Preparation and Implementation of Intrahospital Transfer Protocol for Emergency Department Patients to Decrease Unexpected Events

Introduction: Most of the patients hospitalized in the emergency department (ED) are in need of transfer to other hospital wards or paraclinic units. This process is called intrahospital transfer (IHT) that may lead to a wide range of complications known as unexpected events (UE). Objective: In the present study we decided to evaluate the effect of using a pre-designed protocol on decrease of UEs and safety improvement of IHT among patients hospitalized in ED. Method: The present cross-sectional study was carried out in 2016 in the ED of Imam Khomeini Hospital, Tehran, Iran. All patients with triage levels of 1 and 2 who were in need of temporary or permanent transfer to other departments of the studied treatment center based on clinical indication as decided by the in-charge physician were enrolled in the study. This study was conducted in 3 phases of pre-intervention, intervention and post-intervention. Any UE was recorded in first phase. During intervention phase ED-IHT protocol was prepared and implemented. the checklist of complications and UEs during transfer was filled again and pre- and post-intervention results were compared. Results: In this study, 207 patients with the mean age of 58.9 ± 20.6 years were evaluated (61.4% male). Demographic data and baseline characteristics of the studied patients in the phases before and after implementation of the protocol has no significant difference. Overall, before implementation of the protocol out of the 105 studied patients, a total of 35 patients (33.3%) were affected by UE during transfer, but after implementation of the protocol this rate decreased to 11 patients (10.8%) out of the 103 studied patients and this decrease was statistically significant (p < 0.001). Conclusion: Based on the results obtained from this study, it seems that performing the IHT protocol specialized for ED patients has been effective in decreasing UE cases

Preparation and Implementation of Intrahospital Transfer Protocol for Emergency Department Patients to Decrease Unexpected Events

Introduction: Most of the patients hospitalized in the emergency department (ED) are in need of transfer to other hospital wards or paraclinic units. This process is called intrahospital transfer (IHT) that may lead to a wide range of complications known as unexpected events (UE). Objective: In the present study we decided to evaluate the effect of using a pre-designed protocol on decrease of UEs and safety improvement of IHT among patients hospitalized in ED. Method: The present cross-sectional study was carried out in 2016 in the ED of Imam Khomeini Hospital, Tehran, Iran. All patients with triage levels of 1 and 2 who were in need of temporary or permanent transfer to other departments of the studied treatment center based on clinical indication as decided by the in-charge physician were enrolled in the study. This study was conducted in 3 phases of pre-intervention, intervention and post-intervention. Any UE was recorded in first phase. During intervention phase ED-IHT protocol was prepared and implemented. the checklist of complications and UEs during transfer was filled again and pre- and post-intervention results were compared. Results: In this study, 207 patients with the mean age of 58.9 ± 20.6 years were evaluated (61.4% male). Demographic data and baseline characteristics of the studied patients in the phases before and after implementation of the protocol has no significant difference. Overall, before implementation of the protocol out of the 105 studied patients, a total of 35 patients (33.3%) were affected by UE during transfer, but after implementation of the protocol this rate decreased to 11 patients (10.8%) out of the 103 studied patients and this decrease was statistically significant (p < 0.001). Conclusion: Based on the results obtained from this study, it seems that performing the IHT protocol specialized for ED patients has been effective in decreasing UE cases

Concomitant COVID-19 and acute ischemic stroke in patients transferred by emergency medical service during first wave of pandemic in Tehran, Iran; a cross-sectional study

