The SALT and START Triage System for Classifying Patient Acuity Level: A Systematic Review

Background: Two common triage systems have been widely used in mass casualty incidents (MCIs) and disaster situations, namely START (simple triage algorithm and rapid treatment) and SALT (sort, assess, lifesaving, intervention, and treatment/transport). There is currently controversy regarding the effectiveness of SALT over the START triage system.Purpose: This systematic review aims to compare the accuracy of the SALT and START triage systems in disaster and MCI settings.Methods: The literature was searched using a systematic search strategy for articles published from 2009 to 2020 in the Medline, CINAHL, Web of Science, Scopus, PubMed, ProQuest databases, and the grey literature. This review included simulation-based and medical record-based studies investigating the accuracy and applicability of the SALT and START triage systems in adult and child populations during MCIs and disasters. All types of studies were included. The PRISMA flowchart was used to retain the articles, and the Joanna Briggs Institute critical appraisal tools were used to assess the quality of the reviewed studies.Results: Of 1,450 articles identified in the search, 10 articles were included. It was found that the START triage system had a wide range and inconsistent levels of accuracy (44% to 94.2%) compared to the SALT triage system (70% to 83%). The under-triage error of the START triage system ranged from 2.73% to 20%, which was slightly lower than the SALT triage system (7.6% to 23.3%). The over-triage error of the START triage system (2% to 53%) was slightly higher than the SALT triage system (2% to 22%). However, the time taken to apply START triage system (70 to 72.18 seconds) was faster than for the SALT triage system (78 seconds).Conclusion: The START triage system was simpler and faster than SALT. Conversely, the SALT triage system appeared to be slightly more accurate, more consistent, and had a lower rate of under- and over-triage error than START. It appears that neither the SALT nor the START triage system is superior to the other. Further research is needed to establish the most appropriate disaster and MCI triage system, especially for the Indonesian context.

Picture guided learning - A picture-based clinical skill teaching resource in undergraduate nursing in South Australia

A competent nursing graduate is required to perform psychomotor skills related to clinical procedures, articulate knowledge to support their activities, work in a team with efficient time management skills and have strategies to perform in the increasingly busy clinical environment and with complex patient acuity. Student Evaluation of Teaching data from an undergraduate nursing clinical subject 2014-2018 identified an inconsistency in clinical skill teaching/delivery by educators which needed to be addressed. This study aimed to evaluate the outcome of implementing the Clinical Skill Storybook as an additional teaching resource for students’ clinical skill development. A descriptive analysis approach was applied to summarise quantitative and qualitative subject evaluation data along with Clinical Skill Storybook evaluation questionnaires (2018-2020). Data analysis identified five themes: (1) Clinical Skill Storybook as a Learning Resource, (2) Self-directed learning and peer support, (3) Developing clinical skill competency, (4) Preparation for clinical placement, and (5) Maintaining teaching consistency. It was evident that the Clinical Skill Storybook provided an easy-to-follow visual guide which assisted students’ confidence and competence of skill development. The subject evaluation highlights that students were significantly more satisfied with the teaching resources than in previous years. The implementation of the Clinical Skill Storybook actively improved students’ skill acquisition, confidence, and readiness for placement. The findings indicated that picture-based resources such as the Clinical Skill Storybook are beneficial for nursing students’ clinical skill development. Further involvement with stakeholders such as clinical venues in developing the clinical skill storybook is planned for future exploration.

Medication regimen complexity vs patient acuity for predicting critical care pharmacist interventions

Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Quantifying and predicting critical care pharmacist (CCP) workload has significant ramifications for expanding CCP services that improve patient outcomes. Medication regimen complexity has been proposed as an objective, pharmacist-oriented metric that demonstrates relationships to patient outcomes and pharmacist interventions. The purpose of this evaluation was to compare the relationship of medication regimen complexity versus a traditional patient acuity metric for evaluating pharmacist interventions. Summary This was a post hoc analysis of a previously completed prospective, observational study. Pharmacist interventions were prospectively collected and tabulated at 24 hours, 48 hours, and intensive care unit (ICU) discharge, and the electronic medical record was reviewed to collect patient demographics, medication data, and outcomes. The primary outcome was the relationship between medication regimen complexity–intensive care unit (MRC-ICU) score, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and pharmacist interventions at 24 hours, 48 hours, and ICU discharge. These relationships were determined by Spearman rank-order correlation (rS) and confirmed by calculating the beta coefficient (β) via multiple linear regression adjusting for patient age, gender, and admission type. Data on 100 patients admitted to a mixed medical/surgical ICU were retrospectively evaluated. Both MRC-ICU and APACHE II scores were correlated with ICU interventions at all 3 time points (at 24 hours, rS = 0.370 [P < 0.001] for MRC-ICU score and rS = 0.283 [P = 0.004] for APACHE II score); however, this relationship was not sustained for APACHE II in the adjusted analysis (at 24 hours, β = 0.099 [P = 0.001] for MRC-ICU and β = 0.031 [P = 0.085] for APACHE II score). Conclusion A pharmacist-oriented score had a stronger relationship with pharmacist interventions as compared to patient acuity. As pharmacists have demonstrated value across the continuum of patient care, these findings support that pharmacist-oriented workload predictions require tailored metrics, beyond that of patient acuity.

