A multicenter study on reliability and validity of a new triage system: the Triage Emergency Method version 2

In Italy there are many triage guidelines and methods based on consensus. But, to our knowledge, there are few data on the reliability and predictive validity of triage systems adopted by Italian emergency departments. The Triage Emergency Method version 2 (TEM v2) is a new four-level in-hospital triage system. This paper presentes a before-and-after observational study performed using triage scenarios from June 2008 to September 2009 in 6 Italian emergency departments. Twelve nurses who received a 5-h training on TEM and a panel of experts on TEM assigned priority code to 66 scenarios. To test the inter-rater reliability among participants and the panel of experts (before and after the course), we used the weighted K statistic. We assessed the validity of TEM by calculating sensitivity, specificity and accuracy for predicting the reference standard's triage score. The TEM v2 showed good and very-good agreement among all 6 groups of nurses with a K range=0.61-1. Also, sensitivity, specificity and accuracy of nurses' triage rating for predicting the reference standard's triage code was good (accuracy range=78-90%). In this multicenter study, TEM v2 has a good inter-rater reliability for rating triage acuity among all groups of participating nurses, with a K value similar to the reference standard reliability (K=0.75). Thus, the Triage Emergency Method version 2 seems to be valid and accurate in predicting a reference standard rating

Serum bilirubin value predicts hospital admission in carbon monoxide-poisoned patients. Active player or simple bystander?

OBJECTIVES:Although carbon monoxide poisoning is a major medical emergency, the armamentarium of recognized prognostic biomarkers displays unsatisfactory diagnostic performance for predicting cumulative endpoints.METHODS:We performed a retrospective and observational study to identify all patients admitted for carbon monoxide poisoning during a 2-year period. Complete demographical and clinical information, along with the laboratory data regarding arterial carboxyhemoglobin, hemoglobin, blood lactate and total serum bilirubin, was retrieved.RESULTS:The study population consisted of 38 poisoned patients (23 females and 15 males; mean age 39±21 years). Compared with discharged subjects, hospitalized patients displayed significantly higher values for blood lactate and total serum bilirubin, whereas arterial carboxyhemoglobin and hemoglobin did not differ. In a univariate analysis, hospitalization was significantly associated with blood lactate and total serum bilirubin, but not with age, sex, hemoglobin or carboxyhemoglobin. The diagnostic performance obtained after combining the blood lactate and total serum bilirubin results (area under the curve, 0.90; 95% CI, 0.81-0.99;

Impact of different drug classes on clinical severity of falls in an elderly population: Epidemiological survey in a trauma center

AbstractPurposeCertain classes of drugs have been associated with the risk of falls in elderly individuals. The aim of this study was to evaluate the impact of several classes of drugs on fall-related injuries in individuals aged 65 years or older.MethodsData on all the emergency department (ED) visits for trivial falls during the year 2013 were retrieved from the database of the Academic Hospital of Parma. The individual reports of the visits were analyzed to evaluate where and how the patient fell, the drugs currently taken, the type, and severity of injury.ResultsA total of 2533 visits for trivial falls in patients aged 65 years or older were analyzed. We found a significant positive correlation between age and total number of drugs (r = 0.063; p < 0.03), but no correlation between the number of ED visits for trivial falls and the number of drugs (r = 0.001; p < 0.984). Anticoagulants [odds ratio (OR), 1.59; 95% confidence interval (CI), 1.22–2.07], antiplatelets (OR, 1.41; 95% CI, 1.12–1.79), and narcotic analgesics (OR, 2.38; 95% CI, 1.23–4.62) were predictors of hospital admission. Antiplatelets (OR, 2.02; 95% CI, 1.56–2.62), anticoagulants (OR, 1.89; 95% CI, 1.141–2.55), antihypertensive (OR, 1.44; 95% CI, 1.08–1.93), and psychotropic drugs (OR, 1.93; 95% CI, 1.09–3.44) were predictors of traumatic brain injury. Other classes of drugs were not related to any of the considered outcomes.ConclusionsTo reduce the risk of falling in elderly patients, a major focus should be placed on optimization of antihypertensives, narcotic analgesics, and psychotropic drugs administration. The risk-to-benefit ratio of anticoagulants and antiplatelet drugs should be individually tailored, to minimize the risk of adverse outcome of falls

