Abnormal CR results were infrequent in mild exacerbations and planned discharged patients. The female sex was the only predictor of an abnormal CR result.

Newspaper media reporting of motor vehicle crashes in Singapore: an opportunity lost for injury prevention education?

Newspaper media advocacy can help steer public attention away from motor vehicle crash (MVC) injuries as a personal problem to that of a social and public health issue. If used properly, newspaper media is potentially a powerful mass educator on MVC prevention. However, there is often a conflict of interest in which newspapers, in an attempt to boost readership and revenue, may over-emphasize and sensationalize the human-interest aspect of an MVC story. The aim of this study is to examine newspaper articles of MVCs in Singapore to assess how our newspaper media coverage portray MVCs and identify factors that mitigate injury and educate the public on injury prevention measures. Details of the MVC were extracted from 12 months of newspaper coverage in Singapore. Two independent coders were used to establish inter-rater reliability. From 1 January to 31 December 2007, 201 articles about MVCs were published. About 74.1% of articles assigned blame to a particular road user, negligence on either road user was implied in 56.7% of articles, and road safety messages were mentioned in 8% of the articles. The mainstream communication tone used was positive for law enforcement (71.1%) and neutral towards injury prevention or road safety messages (89.1%). Newspaper media reporting of MVCs in Singapore generally does not include injury prevention messages or highlight injury-mitigating measures. This is a lost opportunity for public education. Collaboration between public health practitioners and newspaper media is required to address this issue.

Identifying risk factors for an abnormal computed tomographic scan of the head among patients with altered mental status in the Emergency Department.

AIMS: The aims of our study are to evaluate the use of computed tomographic scan of the head (CT-head) in patients with altered mental status (AMS) presenting to the Emergency Department (ED) and to identify clinical features associated with an abnormal CT-head result. METHODS: In this prospective observational study, we recruited consecutive adult patients with undifferentiated AMS and no major trauma at a busy urban ED over 11 months. Demographical, clinical, radiological and laboratory data were collected prospectively. The primary outcome measure was an abnormal CT-head result. Secondary outcome measures were the distribution of aetiologies of AMS with age, mortality rate and length of hospital stay. Logistic regression was applied to identify variables associated with an abnormal CT-head result. RESULTS: Nine hundred and sixty-seven patients were recruited. The rate of CT-head use in the ED was 41%, with 45% of the scans being abnormal. We identified eight clinical factors associated with an abnormal CT-head result. Odds ratios (95% confidence intervals) for diastolic blood pressure greater than 80 mmHg, focal weakness, Glasgow Coma Score less than 15, antiplatelet use, upgoing plantar response, presence of headache, anticoagulant use and dilated pupils were 1.016 (1.003-1.029), 1.816 (1.063-3.103), 1.899 (1.113-3.242), 2.203 (1.146-4.234), 2.680 (1.623-4.427), 3.369 (1.449-7.830), 3.589 (1.253-10.283) and 5.212 (1.153-23.558), respectively. CONCLUSION: Our study identified important risk factors for an abnormal CT-head result which can be used in future research to establish a guideline for rational ordering of the test in AMS patients.

Injuries to cargo area passengers of heavy goods vehicles.

Transporting manual labourers in the cargo area of heavy goods vehicles is a common practice in Singapore. Earlier studies have reported higher fatalities and more serious injuries in such unrestrained cargo area passengers compared with those sitting in the cabin of the vehicle. We conducted a case series of injured cargo area passengers presenting to the Emergency Department from 1 January 2006 to 31 December 2007. A total of 34 male casualties (mean age 29.7 years) were treated. They were injured in four separate heavy goods vehicle crashes during the study period. Patients who were nonresident manual labourers comprised 94.1%; 44.1% (15 patients) were ejected from the vehicle but despite this, the mean Injury Severity Score was 2.2 (SD 3.5). Three of the patients were admitted to hospital, with one patient (Injury Severity Score 22) requiring surgery and intensive care stay. The remaining patients were discharged from the Emergency Department, and there were no deaths. Six patients reattended the Emergency Department for unresolved pain from their injuries. A total of 173 absent-days were incurred. This report highlights the fact that cargo area passengers are at high risk of ejection, and they incur significant morbidity from their injuries with subsequent loss of productivity. In addition, heavy goods vehicle crashes are usually mass casualty events, severely taxing the receiving Emergency Department. Safer alternatives for mass transport of manual labourers are required.

Prospective study of patients with altered mental status: clinical features and outcome.

AIMS: Patients with altered mental status (AMS) present commonly to the Emergency Department (ED). The aim of this prospective study is to identify the various clinical features of this diverse group of patients and trace their outcomes. This will allow clinicians to be aware of the natural history of the symptom complex and the difficulties in managing them. METHODS: In this prospective observational study, we recruited patients aged 18 and above diagnosed with AMS at Tan Tock Seng Hospital ED from December 2006 to October 2007. This is an urban ED. Demographic, clinical, radiology, laboratory data, final diagnosis and length of stay were collected from their entry into the ED till discharge or demise using the ED's and inpatient electronic records. RESULTS: From December 2006 to October 2007, 967 patients with a mean age of 66.5 years diagnosed with AMS were recruited into our study. The total number of CT scans done during the study period was 674, of which 246 (37%) were abnormal and 428 (63%) were normal. The mean hospital length of stay was 11.6 days. Patients with abnormal CT results stayed longer than those whose results were normal (median of 9 days versus median of 6 days). The three most common causes of AMS in our study population were of neurological (34.4%), infectious (18.3%) and metabolic (12%) aetiologies. Overall, 106 (11%) patients died during hospitalisation; 36 (33.9%) and 39 (36.8%) deaths were attributed to ischaemic stroke and haemorrhagic stroke, respectively. CONCLUSIONS: AMS remains a symptom complex that carries a significant length of hospital stay and mortality. The most common causes of AMS are those that require timely intervention and are highly treatable. This study will provide insight into proper allocation of resources to manage this group of patients, from triaging to investigations and treatment at the ED and inpatient levels.