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Background: There is difficulty in identifying low-risk patients with acute coronary syndrome in the emergency department (ED). Objectives: The aim of this study was to compare mistriage between the Emergency Severity Index (ESI) plus the cardiac troponin I rapid test (cTnI) and ESI among patients with chest pain. Methods: A randomized clinical trial was conducted from January to April 2019. One hundred patients with low-risk chest pain were randomly allocated to the ESI + cTnI and ESI groups. Triage levels, used resources, and mistriage rate were compared between both groups among patients discharged from the ED and admitted to the cardiac unit (CU) or coronary care unit (CCU). Results: Our samples included 100 patients (age: 52.9 ± 13.92 years; 51% female) who were equally assigned to the ESI + cTnI and ESI groups. Overtriage rate was 6% and 88% for the ESI + cTnI and ESI groups, respectively. The triage level between the ESI + cTnI and ESI groups was significantly different among patients who were discharged from the ED (3.92 vs. 3.00). Conclusions: The ESI + cTnI score seems to be more valid than the ESI scale to triage patients with low-risk chest pain. It is recommended to add cTnI to the ESI for the triage of patients with low-risk chest pain in the ED.

Background: The COVID-19 pandemic has affected in countless ways conventional teaching methods and led to a sudden shift in teaching methods toward distance teaching. Objectives: Hence, this study aimed to evaluate the impact of webinar training compared to conventional training on the risk perception of COVID-19 in emergency medical technicians (EMTs). Methods: This quasi-experimental study selected 70 EMTs employed at the emergency medical services (EMS) affiliated to the Birjand University of Medical Sciences via convenience sampling. The participants were randomly designed into a webinar training group (n = 35) and a conventional training group (n = 35). The risk perception of COVID-19 was evaluated using a researcher-made questionnaire (40 questions) at baseline and immediately after teaching. The study data were analyzed using SPSS V.26, descriptive (frequency, mean, and standard deviation), and inferential statistics (t-test, ANOVA, and chi-square test). Results: All the 70 participants completed the questionnaire. The mean score of COVID-19 risk perception in both groups improved following teaching (P < 0.001). However, there was no statistically significant difference between the groups immediately after training (P = 0.76). Also, independent t-test and one-way ANOVA showed that the mean score of COVID-19 risk perception had no significant difference with the participants’ demographic data in the two groups (P > 0.05). Conclusions: The webinar in the form of distance teaching can be as effective as conventional teaching in improving COVID-19 risk perception. Therefore, a webinar format can be used during pandemics of infectious diseases when conventional training is impossible.

Introduction: It is unclear whether the Emergency Severity Index (ESI) can identify high-risk patients with Chronic Obstructive Pulmonary Disease (COPD). This study aims to compare the mistriage rates of the ESI plus the Peak Expiratory Flowmeter (PEF) approach and ESI approach among dyspneic patients with COPD. Methods: This study was a randomized clinical trial conducted between July and October 2018. We randomly assigned COPD patients with dyspnea to the ESI + PEF or ESI groups. Triage levels, disposition rates, number of resources used, and time to first physician contact were compared in patients admitted to the Intensive Care Unit (ICU), the Pulmonary Care Unit (PU), or discharged from the ED. Reliability of the ESI was evaluated by using the interobserver agreement (Kappa). Results: Seventy COPD patients were equally assigned to the ESI + PEF and ESI groups. The under-triage rates were 11.42% and 0%, the over-triage rates were 31.42% and 2.85% in the ESI and ESI + PEF groups, respectively. The triage levels of the patients admitted to the ICU (2 vs. 3), the PU (2 vs. 4), or discharged from the ED (3 vs. 2) were significantly different between the ESI + PEF and ESI groups. Conclusions: Addition of PEF to the ESI provides a more accurate method for triaging COPD patients compared to ESI alone. We recommend using PEF for the triage of COPD patients in the ED. Keywords: Dyspnea, Chronic obstructive pulmonary disease, Triage, Emergency severity index, Emergency

Few studies have focused on the agreement between emergency physicians and nurses in the triage of emergency patients. The aim of this meta-analytic review was to examine the level of inter-rater reliability between physicians and nurses on the use of triage scales. Detailed searches of a number of electronic databases were performed up to 1 September 2018. Studies that reported sample sizes, reliability coefficients, and a comprehensive description of the assessment of the inter-rater reliability of physicians and nurses were included. The articles were selected according to the Guidelines for Reporting Reliability and Agreement Studies (GRRAS). Two reviewers involved in the study selection, quality assessment, and data extraction performed the review process. The effect size was estimated by z-transformation of reliability coefficients. Data were pooled with random-effects models, and a meta-regression was performed based on the method of moments estimator. Twelve studies were included. The pooled coefficient for the level of agreement between physicians and nurses was substantial, with a value of 0.756 (confidence interval [CI] 95%: 0.659–0.828). The level of agreement was higher for the weighted kappa (κ), live cases, and pediatric cases than the unweighted κ, paper-case scenarios, and adult cases, respectively. The level of agreement between physicians and nurses on triage scales has improved over time (B = 0.011; P