An Assessment of Pediatric Resident Disaster Preparedness for the Neonatal Intensive Care Unit

Objective: To assess the level of neonatal intensive care unit (NICU) disaster preparedness among pediatric residents. Methods: A mixed-methods study including qualitative interviews and quantitative surveys was used. Interviews guided survey development. Surveys were distributed to residents who rotated through Children’s National NICU. Questions assessed residents’ background in disaster preparedness, disaster protocol knowledge, NICU preparedness, roles during surge and evacuation, and views on training and education. Results: Survey response was 62.5% (n = 80) with 51.3% of invited residents completing it. Pediatric residents (PGY-2 and PGY-3) (n = 41) had low levels of individual disaster preparedness, particularly evacuations (86%). None were aware of specific NICU disaster protocols. Patient acuity, role ambiguity, knowledge, and training deficits were major contributors to unpreparedness. Residents viewed their role as system facilitators (eg, performing duties assigned, recruiting other residents, and clerical work like documentation). Resident training requests included disaster preparedness training every NICU rotation (48%) using multidisciplinary simulations (66%), role definition (56%), and written protocols (50%). Despite their unpreparedness, residents (84%) were willing to respond. Conclusion: Pediatric residents lacked knowledge of NICU disaster response but were willing to respond to disasters. Training should include multi-disciplinary simulations that can be refined iteratively to clarify roles, and residents should be involved in planning and execution.

Toward more accurate documentation in neurosurgical care

OBJECTIVE Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service. METHODS At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a “system-based” progress note template was changed to a “problem-based” progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention. RESULTS The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002). CONCLUSIONS Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.

The Impact of COVID-19 on the Service of Emergency Department

(1) Introduction: the COVID-19 pandemic significantly impacted the number and acuity of emergency departments (ED) patients, specifically those with non-COVID-19-related health problems. However, the exact impact of the COVID-19 pandemic on ED services is the subject of comprehensive debate. (2) Aim: to gain insight into the consequences of the first wave of the COVID-19 pandemic based on non-COVID-19 presentations and patient acuity using the Canadian Triage and Acuity Scale (CTAS). (3) Method: in Phase 1, the ED records of one of the main regional non-COVID-19 hospitals in Saudi Arabia were retrospectively audited from August 2020 to February 2021—after the first wave of COVID-19—then compared to information collected for the same period in previous year. Phase 2 included calculating the waiting time to identify delays and issues that may impact the triage effectiveness. (4) Results: a change across all CTAS levels was observed post the 1st wave of COVID-19 pandemic. Specifically, there was an increase in the number of patients presenting as higher acuity (CTAS 1 and 2) and a decrease in patients presenting as lower acuity (CTAS 4 and 5). Longer waiting times for patients presenting to ED were also reported. Specifically, 83% of patients presenting as higher acuity experienced a delay. (5) Conclusion: further studies are required to investigate association between the 1st wave of COVID-19 and patient presentations and/or acuity or patient demand and ED capacity.

Frequency and severity of prehospital obstetric events encountered by emergency medical services in the United States

Background Prehospital obstetric events encountered by emergency medical services (EMS) can be high-risk patient presentations for which suboptimal care can cause substantial morbidity and mortality. The frequency of prehospital obstetric events is unclear because existing descriptions have reported obstetric and gynecological conditions together, without delineating specific patient presentations. Our objective was to identify the types, frequency, and acuity of prehospital obstetric events treated by EMS personnel in the US. Methods We conducted a cross-sectional analysis of EMS patient care records in the 2018 National EMS Information System dataset (n=22,532,890). We focused on EMS activations (i.e., calls for service) for an emergency scene response for patients aged 12-50 years with evidence of an obstetric event. Type of obstetric event was determined by examining patient symptoms, the treating EMS provider’s impression (i.e., field diagnosis), and procedures performed. High patient acuity was ascertained by EMS documentation of patient status and application of the modified early obstetric warning system (MEOWS) criteria, with concordance assessed using Cohen’s kappa. Descriptive statistics were calculated to describe the primary symptoms, impressions, and frequency of each type of obstetric event among these activations. Results A total of 107,771 (0.6%) of EMS emergency activations were identified as involving an obstetric event. The most common presentation was early or threatened labor (15%). Abdominal complaints, including pain and other digestive/abdomen signs and symptoms, was the most common primary symptom (29%) and primary impression (18%). We identified 3,489 (3%) out-of-hospital deliveries, of which 1,504 were preterm. Overall, EMS providers documented 34% of patients as being high acuity, similar to the MEOWS criteria (35%); however, there were high rates of missing data for EMS documented acuity (19%), poor concordance between the two measures (Cohen’s kappa=0.12), and acuity differences for specific conditions (e.g., high acuity of non-cephalic presentations, 77% in EMS documentation versus 53% identified by MEOWS). Conclusion Prehospital obstetric events were infrequently encountered by EMS personnel, and about one-third were high acuity. Additional work to understand the epidemiology and clinical care of these patients by EMS would help to optimize prehospital care and outcomes.

A prospective multicentre observational study to quantify nocturnal light exposure in intensive care

Background Disrupted circadian rhythms can have a major effect on human physiology and healthcare outcomes, with proven increases in ICU morbidity, mortality and length of stay. Methods We performed a multicentre observational study to study the nocturnal lux exposure of patients in 3 intensive care units. Results The median light intensity recorded was 1 lux over the 6-hour recording period; however, this is deceptive as it hides short periods of high lux. When looked at in shorter time segments of 30 minutes, there were significant periods of lux higher than a crude median, especially in higher acuity patients. There was a positive correlation between acuity (as estimated by SOFA score) and maximum lux (R = 0.479, p = .0001), median lux (R = 0.35, p = .006) and cumulative lux (R = 0.55, p = .000001). There was no relationship between neighbouring patient acuity and lux. Conclusions Clinicians should practice vigilance at night to provide optimal environmental conditions for patients to minimise potential harm.