Objective: We conducted this study to evaluate the prevalence of concomitant COVID-19 in acute ischemic stroke (AIS) patients admitted to stroke centers of Tehran, Iran. Methods: We conducted a retrospective cross-sectional study in a 45-day period. AIS patients transferred by emergency medical service (EMS) to all medical centers of the city were included. Information was recorded and compared in two groups: patients who tested positive for COVID-19 and those who were negative. Result: Emergency medical technicians (EMTs) screened 348 patients as AIS cases, of whom, AIS was ultimately confirmed in 311 (89.4%) patients; and 58 (18.6%) of the 311 AIS patients were diagnosed with concomitant COVID-19 infection. The National Institutes of Health Stroke Scale (NIHSS) scores of COVID-19 positive AIS patients were significantly higher than non-COVID-19 AIS patients (16.3±3.7 vs. 11.8±4.3; p<0.001). There was also a significant difference in length of hospital stay between the two groups (11.1±1.8 vs. 8.8±4.3 days; p<0.001). However, data showed no significant difference regarding prevalence of in-hospital mortality between the two groups (1.6% vs. 3.5%; p=0.320). Conclusion: Our study results showed that AIS patients with concomitant COVID-19 infection had higher NIHSS scores and longer length of hospital stay compared to patients without concomitant COVID-19 infection

Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study

Introduction: Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients’ flow in the ED is termed triage. Objective: This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%. Method: This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients’ charts, an expert panel evaluated the validity of the triage level. Results: During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel’s evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen’s weighted kappa being 0.966 (CI 0.985–0.946, p < 0.001) and 0.813 (CI 0.856–0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen’s weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001). Conclusion: The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses

Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study

Introduction: Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients’ flow in the ED is termed triage. Objective: This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%. Method: This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients’ charts, an expert panel evaluated the validity of the triage level. Results: During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel’s evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen’s weighted kappa being 0.966 (CI 0.985–0.946, p < 0.001) and 0.813 (CI 0.856–0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen’s weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001). Conclusion: The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses

Preparation and Implementation of Intrahospital Transfer Protocol for Emergency Department Patients to Decrease Unexpected Events

Introduction: Most of the patients hospitalized in the emergency department (ED) are in need of transfer to other hospital wards or paraclinic units. This process is called intrahospital transfer (IHT) that may lead to a wide range of complications known as unexpected events (UE). Objective: In the present study we decided to evaluate the effect of using a pre-designed protocol on decrease of UEs and safety improvement of IHT among patients hospitalized in ED. Method: The present cross-sectional study was carried out in 2016 in the ED of Imam Khomeini Hospital, Tehran, Iran. All patients with triage levels of 1 and 2 who were in need of temporary or permanent transfer to other departments of the studied treatment center based on clinical indication as decided by the in-charge physician were enrolled in the study. This study was conducted in 3 phases of pre-intervention, intervention and post-intervention. Any UE was recorded in first phase. During intervention phase ED-IHT protocol was prepared and implemented. the checklist of complications and UEs during transfer was filled again and pre- and post-intervention results were compared. Results: In this study, 207 patients with the mean age of 58.9 ± 20.6 years were evaluated (61.4% male). Demographic data and baseline characteristics of the studied patients in the phases before and after implementation of the protocol has no significant difference. Overall, before implementation of the protocol out of the 105 studied patients, a total of 35 patients (33.3%) were affected by UE during transfer, but after implementation of the protocol this rate decreased to 11 patients (10.8%) out of the 103 studied patients and this decrease was statistically significant (p < 0.001). Conclusion: Based on the results obtained from this study, it seems that performing the IHT protocol specialized for ED patients has been effective in decreasing UE cases

Evaluation of the Significance of Vital Signs in the Up-Triage of Patients Visiting Emergency Department from Emergency Severity Index Level 3 to 2

The Emergency Severity Index (ESI) is a five-level triage system that has shown promising reliability and validity. According to ESI algorithm, in the presence of danger zone respiratory rate (RR), heart rate (HR) or Oxygen (O2) saturation, patients should be up-triaged from ESI level 3 to 2 Hence, the current study aimed to investigate the value of the measurement of vital signs in predicting the up-triage of patients from ESI level 3 to 2. Patients who visited the emergency department at Imam Khomeini Hospital Complex, Tehran, Iran, and were categorized into ESI level 3 were investigated. RR, HR, and O2 saturation were recorded by the triage nurse, and the rates of abnormalities in these three variables were evaluated. Out of 551 cases who were up-triaged from ESI level 3 to 2,489 (88.7%) had an increased RR, and 539 (97.8%) had an increased RR or HR. Only 12 cases (2.2%) had normal RR and HR, who were up-triaged only due to abnormal O2 saturation. Out of these 12 cases, 10 had O2 saturations <92% at common health status, 1 had acutely altered mental status and should have been triaged into ESI level 2 in the first place and 1 could not be located for further investigations. In conclusion, compared to O2 saturation, the abnormal findings during the assessment of RR and HR seem to much more commonly result in the up-triage of patients from ESI level 3 to 2

