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201 Agreement of a Computerized Triage Tool Using Written Case Scenarios Dong SL, Bullard MJ, Meurer DP, Akhmetshin E, Holroyd BR, Rowe BH/ University of Alberta, Edmonton, Alberta, Canada Study Objectives: Emergency department (ED) triage prioritizes patients based on urgency of care. A Web-based triage tool (eTRIAGE) has been developed with Canadian Triage and Acuity Scale templates and studied in an active clinical setting. Some authors also advocate the use of written case scenarios to evaluate triage. This study examined the agreement between nurses using eTRIAGE with written patient case scenarios, and agreement between these nurses and a consensus standard triage score. Methods: Volunteer experienced triage nurses were recruited for this study. Each nurse was provided 50 written case scenarios and used eTRIAGE to arrive at a triage score. The cases were representatively balanced between CTAS 1 through 5, and the nurses evaluated triage notes and vital signs but were blinded to identifying characteristics or the other nurses’ triage. These scores were compared to each other and to a consensus score using the weighted and unweighted kappa () statistics. Results: Eight triage nurses volunteered for this project; all completed the 50 cases. An experienced emergency nurse and 2 emergency physicians generated the consensus scores. Agreement was very good among the eight nurses (overall 0.73; 95%CI: 0.69, 0.77). When compared to each other, the agreement was excellent (mean quadratic weighted 0.88; 95%CI: 0.61-1.00). When compared to the consensus scores agreement was excellent (mean quadratic weighted 0.91; 95%CI: 0.77, 1.00). Conclusions: Nurses using eTRIAGE to evaluate written patient scenarios had good to excellent inter-rate agreement and excellent agreement when compared to a triage score generated by consensus. Further research to create this degree of agreement in the live setting is needed. It is also unclear what amount of training and experience with eTRIAGE is required to become competent or to maintain competence. 202 Best “Better Early Stroke Treatment”: Implementation of Nursing Questionnaire Aids in Triage of Acute Ischemic Stroke Patients Hoff AM, Yassa AS, Bellolio MF, Vaidyanathan L, Kashyap R, Enduri S, Suravaram S, Brown Jr RD, Decker WW, Stead LG/Mayo Clinic College of Medicine, Rochester, MN Background: As part of the recommendations of the current guidelines for the management of acute stroke, hospitals must create efficient pathways and processes to rapidly identify and evaluate stroke patients. All patients with suspected acute stroke should be triaged with the same priority as patients with acute myocardial infarction or serious trauma, regardless of the severity of the deficits. To minimize delays in triage, we developed an organized protocol and stroke team to speed up the clinical assessment, the performance of diagnostic studies, and the decisions for early management. Study Objectives: To study whether implementation of a nursing questionnaire prior to the arrival of patients with acute ischemic stroke (AIS) aids in triage to a specialized (critical) area and expedites patient management within the emergency department (ED). Methods: A random cohort of 43 patients were collected after implementation of the “Better Early Stroke Treatment” (BEST) Nursing Questionnaire in the setting of a tertiary care ED with over 77,000 visits a year. Only patients who were admitted via the ED with AIS were included. The elements of BEST Nursing Questionnaire include: Patient’s name Medical record number Location of referring ED Time of symptom onset Consideration of t-PA by outside physician t-PA administration Referring and accepting physician Mode of patient transportation Estimated time of arrival For our prospective observational study we collected symptom onset to ED presentation, consideration of t-PA, t-PA administration, and ED length of stay (LOS). Descriptive statistics and Wilcoxon/Kruskal-Wallis test were performed in JMP software, SAS institute, Version 6.0. Results: The BEST Nursing Questionnaire was completed in all 43 patients (100%) prior to arrival at the tertiary care ED. Only 16 of the 43 (37.2%) patients were considered to be candidates for t-PA by the outside facilities. Of those 16, a total of 4 (25%) received t-PA prior to their arrival at the tertiary care ED. All patients were triaged to the specialized (critical) area of the ED upon arrival and managed by a standardized acute stroke protocol. The ED LOS was available in 35 of 43 patients. The median ED LOS was 2.83 hours (interquartile range 2.08 to 5.25 hours). This time is significantly lower than the recorded times during the previous 12 months (August 2006 to July 2007) with a median of 3.55 hours (interquartile range 2.63 to 4.70 hours), p0.0456. Conclusion: Implementation of the BEST Nursing Questionnaire aids in management of AIS patients by triaging patients to a specialized (critical) area of the ED and decreasing ED LOS. The questionnaire enhanced ED throughput by shortening the median ED LOS by approximately 1 hour which is of paramount importance given the current overcapacity trends. 203 Do Emergency Physicians Admit More or Fewer Patients on Busy Days? Albrecht RA, Melanson S, Jacoby J/St. Luke’s Hospital, Bethlehem, PA Study Objectives: Although the issues concerning the impact of ED crowding have been the subject of much recent concern, there are few data regarding the effect of ED census on emergency physician behavior with respect to the decision to admit patients. Admission rates might either increase or decrease on busy days, when the system and the physician are under stress. The purpose of this study was to determine if ED physicians change their admitting behavior depending on ED census. Methods: This was a retrospective review of 3 months’ data (92 consecutive days, 7/9/06 - 10/9/06) in a community ED with an annual census of approximately 62,000 patients and an EM residency program. We defined each of the 92 days to be either “busy” (181 patients seen), “slow” ( 146 patients seen) or “medium” (146- 181 patients seen). We then compared the rates of admission to the hospital on the “busy,” “medium,” and “slow” days. We also compared each attending physician’s personal rates of admission on slow days to his or her rate of admission on medium or busy days. ED staffing was constant throughout the study period. All comparisons were with chi-square. Results: There were 14,969 patients seen in the ED during the 92 study days. On “busy” days 20.1% of the 3,400 patients were admitted to the hospital; on “medium” days 20.6% of the 9,057 patients were admitted; on “slow” days 19.7% of the 2,512 patients were admitted. There was no significant association between the level of patient volume in the ED and rate of admission (p.55). When comparing each of 14 attending physicians to him or herself there was no significant association found between rate of admission and ED census (all p values .3). All 3 categories of days, “busy,” “medium,” and “slow” did not differ in terms of acuity as judged by triage level distribution. Conclusion: The likelihood of a patient’s admission versus discharge is not affected by ED patient volume. Furthermore we found no evidence that individual physician’s admitting behavior was associated with ED patient volume. 204 Use of Diagnostic Tools on Daily Surge Days in the Emergency Department Davis G, Milzman DP/Georgetown U School of Medicine/WHC EM Residency, Washington, DC Study Objectives: To evaluate the ordering of diagnostic labs, radiographs, and CT scans by emergency physicians on days with high patient volume as compared to days with lower or average volume days. ICEM 2008 Scientific Abstract Program 532 Annals of Emergency Medicine Volume , . : April