The number of emergency department visits for psychiatric emergencies is strongly associated with mean temperature and humidity variations. Results of a nine year survey

Several disorders, such as renal colics, stroke, atrial fibrillation and others, are epidemiologically associated with seasonality and microclimatic variations. Although evidence is still limited, an association between psychiatric emergencies and seasonality has also been previously described. In order to elucidate the possible association between weather and incidence of psychiatric emergencies in a country with temperate climate, we analyzed the influence of day by day climate changes on the number of visits for psychiatric emergencies in an urban emergency department (ED) of northern Italy. All ED visits for psychiatric emergencies were retrieved from the hospital database from 2002 to 2010. The total number of ED visits was 725,812 throughout the study period, 11,786 of which for emergency psychiatric problems. We found a strong seasonal distribution of emergency psychiatric visits, peaking in summer and at the beginning of spring. The linear regression analysis showed a strong positive association between number of daily emergency psychiatric visits and mean daily air temperature (R=0.82; P<0.001), and an inverse association with mean daily air humidity (R=-0.52; P<0.001). These findings suggest that psychiatric disorders follow a significant seasonal variation, so that it may be advisable to strengthen psychiatric emergency services during the hottest months

Multicenter survey on emergency nurses’ perception of Numerical Rating Scale reliability at triage time in adult Emergency Department patients

Since pain perception is highly subjective and culturally mediated, its objective evaluation remains difficult. Nevertheless, pain measurement should ideally be a part of the assessment of patients in order to plan adequate pain relief. Several scales have been proposed for pain measurement, being the numerical rating scale (NRS) the most widely used, often at triage time. NRS have demonstrated acceptable reliability and validity, in post-operative medicine and in oncologic pain, but data in the Emergency Departments (EDs) are poor. The aim of this study is to evaluate the Emergency Nurses’ (ENs) perception about the reliability of NRS in the triage process. A questionnaire based on 11 items was designed and subsequently administered to a large number of ENs in several EDs in Northern and Central Italy. 301 questionnaires were filled out and returned. The majority declares using NRS scale to measure pain (item 2, mode = 4, mean = 3.8), and attributing priority code based on NRS value (item 3, mode = 4, mean = 3.4). In general, triage nurses believe that NRS is only indicative and that their judgement matters (item 4, mode = 4, mean = 3.2). The vast majority of triage nurses do believe that the patients will indicate a fake higher NRS value with the aim to get a more urgent code (item 5, mode = 5, mean = 4), while only a small minority expects that patients would underestimate their NRS for fear of penalizing more urgent patients. Very few believe that such scale underestimates the patients’ condition, while the majority is ambivalent about whether such scale overestimates it. In conclusion, NRS confirms to be a potentially valuable tool for pain evaluation at triage time, but many nurses express some doubts on its reliability, and will attribute the triage code mainly basing on their own judgement

An Italian prospective multicenter study on colonoscopy practice and quality: What has changed in the last 10 years

Background: A relevant number of adenomas can be missed during colonoscopy. Aims: Assess the current status of colonoscopy procedures in Italian centers. Methods: A prospective observational study involving 17 hospitals (34 endoscopists) included consecutive patients undergoing standard colonoscopy. In the first phase, endoscopists performed consecutive colonoscopies. In the second phase, retraining via an online learning platform was planned, while in the third phase data were collected analogously to phase 1. Results: A total of 3,504 patients were enrolled. Overall, a BBPS score ≥6 was obtained in 95.6% of cases (94.8% and 96.9% in the pre- and post-training phases, respectively). 88.4% of colonoscopies had a withdrawal time ≥6 min (88.2% and 88.7% in the pre- and post-training phases). Median adenoma detection rate (ADR) was 39.1%, with no significant differences between the pre- and post-training phases (40.1% vs 36.9%; P = 0.83). In total, 81% of endoscopists had a ADR performance above the 25% threshold. Conclusion: High colonoscopy quality standards are achieved by the Italian hospitals involved. Quality improvement initiatives and repeated module-based colonoscopy-training have been promoted in Italy during the last decade, which appear to have had a significant impact on quality colonoscopy metrics together with the activation of colorectal cancer screening programs