Background and aim Prompt identification of traumatic brain injury (TBI) is vital for patients in critical condition; however, it is not clear which acuity scoring tools are associated with short-term mortality. The aim of this study was to determine the accuracy of acuity scoring tools and 24-h mortality among TBI patients in both prehospital and hospital settings. Methods This study was an observational, prospective cohort, in which patients with TBI were followed from the accident scene to the hospital. Vital signs and acuity scoring tools, including the Revised Trauma Score (RTS), Injury Severity Score (ISS), National Early Warning Score (NEWS), Shock Index (SI), Modified Shock Index (MSI) and Trauma and Injury Severity Score (TRISS), were collected both on the scene as well as at the hospital. A logistic regression was performed to ascertain the effects of clinical parameters on the likelihood of survival of patients with TBI regarding 24-h mortality. Results: A total of 185 patients were included in this study. The mortality rate was 14% (25/185). The logistic regression model was statistically significant at χ 2 =60.8, p=0.001. A hierarchical forward stepwise logistic regression analysis showed that age, hospital RTS and prehospital NEWS significantly improved mortality predictions. The model explained the 51.2% variance in survival of patients with TBI. Conclusions The NEWS and the RTS may be used to triage TBI patients for prehospital and hospital emergency care, respectively. Therefore, because traditional vital signs criteria may be of limited use for the triage of TBI patients, it is recommended that acuity scoring tools be used in such cases.

Objective : Although the Manchester Triage System (MTS) was first developed two decades ago, the reliability of the MTS has not been questioned through comparison with a moderating variable; therefore, the aim of this study is to determine the extent of the reliability of MTS using a meta-analytic review. Method : Electronic databases were searched up to March 1st, 2014. Studies were only included if they had reported sample sizes, reliability coefficients, and adequate description of the Emergency Severity Index (ESI) reliability assessment. The Guidelines for Reporting Reliability and Agreement Studies (GRRAS) was used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models, and meta-regression was performed based on the method of moments estimator. Results : Seven studies were included. The pooled coefficient for the MTS was substantial at 0.751 (CI 95%: 0.677-0.810); the incidence of mistriage is greater than fifty percent. Agreement is higher for the latest version of MTS (for adults) among nurse-experts and in countries in closer proximity to the country of MTS origin (the UK, in Manchester) than for the oldest (pediatric) version, nurse-nurse raters, and countries at a greater distance from the UK. Conclusion : The MTS showed an acceptable level of overall reliability in the emergency department, but more development is required to attain almost perfect agreement. This article is protected by copyright. All rights reserved

BACKGROUND: It is not clear whether Emergency Severity Index (ESI) is valid to triage heart failure (HF) patients and if HF patients benefit more from a customized triage scale or not. The aim of study is to compare the effect of Heart Failure Triage Scale (HFTS) and ESI on mistriage among patients with HF who present to the emergency department (ED). METHODS: A randomized clinical trial was conducted from April to June 2017. HF patients with dyspnea were randomly assigned to HFTS or ESI groups. Triage level, used resources and time to electrocardiogram (ECG) were compared between both groups among HF patients who were admitted to coronary care unit (CCU), cardiac unit (CU) and discharged patients from the ED. Content validity was examined using Kappa designating agreement on relevance (K*). Reliability of both scale was evaluated using inter-observer agreement (Kappa). RESULTS: Seventy-three and 74 HF patients were assigned to HFTS and ESI groups respectively. Time to ECG in HFTS group was significantly shorter than that of ESI group (2.05 vs. 16.82 minutes). Triage level between HFTS and ESI groups was significantly different among patients admitted to CCU (1.0 vs. 2.8), cardiac unit (2.26 vs. 3.06) and discharged patients from the ED (3.53 vs. 2.86). Used resources in HFTS group was significantly different among triage levels (H=25.89; df=3; P

