The nuclear accident at Chernobyl accounted for an acute radiation syndrome in 237 persons on the site. Triage was the initial problem and was carried out according to clinical and biological criteria; evaluating the doses received was based on these criteria. Thirty one persons died and only 1 survived a dose higher than 6 Gy. Skin radiation burns which were due to inadequate decontamination, greatly worsened prognosis. The results of 13 bone marrow transplantations were disappointing, with only 2 survivors. Some time after the accident, these severely irradiated patients are mainly suffering from psychosomatic disorders, in the USSR, some areas have been significantly contaminated and several measures were taken to mitigate the impact on population: evacuating 135,000 persons, distributing prophylactic iodine, establishing standards and controls on foodstuff. Radiation phobia syndrome which developed in many persons, is the only sanitary effect noticed up to now. Finally, in Europe, there was only an increase in induced abortions and this was totally unwarranted. If we consider the risk of radiation induced cancer, an effect might not be demonstrated.
Assessment and treatment of the acutely ill patient have improved by introducing systematic assessment and accelerated protocols for specific patient groups. Triage systems are widely used, but few studies have investigated the ability of the triage systems in predicting outcome in the unselected acute population. The aim of this study was to quantify the association between the main component of the Hillerød Acute Process Triage (HAPT) system and the outcome measures; Admission to Intensive Care Unit (ICU) and in-hospital mortality, and to identify the vital signs, scored and categorized at admission, that are most strongly associated with the outcome measures.
The HAPT system is a minor modification of the Swedish Adaptive Process Triage (ADAPT) and ranks patients into five level colour-coded triage categories. Each patient is assigned a triage category for the two main descriptors; vital signs, T(vitals), and presenting complaint, T(complaint). The more urgent of the two determines the final triage category, T(final). We retrieved 6279 unique adult patients admitted through the Emergency Department (ED) from the Acute Admission Database. We performed regression analysis to evaluate the association between the covariates and the outcome measures.
The covariates, T(vitals), T(complaint) and T(final) were all significantly associated with ICU admission and in-hospital mortality, the odds increasing with the urgency of the triage category. The vital signs best predicting in-hospital mortality were saturation of peripheral oxygen (SpO(2)), respiratory rate (RR), systolic blood pressure (BP) and Glasgow Coma Score (GCS). Not only the type, but also the number of abnormal vital signs, were predictive for adverse outcome. The presenting complaints associated with the highest in-hospital mortality were 'dyspnoea' (11.5%) and 'altered level of consciousness' (10.6%). More than half of the patients had a T(complaint) more urgent than T(vitals), the opposite was true in just 6% of the patients.
The HAPT system is valid in terms of predicting in-hospital mortality and ICU admission in the adult acute population. Abnormal vital signs are strongly associated with adverse outcome, while including the presenting complaint in the triage model may result in over-triage.
In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers' assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.
In a pandemic situation, resources in intensive care units may be stretched to the breaking point, and critical care triage may become necessary. In such a situation, I argue that a patient's combined vulnerability to illness and social disadvantage should be a justification for giving that patient some priority for critical care. In this article I present an example of a critical care triage protocol that recognizes the moral relevance of vulnerability to illness and social disadvantage, from the Canadian province of Newfoundland and Labrador.
In the emergency department (ED) Registered Nurses (RNs) often perform triage, i.e. the sorting and prioritizing of patients. The allocation of acuity ratings is commonly based on a triage scale. To date, three reliable 5-level triage scales exist, of which the Canadian Triage and Acuity Scale (CTAS) is one. In Sweden, few studies on ED triage have been conducted and the organization of triage has been found to vary considerably with no common triage scale. The aim of this study was to investigate the accuracy and concordance of emergency nurses acuity ratings of patient scenarios in the ED setting. Totally, 423 RNs from 48 (62%) Swedish EDs each triaged 18 patient scenarios using the CTAS. Of the 7,550 triage ratings, 57.6% were triaged in concordance with the expected outcome and no scenario was triaged into the same triage level by all RNs. Inter-rater agreement for all RNs was kappa = 0.46 (unweighted) and kappa = 0.71 (weighted). The fact that the kappa-values are only moderate to good and the low concordance between the RNs call for further studies, especially from a patient safety perspective.
