Abstract
Aims
Patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are routinely transferred to the emergency department (ED). A clinical risk score with point-of-care ...(POC) troponin measurement might enable ambulance paramedics to identify low-risk patients in whom ED evaluation is unnecessary. The aim was to assess safety and healthcare costs of a pre-hospital rule-out strategy using a POC troponin measurement in low-risk suspected NSTE-ACS patients.
Methods and results
This investigator-initiated, randomized clinical trial was conducted in five ambulance regions in the Netherlands. Suspected NSTE-ACS patients with HEAR (History, ECG, Age, Risk factors) score ≤3 were randomized to pre-hospital rule-out with POC troponin measurement or direct transfer to the ED. The sample size calculation was based on the primary outcome of 30-day healthcare costs. Secondary outcome was safety, defined as 30-day major adverse cardiac events (MACE), consisting of ACS, unplanned revascularization or all-cause death. : A total of 863 participants were randomized. Healthcare costs were significantly lower in the pre-hospital strategy (€1349 ± €2051 vs. €1960 ± €1808) with a mean difference of €611 95% confidence interval (CI): 353–869; P < 0.001. In the total population, MACE were comparable between groups 3.9% (17/434) in pre-hospital strategy vs. 3.7% (16/429) in ED strategy; P = 0.89. In the ruled-out ACS population, MACE were very low 0.5% (2/419) vs. 1.0% (4/417), with a risk difference of −0.5% (95% CI −1.6%–0.7%; P = 0.41) in favour of the pre-hospital strategy.
Conclusion
Pre-hospital rule-out of ACS with a POC troponin measurement in low-risk patients significantly reduces healthcare costs while incidence of MACE was low in both strategies.
Trial registration
Clinicaltrials.gov identifier NCT05466591 and International Clinical Trials Registry Platform id NTR 7346.
Structured Graphical Abstract
Structured Graphical Abstract
ACS, acute coronary syndrome; CI, confidence interval; ED, emergency department; MACE, major adverse cardiac events; NSTE-ACS, non-ST-elevation acute coronary syndrome; POC, point-of-care
Objective: This study aimed to clarify the practice of in-hospital triage by certified nurses in emergency nursing in the emergency room.Methods: The study conducted semi-structured interview among ...seven certified nurses in emergency nursing that was followed by qualitative and descriptive analyses.Results: The in-hospital triage included “practices that lead to urgency judgment,” such as interviews to quickly and systematically collect information, reliable observation, and re-evaluation to avoid unexpected changes; “practice for emotional aspects of waiting patients,” where the patient’s state of mind is assessed and a sense of security is provided; “implementation of management,” promote infection control and efficient in-hospital triage; and “utilization of accumulated knowledge and skills.”Conclusions: To practice safe in-hospital triage in crowded and complicated emergency outpatient settings, the “implementation of management” for coordination, collaboration, and leadership among nurses and medical professionals is essential.
Background Early triage is essential to improve outcomes in patients with suspected acute myocardial infarction (AMI). This study investigated whether cMyC (cardiac myosin-binding protein), a novel ...biomarker of myocardial necrosis, can aid early diagnosis of AMI and risk stratification. Methods and Results cMyC and high-sensitivity cardiac troponin T were retrospectively quantified in blood samples obtained by ambulance-based paramedics in a prospective, diagnostic cohort study. Patients with ongoing or prolonged periods of chest discomfort, acute dyspnoea in the absence of known pulmonary disease, or clinical suspicion of AMI were recruited. Discrimination power was evaluated by calculating the area under the receiver operating characteristics curve; diagnostic performance was assessed at predefined thresholds. Diagnostic nomograms were derived and validated using bootstrap resampling in logistic regression models. Seven hundred seventy-six patients with median age 68 58;78 were recruited. AMI was the final adjudicated diagnosis in 22%. Median symptom to sampling time was 70 minutes. cMyC concentration in patients with AMI was significantly higher than with other diagnoses: 98 43;855 versus 17 9;42 ng/L. Discrimination power for AMI was better with cMyC than with high-sensitivity cardiac troponin T (area under the curve, 0.839 versus 0.813; P=0.005). At a previously published rule-out threshold (10 ng/L), cMyC reaches 100% sensitivity and negative predictive value in patients after 2 hours of symptoms. In logistic regression analysis, cMyC is superior to high-sensitivity cardiac troponin T and was used to derive diagnostic and prognostic nomograms to evaluate risk of AMI and death. Conclusions In patients undergoing blood draws very early after symptom onset, cMyC demonstrates improved diagnostic discrimination of AMI and could significantly improve the early triage of patients with suspected AMI.