Aim: Because emergency medicine is extremely demanding and challenging for emergency medical personnel (EMP), it is important that the personality traits of EMP be understood. Few studies have addressed the personality traits that EMP should possess. The aim of this study was to systematically review the personality traits of EMP to establish a profile that can help identify individuals whose personalities are suited to prehospital emergency occupations.Materials and Methods:Electronic databases, including MEDLINE, SCOPUS, CINAHL, and PsychINFO, with information accumulated from their conception to March 2015, were searched using the terms “personality,” “trait,” “rescue,” “emergency,” “medical,” “services,” “personnel,” “paramedic,” and “technician.” The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was followed in this review. Data extraction was performed by two authors who independently reviewed each article.Results: Of 398 articles found, 27 were eligible for review. A total of 9,721 paramedics had participated in the selected studies. Nearly half of the studies were performed in the USA and Australia. The paramedics scored high in conscientiousness, sensation seeking, resiliency, and empathy but low in extroversion, neuroticism, and agreeableness.Conclusion:While high conscientiousness and low neuroticism could be assumed to be protective factors against post-traumatic stress disorder among EMP, certain personality traits, such as conscientiousness, put them at risk of burnout. The personality traits of paramedics need to be further investigated in terms of role model traits and performance indicators related to personality traits.

Mis-triage including undertriage and overtriage is associated with morbidity and mortality. It is not clear what the extent of mis-triage rates among traumatic patients is. The aim of this study is to determine of mis-triage (undertriage and overtriage) in traumatic patients. This study was a systematic review about mis-triage rate among trauma patients. The following electronic databases were searched (Web of Knowledge, Scoups, PubMed, Cochrane library) from conception through February 1, 2018. Search terms included trauma, undertriage, and over-triage. Inclusion criteria were studies which report overtriage or undertriage rate in regard to triage of trauma patients; patients older than 18 years old, English-written papers. Irrelevant papers as well as conference abstract, letter, editorial, thesis and studies on special population were excluded. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Checklist was used to examine review process. Twenty-one papers were included in this study. Sample size ranged from 244 to 550683 trauma patients. Fourteen studies originated from USA. Definition of mis-triage was summarized into four categories: ISS used to define undertriage error, formula for mis-triage (1—sensitivity), need for life-saving emergency intervention and patients triaged to a non-trauma center. Undertriage rate ranged from 1 to 71.9% and overtriage rate ranged from 19 to 79%. The standardization of mis-triage definitions is vital to estimate true rate of mis-triage among different studies and clarify the role of triage scales. The trauma triage scales need to be further developed to provide more valid and reliable results.

Summary Role modeling is a powerful form of learning and an integral part of medical education. Although role modeling has a longstanding history, it has not received enough attention in medical education. The aim of this study was to present a comprehensive review of the literature to describe dimensions of role modeling in medical education. Review of the literature was undertaken using the international databases with the following search terms or their combinations: “role modeling”, “observational learning” and “medical education” up to September 2014. Relevant articles were retrieved. A total of 39 articles were included in this review. The results showed that clinical excellence, humanistic personality and excellence in teaching composed three essential elements of role modeling. Basic outcomes of role modeling in medical education are humanism and professionalism. In conclusion, role modeling as an outstanding educational approach has been recommended for enhancing humanism and professionalism in medical education.

Relationship was introduced as an essential element of care since the beginning of theorizing in nursing. However therapeutic relationship has been conceptualized by different theorists, an integrated approach is not provided. This study aimed to perform a systematic review to explain the therapeutic relationship in the contemporary nursing practice. Electronic databases were searched from conception to October 2015 using keywords including therapeutic, relationship, communication, nurse, and patient. We used PRISMA guideline to report data. Original studies relevant to the therapeutic relationship were included. Exclusion criteria include abstracts that were irrelevant to the concept of study, grey literature and review and commentary articles. Disagreements between researchers were solved by consensus. Twenty studies were finally included into the review process. Data were organized into three categories including composition of therapeutic relationship, context of therapeutic relationship and confirmation of therapeutic relationship. The therapeutic relationship is composed of significant knowing and meaningful connecting with patients. Few studies confirmed applicability of therapeutic relationship in nursing practice. Therapeutic relationship ensures humanity to be preserved during nursing care and patients’ hospital stay; it faces with strong barriers such as nursing shortage. The nursing shortage seriously threatens the heart of nursing. Therapeutic relationship needs to be investigated further in order to be supported by evidence-based nursing in order to confirm the applicability of relationshipbased caring theories.

Dear Editor,The South African Triage Scale (SATS) consists of the Triage Early Warning Score (TEWS) and the discriminator list. A patient’s vital signs, mobility status, trauma history and level of...

