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‘Eyeballing’ patients best predicts those most at risk of death in A&E

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A simple clinical assessment by experienced nurses is “superior” to systematic triage in prediction of mortality in the emergency department, according to Danish researchers.

They said “simply eyeballing” a patient may be more effective than using a formal structured assessment to prioritise those who are the sickest and therefore most in need of urgent care.

“We need new initiatives in order to evaluate triage and optimise initial patient stratification”

Study authors

A basic clinical assessment seems to better predict those most at risk of death, even in the hands of healthcare professionals with relatively little emergency care experience, their findings indicated.

The researchers compared the triage decisions made by experienced nurses and phlebotomists and medical students to prioritise 6,383 patients at one A&E department over a period of three months.

The nurses used an established algorithm known as the Danish Emergency Process Triage, or DEPT for short, to decide which patients were the sickest. In contrast, the phlebotomists and medical students made their decisions by simply looking at each patient.

Both approaches categorised need from blue – minor injuries or conditions – up to red – the most urgent, noted the study authors in the in the Emergency Medicine Journal. In addition, both were compared for their ability to assess the likelihood of death within 30 days.

The researchers also looked at any associations between triage method and death within 48 hours, and how often both methods reached the same decisions for the same patients.

The study authors concluded that it was rare for both methods to arrive at the same decisions for the same patients. However, when the ability to assess the likelihood of death within 48 hours and 30 days was compared, simply eyeballing the patient was more accurate than structured triage.

“We have adopted complex systems that take up the time of highly qualified nurses [and] potentially delay care”

Ellen Weber

In a linked editorial, Dr Ellen Weber, from the University of California, San Francisco, cautioned that the study was carried out in only one emergency care department. But she added that the study “should make us rethink our current process and the evidence behind it”.

Whichever form of structured triage is used, it forces experienced nurses to follow an algorithm rather than use their considerable experience and clinical judgment, noted Dr Weber.

She highlighted that structured triage does not distinguish those with troubling conditions that may become much more serious from those who may need some fluids and who can then be discharged.

“Like a saggy bed, too many patients fall to the centre,” she said. “In short, we have adopted complex systems that take up the time of highly qualified nurses [and] potentially delay care.”

She added: “We need to ask ourselves in these days of rising medical costs and rising patient numbers if we can afford to continue doing it the way we have always done it if we can do it just as well or better a simpler way.”

 

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