Knowledge of a patient's perception of her medical needs and urgency may make it possible for emergency nurses to communicate the triage decision and make the patient understand the assessment and triage category. The aim of this study was to compare the patients' own assessments of their acuity to the triage nurse's assessment, as well as describe patient satisfaction and levels of anxiety.
A prospective, cross-sectional survey design was used. The sample consisted of 72 patients, 54% of whom were women. Median age was 55.9 years.
Agreement between the nurse and patient regarding acuity and triage category was rare. This may have consequences for patient safety, because patients may seek care at an inappropriate level, in both directions. Communication between the nurse and patient during the waiting time in the emergency department is very important, both for patient satisfaction and reduction of anxiety levels.
Helping the patient understand the severity of his medical condition and providing information about the triage category and its implications for care in the emergency department should be a focus in communication between the triage nurse and patient. It may well be that the patient's anxiety level is reduced and satisfaction increased if the triage code is known and understood by the patient.
BACKGROUND: Diagnosis of acute abdominal pain in older persons is a challenge, with the age-related increase in concurrent diseases. In most western countries the number of elderly people is constantly rising, which means that an increasing proportion of patients admitted for abdominal pain at the emergency department are elderly. OBJECTIVE: To characterize differences in clinical presentation and diagnostic accuracy between younger and more elderly patients with acute abdominal pain. METHODS: Patients admitted to Mora Hospital with abdominal pain of up to seven days' duration were registered according to a detailed schedule. From 1st February 1997 to 1st June 2000, 557 patients aged 65-79 years and 274 patients aged > or = 80 years were registered. Patients aged 20-64 years (n = 1,458) served as a control group. RESULTS: A specific diagnosis, i.e. other than 'nonspecific abdominal pain', was established in 76 and 78% of the patients aged 65-79 and > or = 80 years respectively, and in 64% of those aged 20-64 (p or = 65 years. Rebound tenderness (p or = 65 years, C-reactive protein did not differ between patients operated on and those not, contrary to the finding in patients
Acute chest pain is a frequently occurring symptom in patients with medical emergencies and imposes potentially life threatening situations outside hospitals. Little is known about the epidemiology of patients with acute chest pain in a primary care setting in Norway, and we aimed to obtain more representative data on such patients using data from emergency medical communication centres (EMCCs).
Data were collected prospectively during three months in 2007 from three EMCCs, covering 816 000 inhabitants. The EMCCs gathered information on every situation that was triaged as a red response (defined as an "acute" response, with the highest priority), according to the Norwegian Index of Medical Emergencies. Records from ambulances and primary care doctors were subsequently collected. International Classification of Primary Care - 2 symptom codes and The National Committee on Aeronautics (NACA) System scores were assigned retrospectively. Only chest pain patients were included in the study.
5 180 patients were involved in red response situations, of which 21% had chest pain. Estimated rate was 5.4 chest pain cases per 1000 inhabitants per year. NACA-scores indicated that 26% of the patients were in a life-threatening medical situation. Median prehospital response time was 13 minutes; an ambulance reached the patient in less than 10 minutes in 30% of the cases. Seventy-six per cent of the patients with chest pain were admitted to a hospital for further investigation, 14% received final treatment at a casualty clinic, while 10% had no further investigation by a doctor ("left at the scene").
The majority of patients with acute chest pain were admitted to a hospital for further investigation, but only a quarter of the patients were assessed prehospitally to have a severe illness. This sheds light on the challenges for the EMCCs in deciding the appropriate level of response in patients with acute chest pain. Overtriage is to some extent both expected and desirable to intercept all patients in need of immediate help, but it is also well known that overtriage is resource demanding. Further research is needed to elucidate the challenges in the diagnosis and management of chest pain outside hospitals.
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