Detection and molecular characterization of Polymyxa betae, transmitting agent of sugar beet rhizomania disease, in Iran

The plasmodiophorid Polymyxa betae is considered as the only natural transmitting agent of Beet necrotic yellow vein virus (BNYVV), the most devastating agent of sugar beet fields throughout the world. To evaluate for the first time the genetic diversity of P. betae isolated from different autumn and spring sugar beet fields, and also to detect the presence of virus in these isolates, susceptible sugar beet plants (cv. Regina) were grown in soil samples collected from 10 different regions of Iran. P. betae detection was carried out using root microscopic observations, DAS-ELISA, and PCR-based methods. Results showed the presence of plasmodiophorids in all soil samples. Complementary assays also revealed the presence of viruses in soil samples collected from Khorasan Razavi, Fars, Hamadan and Kermanshah regions. The genetic diversity was evaluated through comparing glutathione-S-transferase nucleotide sequences amplified by PCR with the Internal Transcribed Spacers region. Results showed no significant differences in nucleotide sequences between virus-bearing and virus-free isolates of P. betae

Clinical Course Teaching in Transport of Critically Ill Patients: Small Group Methods

Critically ill patient transfer is potentially risky and may be lead to morbidity and mortality. Physicians' skill is very important for safe transport. We want to evaluate the effect of clinical course teaching on the promotion of physicians' abilities in the transport of critically ill patients. In an interventional study, 320 interns, male and female, were taught about patient transfer in two groups include in one day clinical course as the small group system (n=160) and other group the lecture base learning (n=160). In the clinical course, each participant under observation of an anesthesiologist in the operation room and ICU was acquainted with mask ventilation, intubation and learned to work with a defibrillator, infusion pump, portable ventilator and pulse oximeter. In lecture group, the anesthesiologist explained the topics by video and dummy. At the end of education course, the interns’ abilities were evaluated based on checklist method and scored by the project colleague in all educational items. Three hundred twenty interns, 122 males, and 198 females; were enrolled, two groups. The clinical course training caused improvements in the interns’ knowledge and abilities in intubation and use of the defibrillator and portable ventilator vs.lecture group significantly (P<0.005). The males were better than females in laryngoscopy, but the progress of the females was significantly better than males (P=0.003). The rate of adverse events was reduced significantly after clinical course teaching (P=0.041) Clinical course teaching could promote interns' clinical competencies in the transport of critically ill patients

Detection and molecular characterization of Polymyxa betae, transmitting agent of sugar beet rhizomania disease, in Iran

The plasmodiophorid Polymyxa betae is considered as the only natural transmitting agent of Beet necrotic yellow vein virus (BNYVV), the most devastating agent of sugar beet fields throughout the world. To evaluate for the first time the genetic diversity of P. betae isolated from different autumn and spring sugar beet fields, and also to detect the presence of virus in these isolates, susceptible sugar beet plants (cv. Regina) were grown in soil samples collected from 10 different regions of Iran. P. betae detection was carried out using root microscopic observations, DAS-ELISA, and PCR-based methods. Results showed the presence of plasmodiophorids in all soil samples. Complementary assays also revealed the presence of viruses in soil samples collected from Khorasan Razavi, Fars, Hamadan and Kermanshah regions. The genetic diversity was evaluated through comparing glutathione-S-transferase nucleotide sequences amplified by PCR with the Internal Transcribed Spacers region. Results showed no significant differences in nucleotide sequences between virus-bearing and virus-free isolates of P. beta