Overcrowded ERs: analysis of the phenomenon and managing proposals

The &ldquo;overcrowding&rdquo; in Emergency Departments (EDs) and its potentially negative consequences, is a well known phenomenon in western countries. The causes of this phenomenon in this area are: constantly decreased number of hospital beds, increased number of ED visits and demographic changes (increasing prevalence of elderly people and migrants). Overcrowding in EDs accounts different timing of various care-paths (e.g. door-to-balloon time in STEMI) and also influences the degree of care given to patients. Moreover overcrowding has also been considered as a first-line cause of doctor&rsquo;s and nurse&rsquo;s burnout and of verbal or physical assault. The overcrowding phenomenon seems to be more effectively influenced by interventions directed to improve patient&rsquo;s output from ED to wards; by contrast interventions directed to limit ED visits failed to be effective

A multicenter study on reliability and validity of a new triage system: the Triage Emergency Method version 2

In Italy there are many triage guidelines and methods based on consensus. But, to our knowledge, there are few data on the reliability and predictive validity of triage systems adopted by Italian emergency departments. The Triage Emergency Method version 2 (TEM v2) is a new four-level in-hospital triage system. This paper presentes a before-and-after observational study performed using triage scenarios from June 2008 to September 2009 in 6 Italian emergency departments. Twelve nurses who received a 5-h training on TEM and a panel of experts on TEM assigned priority code to 66 scenarios. To test the inter-rater reliability among participants and the panel of experts (before and after the course), we used the weighted K statistic. We assessed the validity of TEM by calculating sensitivity, specificity and accuracy for predicting the reference standard&rsquo;s triage score. The TEM v2 showed good and very-good agreement among all 6 groups of nurses with a K range=0.61-1. Also, sensitivity, specificity and accuracy of nurses&rsquo; triage rating for predicting the reference standard&rsquo;s triage code was good (accuracy range=78-90%). In this multicenter study, TEM v2 has a good inter-rater reliability for rating triage acuity among all groups of participating nurses, with a K value similar to the reference standard reliability (K=0.75). Thus, the Triage Emergency Method version 2 seems to be valid and accurate in predicting a reference standard rating

A multicenter retrospective study on falls in elderly population. Epidemiology and impact on hospital workload in two Emergency Departments of Northern Italy

Aims of this study were to evaluate the incidence of falls in subjects aged ≥65 years in Parma Province (Northern Italy), and the burden of fall-related hospitalizations. All the Emergency Department (ED) visits for domestic or trivial falls were retrieved from the database of the two EDs of Parma Province during 2013. All cases were classified according to age and gender. Out of 129,898 total ED visits, 3720 (2.9%) were related to trivial falls in patients aged ≥65 years. Females accounted for 2648 visits and males for 1072. The absolute number of visits due to falls increased with age in both genders, with a peak between 80 and 84 yrs. When related with the actual number of residents by age groups, females showed a continuous increase, peaking at age &gt;100 yrs, and males a continuous increase, peaking at age 95-99 yrs. Of these patients, 963 (25.9%) needed hospitalization, 605 in the orthopedic ward, 342 in medical wards, and 16 in specialist surgical units. In conclusion, falls represent a major cause of morbidity in the elderly in Northern Italy, representing 13.3% of the ED visits for people aged ≥65, with a high impact on hospital workload

Elastodontic Devices in Orthodontics: An In-Vitro Study on Mechanical Deformation under Loading

The purpose of the present study was to evaluate the mechanical resistance of elastodontic devices (ED): their maximum compression loads and plastic deformation under loading (percentage). An Instron universal machine (Model 3365, Instron, Industrial Product Group, Grove City, PA, USA) was employed with a 100 N load cell and with Bluehill software for loading analyses. Each device was submitted to a five-cycles test. The following ED were evaluated: A.M.C.O.P. (Micerium, Genova, Italy) in red color, in orange color, and in blue color; HealthyStart (Ortho-Tain, Winnetka, IL, USA), and T4K™ phase 1 (Myofunctional Research Co., Helensvale, Australia). During the five-cycles test, the Ortho-Tain device delivered the greatest compression load (7.56 N), with the lowest percentage of deformation (0.95%). For all devices, a slight plastic deformation of the material was registered, ranging from 0.95% to 1.75%. For the T4K device it was not possible to complete the five-cycles test. For all the analyzed ED, a slight plastic deformation under loading was registered, that in all cases can be considered clinically acceptable. Further studies are needed to test the appliances after clinical usage