The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool ...(STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample.
Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005.
Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar.
This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The American College of Surgeons (ACS) requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation. Our goal was to evaluate the effect of adding age-adjusted shock ...index (SI) to the ACS-6 for the prediction of severe injury among pediatric trauma patients with the hypothesis that SI would significantly improve sensitivity with an acceptable decrease in specificity.
We performed a secondary analysis of prospectively collected EMS and trauma registry data from two urban pediatric trauma centers. Age-adjusted SI thresholds were calculated as heart rate divided by systolic blood pressure using 2020 Pediatric Advanced Life Support SI vital sign ranges and previously published Shock Index, Pediatric Adjusted (SIPA) thresholds. The primary outcome was a composite of emergency operative (within 1 hour of arrival) or emergency procedural intervention (EOPI) or Injury Severity Score (ISS) greater than 15. Sensitivities, specificities, and 95% CIs were calculated for the ACS-6 alone and in combination with age-adjusted SI.
There were 8,078 patients included; 20% had an elevated age-adjusted SI and 17% met at least one ACS minimum criterion; 1% underwent EOPI; and 17% had ISS >15. Sensitivity and specificity of the ACS-6 for EOPI or ISS > 5 were 45% (95% confidence interval CI, 41-50%) and 89% (95% CI, 81-96%). Inclusion of Pediatric Advanced Life Support-SI and SIPA resulted in sensitivities of 51% (95% CI, 47-56%) and 69% (95% CI, 65-72%), and specificities of 80% (95% CI, 71-89%) and 60% (95% CI, 53-68%), respectively. Similar trends were seen for each secondary outcome.
In this cohort of pediatric trauma registry patients, the addition of SIPA to the ACS-6 for trauma team activation resulted in significantly increased sensitivity for EOPI or ISS greater than 15 but poor specificity. Future investigation should explore using age-adjusted shock index in a two-tiered trauma activation system, or in combination with novel triage criteria, in a population-based cohort.
Diagnostic Tests or Criteria; Level II.
'Background': Differences between pre-hospital triage by an emergency medical technician and Simple Triage and Rapid Treatment triage (START) by emergency staffs often affect manpower management and ...aggravate the chaos condition of emergency room.
'Objectives': Under the assistance of instant messaging, the authors aimed to identify ways of improving triage differences between emergency medical technician triage grading and Simple Triage and Rapid Treatment triage grading by emergency staffs.
'Methods': Recorded photographs of all patients were reviewed by a smartphone. We categorized patients according to three triage conditions: group 1, accident scene on-site or instantaneous Simple Triage and Rapid Treatment triage by the emergency medical technician; group 2, triage under Simple Triage and Rapid Treatment grading by emergency staffs; group 3, re-triage with START grading using recorded photographs, Glasgow Coma Scale, and vital signs when these patients were arrived in emergency room. The Wilcoxon Signed-Rank test, Spearman rank correlations, and Kruskal-Wallis test are employed to test differences among the groups. We used risk estimates with odds ratios and the chi-square test to statistically analyze the differences in triage grading.
'Results': Statistical analysis found conflicting results among Wilcoxon Signed-Rank test, Spearman rank correlations, and Kruskal-Wallis test. The difference in triage grading between groups 2 and 1 was greater than that between groups 2 and 3 (odds ratio, 6.473; 95% confidence interval, 1.693-24.470; p-value < 0.05).
'Conclusion': Transferred photographs combined with Glasgow Coma Scale and vital signs can help us to understand the real situations of patients. With instant messaging applications, it is possible to make more precise pre-hospital or instantaneous triage.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
To determine the influence of intoxication on the pre-hospital recognition of severely head-injured patients by Emergency Medical Services (EMS) professionals and to investigate the relationship ...between suspected alcohol intoxication and severe head injury.