202: Best “Better Early Stroke Treatment”: Implementation of Nursing Questionnaire Aids in Triage of Acute Ischemic Stroke Patients

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Page 1: 202: Best “Better Early Stroke Treatment”: Implementation of Nursing Questionnaire Aids in Triage of Acute Ischemic Stroke Patients

201 Agreement of a Computerized Triage Tool UsingWritten Case Scenarios

Dong SL, Bullard MJ, Meurer DP, Akhmetshin E, Holroyd BR, Rowe BH/University of Alberta, Edmonton, Alberta, Canada

Study Objectives: Emergency department (ED) triage prioritizes patients based onurgency of care. A Web-based triage tool (eTRIAGE) has been developed with CanadianTriage and Acuity Scale templates and studied in an active clinical setting. Some authorsalso advocate the use of written case scenarios to evaluate triage. This study examined theagreement between nurses using eTRIAGE with written patient case scenarios, andagreement between these nurses and a consensus standard triage score.

Methods: Volunteer experienced triage nurses were recruited for this study. Eachnurse was provided 50 written case scenarios and used eTRIAGE to arrive at a triagescore. The cases were representatively balanced between CTAS 1 through 5, and thenurses evaluated triage notes and vital signs but were blinded to identifyingcharacteristics or the other nurses’ triage. These scores were compared to each otherand to a consensus score using the weighted and unweighted kappa (�) statistics.

Results: Eight triage nurses volunteered for this project; all completed the 50 cases. Anexperienced emergency nurse and 2 emergency physicians generated the consensus scores.Agreement was very good among the eight nurses (overall � � 0.73; 95%CI: 0.69, 0.77).When compared to each other, the agreement was excellent (mean quadratic weighted� � 0.88; 95%CI: 0.61-1.00). When compared to the consensus scores agreement wasexcellent (mean quadratic weighted � � 0.91; 95%CI: 0.77, 1.00).

Conclusions: Nurses using eTRIAGE to evaluate written patient scenarios had goodto excellent inter-rate agreement and excellent agreement when compared to a triage scoregenerated by consensus. Further research to create this degree of agreement in the livesetting is needed. It is also unclear what amount of training and experience witheTRIAGE is required to become competent or to maintain competence.

202 Best “Better Early Stroke Treatment”:Implementation of Nursing Questionnaire Aids inTriage of Acute Ischemic Stroke Patients

Hoff AM, Yassa AS, Bellolio MF, Vaidyanathan L, Kashyap R, Enduri S,Suravaram S, Brown Jr RD, Decker WW, Stead LG/Mayo Clinic College ofMedicine, Rochester, MN

Background: As part of the recommendations of the current guidelines for themanagement of acute stroke, hospitals must create efficient pathways and processes torapidly identify and evaluate stroke patients. All patients with suspected acute strokeshould be triaged with the same priority as patients with acute myocardial infarction orserious trauma, regardless of the severity of the deficits. To minimize delays in triage, wedeveloped an organized protocol and stroke team to speed up the clinical assessment, theperformance of diagnostic studies, and the decisions for early management.

