Emergencies Clinical Trial
Official title:
Optimizing Triage and Hospitalisation In Adult General Medical Emergency Patients: the TRIAGE Study
Patients presenting to the emergency department (ED) currently face inacceptable delays in initial treatment, and long and costly hospital stays due to suboptimal initial triage. Accurate ED triage should focus not only on initial treatment priority, but also on prediction of medical risk and nursing needs to improve site of care decision and to simplify early discharge management. Herein, we propose a large prospective cohort study to optimize initial patient triage for (a) better determination of initial treatment priority, (b) overall risk and need for inhospital treatment and (c) early assessment of post-acute nursing needs.
Background: Patients presenting to the emergency department (ED) currently face inacceptable
delays in initial treatment, and long and costly hospital stays due to suboptimal initial
triage. Accurate ED triage should focus not only on initial treatment priority, but also on
prediction of medical risk and nursing needs to improve site of care decision and to
simplify early discharge management. Different triage scores have been proposed, such as the
Manchester Triage Score (MTS). Yet, these scores focus only on treatment priority, have
suboptimal performance and lack validation in the Swiss Health care system. Because the MTS
will be introduced into clinical routine of the Kantonsspital Aarau, we propose a large
prospective cohort study to optimize initial patient triage. Specifically, the aim of this
trial is to derive a three part triage algorithm to better predict (a) treatment priority;
(b) medical risk and thus need for inhospital treatment; (c) post-acute care needs of
patient's at the most proximal time point of ED admission.
Methods / Design: Prospective, observational, cohort study. We will include all consecutive
medical patients seeking ED care into this observational registry. There will be no
exclusions except for non-adult and non-medical patients. Vital signs will be recorded and
left over blood samples will be stored for later batch analysis of blood markers. Upon ED
discharge, the post-acute care score will be recorded. Attending ED physicians will
adjudicate triage priority based on all available results at the time of discharge. Patients
will be reassessed daily during the hospital course for medical and nursing stability. To
assess outcomes, data from electronic medical records will be used and all patient will be
contacted 30 days after hospital admission to assess vital status, rehospitalisation and
quality of life measures.
We aim to include between 5000 and 7000 patients over one year of recruitment to derive the
three part triage algorithm. The respective main endpoints were defined as (a) initial
triage priority (high vs. low priority) adjudicated by the attending ED physician at ED
discharge, (b) adverse 30 day outcome (death or intensive care unit admission) within 30
days following ED admission to assess patients risk and thus need for inhospital treatment
and (c) care needs after hospital discharge, defined as transfer of patients to a post-acute
care institution, for early recognition and planning of post-acute care needs. Other
outcomes are time to first physician contact, time to initiation of adequate medical
therapy, length of hospital stay, patient's satisfaction with care and overall hospital
costs.
Discussion: Using a reliable initial triage system for estimating initial treatment
priority, need for inhospital treatment and post-acute care needs is an innovative and
persuasive approach for a more targeted management of medical patients in the ED. Our group
has proven feasibility with a track record of several completed and ongoing trials. The
proposed interdisciplinary project has unprecedented potential to improve initial triage
decisions and optimize resource allocation to the sickest patients from admission to
discharge. The algorithms derived in this study will be compared in a later randomized
controlled trial against a usual care control group in terms of resource use, length of
hospital stay, overall costs and patient's outcomes in terms of mortality,
rehospitalisation, quality of life and satisfaction with care.
;
Observational Model: Cohort, Time Perspective: Prospective
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