Dear Editor , I have read the outstanding publication of Abolfotouh et al 1 entitled ‘Predictors of patient satisfaction in an emergency care center in central Saudi Arabia: a prospective study’ published in this journal. The authors reported that lower satisfaction was associated with male gender, long waiting time and low perceived health status. Several features of Abolfotouh et al 's study merit attention, particularly those of sociocultural values, as few studies have investigated sociocultural predictors of …

Background: Opium addiction is a major issue amongst burn-patients in Iran. A few studies have addressed interactions between burn and addiction. Objectives: The aim of the present study was to compare mortality and morbidity between addicted and non-addicted patients with burn injuries. Patients and Methods: This research was a prospective paired matched-cohort study that was conducted from October 2012 to July 2013 at the Burn Unit of Mashhad University of Medical Sciences. One hundred and fifty-two burn patients (64% of 237) were matched in pairs based on age, gender, total body surface area and burn thickness. Mortality and morbidity was compared between the two groups using the McNemar test, the conditional logistic regression model and the Kaplan-Meier method. Results: Fourteen (9.2%) patients died at the Burn unit. McNemar test found statistically significant differences in mortality between the two groups. Survival analysis using the Kaplan-Meier method revealed that the estimated mean survival time was 59.02 (CI 95%: 41.83 - 76.21) for non-addicted patients and 118.78 (CI 95%: 106.52 - 131.04) for addicted patients. The odds ratio for mortality was 0.524 (CI 95%: 0.167 - 1.64) times greater for addicted patients compared with non-addicted patients. Conclusions: Addiction in burn patients could be considered as a factor against mortality that deserves further studies. Besides, addicted patients didn`t show significantly higher morbidity than non-addicted patients.

Background. Triage nurses play a pivotal role in the emergency department. However some researchers have attempted to expand triage nurse’s role; remarkable discrepancies exist among scholarly communities. The aim was to develop a role description of triage nurse relying on the experts.Methods. A modified Delphi study consisting of 3 rounds was performed from March to October 2014. In the first round, an extensive review of the literature was conducted. Expert selection was conducted through a purposeful sample of 38 emergency medicine experts.Results. Response rates for the second and third rounds were 37% and 58%. Average age of panelists was (38.42±5.94) years. Thirty-nine out of 54 items reached to the final round. Prioritizing had the higher agreement rate and least agreement on triage related interventions.Conclusion. Triage nursing as a relatively new role for nurses needs significant development to be practiced. Comprehensive educational programs and developmental research are required to support diagnostic and therapeutic interventions in triage practice by nurses.

The study highlights the prognostic role of patient’s vital signs at presentation to the emergency department (ED): The predictive role of vital signs in ED triage has been controversially discussed probably due to a paucity of data on the value of vital signs in ED at presentation. However, the authors did not find a suitable way to adjust for the inherent influence of triage decision and medical treatment on mortality. We have discussed that ambiguity concerning the assessment of vital signs criteria in RETTS-A Red priority may threaten any association between patient acuity and fatal outcome.

Background: Triage in the interactive atmosphere of the emergency department (ED) has been described as complex and challenging. Nonemergent ED visits have been accompanied by ethical and legal conflicts. Objectives: The aim of this study was to gain an understanding of ED nurses’ practice regarding triage of nonemergent patients. Patients and Methods: Focused micro-ethnography based on Spradley’s developmental research sequence (DRS) was used. This study was conducted in an emergency department. Data was collected through complete participant observations along with formal and informal interviews, and then analyzed using DRS. Results: Nine key informants were interviewed formally. Four main categories emerged from the nurses’ culture: nonemergent patient as an uninvited guest, nonemergent patient as an elephant in a dark room, nonemergent patient as an aggressive client, and being nonemergency unless at risk of death. Conclusions: Providing care in the emergency department is significantly affected by nonemergent patients, as the emergency department is a place for critically ill patients thus awareness training program is recommended.

Objective.The aim of this study was to present a comprehensive review of the literatures describing barriers and facilitators of patient education (PE) perceived by Iranian nurses in order to explain clinical applicability of patient education. Methods. Review of the literature was undertaken using the international databases including PubMed/Medline, Scopus, ScienceDirect, as well as Google Scholar. Also, Persian electronic databases such as Magiran, SID and IranMedex were searched. Electronic databases were searched up from conception to September 2014 using search terms: "patient education", " patients education", "patient teaching", "patient training", "nurse", " nurses", " nursing", " and "Iran". Only studies were included that were related to barriers and facilitators of PE among Iranian nurses. Results. Twenty-seven studies were included. The main influential barriers were categorized into three major areas: 1) Nurse-related factors: nursing shortage 2) Administration-related factors: unsupportive organizational culture, and 3) Patient-related factors: low compliance. The most perceived facilitators were recognized as "increasing, selecting and training special nurses for providing PE" and "providing PE courses for nurses and appropriate facilities for PE". Conclusion. Iranian nurses encounter barriers in PE, and the most frequently encountered barriers were related to administration factors. These findings have implications for administrators and managers in health settings. In order to promote PE among nurses, administrators should create a supportive environment and use effective strategies to smooth the progress of PE by nurses in their practice in order to ensure optimal outcomes for patients.