This multi-center, retrospective, cohort study included trauma patients, aged ≥ 16 years, transported by an ambulance of the Regional Ambulance Facility Utrecht to any emergency department in the participating trauma regions.
Between January 1, 2015 and December 31, 2017, 19,206 patients were included, of whom 1167 (6.0%) were suspected to have a severe head injury in the field, and 623 (3.2%) were diagnosed with such an injury at the hospital. These injuries were less frequently recognized in patients with a GCS ≥ 13 than in patients with a GCS < 13 (25.0% vs. 76.2%). Patients suspected to be intoxicated had a higher chance to suffer from severe head injury (OR 1.42, 95%-CI 1.22-1.65) and were recognized slightly more often (45.3% vs. 40.2%).
Severe head injuries are difficult to recognize in the field, especially in patients without a decreased GCS. Suspicion of alcohol intoxication did not seem to influence pre-hospital injury recognition, as it possibly makes a severe head injury harder to recognize and simultaneously raises caution for a severe injury.
Background
The American College of Surgeons requires trauma centers to use six minimum criteria (ACS‐6) for full trauma team activation: hypotension, gunshot wound to the neck or torso, Glasgow Coma ...Scale (GCS) score < 9, respiratory compromise, transfers receiving blood transfusion, or physician discretion. Our goal was to evaluate the effect of adding varying shock index (SI) thresholds to the ACS‐6 in an adult trauma population with the hypothesis that SI would significantly improve sensitivity at the expense of an acceptable decrease in specificity.
Methods
We performed a secondary analysis of EMS and trauma registry data from an urban Level I trauma center. Consecutive patients > 15 years of age were included from 1993 through 2006. SI at thresholds of ≥0.8, ≥0.85, ≥0.9, and ≥1 were evaluated. Primary outcome was emergency operative (within 1 h of arrival) or procedural (cricothyrotomy or thoracotomy) intervention (EOPI); secondary outcomes were Injury Severity Score (ISS) > 15, ISS > 24, a composite of EOPI or ISS > 15, and urgent operative intervention (within 4 h).
Results
A total of 20,872 patients were included, 27% with an ISS > 15 and 5% who underwent EOPI. Sensitivity and specificity of the ACS‐6 alone for EOPI were 86% (95% confidence interval CI = 84% to 88%) and 81% (95% CI = 80% to 81%), respectively. Inclusion of SI thresholds of 0.8, 0.85, 0.9, and 1 resulted in sensitivities of 95% (95% CI = 93% to 96%), 93% (CI = 91% to 94%), 92% (95% CI = 90% to 93%), and 90% (95% CI = 88% to 92%), respectively, and specificities of 52% (95% CI = 51% to 52%), 59% (95% CI = 58% to 59%), 64% (95% CI = 64% to 65%), and 72% (95% CI = 71% to 73%), respectively. Similar trends were found for each secondary outcome.
Conclusion
The addition of SI to the ACS‐6 for trauma team activation increased sensitivity for EOPI with a larger decrease in specificity across all thresholds. Inclusion of a SI threshold of ≥0.9 closely aligns with under‐ and overtriage benchmarks in this trauma registry cohort using a strict definition of trauma team activation need.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Aim
The objective of this study was to determine and compare the effectiveness of two methods of role playing and lecture on knowledge, attitude and performance of nursing' students in the context of ...pre‐hospital triage.
Design
This was a pre‐test–posttest quasi‐experimental study.
Methods
A total of 66 nursing students (third year) were assigned to two groups, the control group (N = 23) and intervention group (N = 23). START pre‐hospital triage was taught to two groups by using a lecture (control group) and role playing (intervention group) method. Immediately before the intervention and 4 weeks after the training, students' knowledge, attitude and practice in both groups were assessed through a questionnaire and a checklist. Data were analysed using SPSS software version 21.
Results
The results showed that the mean scores of knowledge, attitude and performance increased after intervention in both groups (p < .05). The mean (SD) difference of total performance score from baseline to follow‐up in the experimental group and the control group was 23.91 (13.83) and 7.00 (13.20), respectively (p < .001). While there was no significant difference between the mean (SD) difference of knowledge and attitude scores in the experimental group and the control group before and after the intervention (p > .05).
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
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