Study Objectives: To study whether implementation of a nursing questionnaire priorto the arrival of patients with acute ischemic stroke (AIS) aids in triage to a specialized(critical) area and expedites patient management within the emergency department (ED).

Methods: A random cohort of 43 patients were collected after implementation ofthe “Better Early Stroke Treatment” (BEST) Nursing Questionnaire in the setting ofa tertiary care ED with over 77,000 visits a year. Only patients who were admitted viathe ED with AIS were included.

The elements of BEST Nursing Questionnaire include:● Patient’s name

● Medical record number● Location of referring ED● Time of symptom onset● Consideration of t-PA by outside physician● t-PA administration● Referring and accepting physician● Mode of patient transportation● Estimated time of arrival

For our prospective observational study we collected symptom onset to EDpresentation, consideration of t-PA, t-PA administration, and ED length of stay(LOS). Descriptive statistics and Wilcoxon/Kruskal-Wallis test were performed inJMP software, SAS institute, Version 6.0.

Results: The BEST Nursing Questionnaire was completed in all 43 patients(100%) prior to arrival at the tertiary care ED. Only 16 of the 43 (37.2%) patientswere considered to be candidates for t-PA by the outside facilities. Of those 16, a totalof 4 (25%) received t-PA prior to their arrival at the tertiary care ED. All patientswere triaged to the specialized (critical) area of the ED upon arrival and managed by astandardized acute stroke protocol. The ED LOS was available in 35 of 43 patients.The median ED LOS was 2.83 hours (interquartile range 2.08 to 5.25 hours). Thistime is significantly lower than the recorded times during the previous 12 months(August 2006 to July 2007) with a median of 3.55 hours (interquartile range 2.63 to4.70 hours), p�0.0456.

Conclusion: Implementation of the BEST Nursing Questionnaire aids inmanagement of AIS patients by triaging patients to a specialized (critical) area of theED and decreasing ED LOS. The questionnaire enhanced ED throughput byshortening the median ED LOS by approximately 1 hour which is of paramountimportance given the current overcapacity trends.

203 Do Emergency Physicians Admit More or FewerPatients on Busy Days?

Albrecht RA, Melanson S, Jacoby J/St. Luke’s Hospital, Bethlehem, PA

Study Objectives: Although the issues concerning the impact of ED crowdinghave been the subject of much recent concern, there are few data regarding the effectof ED census on emergency physician behavior with respect to the decision to admitpatients. Admission rates might either increase or decrease on busy days, when thesystem and the physician are under stress. The purpose of this study was to determineif ED physicians change their admitting behavior depending on ED census.

Methods: This was a retrospective review of 3 months’ data (92 consecutive days,7/9/06 - 10/9/06) in a community ED with an annual census of approximately62,000 patients and an EM residency program. We defined each of the 92 days to beeither “busy” (�181 patients seen), “slow” (� 146 patients seen) or “medium” (146-181 patients seen). We then compared the rates of admission to the hospital on the“busy,” “medium,” and “slow” days. We also compared each attending physician’spersonal rates of admission on slow days to his or her rate of admission on medium orbusy days. ED staffing was constant throughout the study period. All comparisonswere with chi-square.

Results: There were 14,969 patients seen in the ED during the 92 study days. On“busy” days 20.1% of the 3,400 patients were admitted to the hospital; on “medium”days 20.6% of the 9,057 patients were admitted; on “slow” days 19.7% of the 2,512patients were admitted. There was no significant association between the level ofpatient volume in the ED and rate of admission (p�.55). When comparing each of14 attending physicians to him or herself there was no significant association foundbetween rate of admission and ED census (all p values � .3). All 3 categories of days,“busy,” “medium,” and “slow” did not differ in terms of acuity as judged by triagelevel distribution.

Conclusion: The likelihood of a patient’s admission versus discharge is notaffected by ED patient volume. Furthermore we found no evidence that individualphysician’s admitting behavior was associated with ED patient volume.

204 Use of Diagnostic Tools on Daily Surge Days in theEmergency Department

Davis G, Milzman DP/Georgetown U School of Medicine/WHC EM Residency,Washington, DC

Study Objectives: To evaluate the ordering of diagnostic labs, radiographs, andCT scans by emergency physicians on days with high patient volume as compared todays with lower or average volume days.

ICEM 2008 Scientific Abstract Program

532 Annals of Emergency Medicine Volume , . : April