Dear Editor, With great interest we have read the publication in the Emergency Medicine Journal from Kuriyama et al entitled ‘Validity of the Japan Acuity and Triage Scale (JTAS) in adults: a cohort study’.1 We bring your attention to a few points …

It is very common to examine reliability of triage scales using (weighted) kappa statistics. The point is that weighted kappa has grossly underestimated disagreements by one category and put more emphasis on extreme category disagreements; therefore, low prevalence of critically-ill and non-urgent patients has excluded the effect of extreme categories disagreement from calculated kappa coefficient and also contributed to significant overestimation. As a result, weighted kappa coefficient as an estimate of scale reliability is overestimated by the anchoring effect.

Background: The emergency medical service is designed to recognize and transfer critically ill patients. Evidence-based practice has rarely been emphasized in the emergency medical service field, especially in the dispatch center. Aims: To identify the effect of the Cincinnati Prehospital Stroke Scale (CPSS) on telephone triage of stroke patients by telephone triage nurses at the emergency medical dispatch center and to compare CPSS with the National Guidelines for Telephone Triage Tool (NGTT). Methods: A quasi-empirical study was conducted from June 2013 to June 2014. The setting of the study was the Mashhad dispatch center of the EMS. Two hundred and forty-six patients were randomly allocated to the CPSS intervention group (n = 121) and the NGTT control group (n = 125). True triage, triage error and odds ratio were statistically reported. Results: The mean age of the patients was 70.9 ± 12.7 years. Of all the cases, 77.7 and 65.6% of patients in the intervention and the control groups, respectively, were accurately triaged. Under-triage cases were 10.7 and 13.6% of the patients in the intervention and the control groups. Odds ratio was 1.14 (95% confidence interval 0.62–2.07) for the CPSS compared with the NGTT. Conclusion: CPSS is more efficient for use by telephone triage nurses in identifying stroke. The use of CPSS assists nurses by reducing the triage error and supports the evidence-based care. It needs to be developed to cover signs and symptoms of posterior-circulation stroke patients.

Introduction: Hospital triage scale in emergency departments needs to be valid and reliable. Lack of sufficient data exists on triage scale rigor in emergency departments of Iran. This study aimed to determine the impact of the emergency severity index (ESI) triage scale in the emergency department. Materials and Methods: A single-center study was conducted. Proportion of triage categories allocated to high-risk patients admitted to high-acuity departments was examined in observational period in June 2012 and May 2013. True triage score was reported based on patients` paper- based scenario questionnaire. Interrater reliability was assessed using unweighted kappa. Concordance among experts, nurses and physicians was examined. The Chi-square test and Kappa statistics was used for statistical analysis. Results: Triage decisions regarding high-risk patients before and after implementation period are independent from each other (χ2 = 22.254; df=1; p

The study published in the April 2016 issue of Asian Biomedicine recruited 2 different sets of observers to perform triage assessments. We know that each observation is subjected to an error. The error has 2 varieties including interobserver variation and intraobserver variation. So effort must be devoted to reduce these errors. The methodology reported may suffer from both intraobserver and interobserver error substantially.

Background: Although the Canadian Triage and Acuity Scale (CTAS) have been developed since two decades ago, the reliability of the CTAS has not been questioned comparing to moderating variable. Aims: The study was to provide a meta-analytic review of the reliability of the CTAS in order to reveal to what extent the CTAS is reliable. Materials and Methods: Electronic databases were searched to March 2014. Only studies were included that had reported samples size, reliability coefficients, adequate description of the CTAS reliability assessment. The guidelines for reporting reliability and agreement studies (GRRAS) were used. Two reviewers independently examined abstracts and extracted data. The effect size was obtained by the z-transformation of reliability coefficients. Data were pooled with random-effects models and meta-regression was done based on method of moments estimator. Results: Fourteen studies were included. Pooled coefficient for the CTAS was substantial 0.672 (CI 95%: 0.599-0.735). Mistriage is less than 50%. Agreement upon the adult version, among nurse-physician and near countries is higher than pediatrics version, other raters and farther countries, respectively. Conclusion: The CTAS showed acceptable level of overall reliability in the emergency department but need more development to reach almost perfect agreement.