To analyze the unique factors involved in providing medical support for a long-distance, cross-border, cycling event, and to describe patient presentations and event characteristics for the British Columbia (BC) Ride to Conquer Cancer from 2010 through 2012.

This study was a 3-year, descriptive case series report. Medical encounters were documented, prospectively, from 2010-2012 using an online registry. Data for event-related variables also were reported.

Providing medical support for participants during the 2-day ride was complicated by communication challenges, weather conditions, and cross-border issues. The total number of participants for the ride increased from 2,252 in 2010 to 2,879 in 2011, and 3,011 in 2012. Patient presentation rates (PPRs) of 125.66, 155.26, and 198.93 (per 1,000 participants) were documented from 2010 through 2012. Over the course of three years, and not included in the PPR, an additional 3,840 encounters for “self-treatment” were documented.

The Ride to Conquer Cancer Series has shown that medical coverage at multi-day, cross-national cycling events must be planned carefully to face a unique set of circumstances, including legislative issues, long-distance communication capabilities, and highly mobile participants. This combination of factors leads to potentially higher PPRs than have been reported for noncycling events. This study also illuminates the additional workload “self-treatment” visits place on the medical team.

LundA , TurrisSA , WangP , MuiJ , LewisK , GutmanSJ . An Analysis of Patient Presentations at a 2-Day Mass-participation Cycling Event: The Ride to Conquer Cancer Case Series, 2010-2012. Prehosp Disaster Med. 2014;29(4):1-8.

We sought to assess the applicability of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the prehospital setting by comparing CTAS scores assigned during ambulance transportation by base hospital (BH) nurses with CTAS scores given by emergency department (ED) nurses on patients' arrival.

We recruited a prospective sample of consecutive patients who were transported to the ED by ambulance between December 2006 and March 2007 for whom a contact was made with the BH. Patients were triaged by the BH nurse with online communication and vital signs transmission. On arrival, patients were blindly triaged again by the ED nurse. We used the quadratic weighted κ statistic to measure the agreement between the 2 CTAS scores.

Ninety-four patients were triaged twice by 2 nursing teams (9 nurses at the BH and 39 nurses in the ED). The agreement obtained on prehospital and ED CTAS scores was moderate (κ = 0.50; 95% confidence interval 0.37–0.63).

The moderate interrater agreement we obtained may be a result of the changing conditions of patients during transport or may indicate that CTAS scoring requires direct contact to produce reliable triage scores. Our study casts a serious doubt on the appropriateness of BH nurses performing triage with CTAS in the prehospital setting.

For a variety of reasons, many emergency department (ED) visits are classified as less- or nonurgent (Canadian Triage and Acuity Scale [CTAS] level IV and V). A recent survey in a tertiary care ED identified some of these reasons. The purpose of our study was to determine if these same reasons applied to patients presenting with problems triaged at a similar level at a low-volume rural ED.

A 9-question survey tool was administered to 141 CTAS level IV and V patients who attended the South Huron Hospital ED, in Exeter, Ontario, over a 2-week period in December 2006.

Of the 141 eligible patients, 137 (97.2%) completed the study. One hundred and twenty-two patients (89.1%) reported having a family physician (FP) and 53 (38.7%) had already seen an FP before presenting to the ED. Just over one-half of all patients (51.1%) had their problem for more than 48 hours, and 42 (30.7%) stated that they were referred to the ED for care. Fifty-three (38.7%) of the respondents felt they needed treatment as soon as possible. Many patients reported coming to the ED because: 1) their FP office was closed (21.9%); 2) they could not get a timely appointment (16.8%); or 3) the walk-in clinic was closed (24.8%). Only 6 patients (4.4%) specifically stated that they came to the ED because they had no FP. One-third of patients attended the ED because they believed it offered specialized services.

In this rural setting, most less- or nonurgent ED patients had an FP yet they went to the ED because they did not have access to primary care, because they perceived their problem to be urgent or because they were referred for or sought specific services.

Many emergency department (ED) visits are non-urgent. Postulated reasons for these visits include lack of access to family physicians, convenience and 24/7 access, perceived need for investigations or treatment not available elsewhere, and as a mechanism for expedited referral to other specialists. We conducted a patient survey to determine why non-urgent patients use our tertiary care ED. Our primary objective was to determine how often the lack of a family physician was associated with non-urgent ED use.

The survey was administered to Canadian Emergency Department Triage and Acuity Scale (CTAS) Level IV and V patients who attended the ED of the Queen Elizabeth II Health Sciences Centre in Halifax, NS, from March 7 to March 13, 2005.

Of the 352 eligible patients, 235 completed the survey (response rate, 67%). Fifty-six percent (132/235) had an acute medical problem of less than 48 hours, including 48% (114/235) with a recent injury. Thirty-four percent (82/235) had been referred to the ED, 49% (114/235) believed they required a specific service that was unavailable elsewhere (e.g., radiology, suturing, casting) and 43% (100/235) presented because of self-perceived urgency of their condition. Eighty-four percent (198/235) had a family physician; 23% (55/235) used the ED because of limited access to theirfamily physician and 3% (6/235) used the ED because they did not have a family physician.

In this setting, most non-urgent ED visits involved patients who required a specific service offered by the ED, patients who believed their condition was urgent, or patients who were referred from the community to the ED. From a patient perspective, relatively few visits would be considered inappropriate. Lack of a family physician was not associated with non-urgent ED use; however, inability to obtain timely access to the FP was a factor in one-quarter of cases.

Non-urgent visits comprise a significant proportion of visits to most emergency departments (EDs). Given the severe overcrowding issues faced by many EDs, the use of the Canadian Emergency Department Triage and Acuity Scale (CTAS) to identify patients who could be managed elsewhere seems to be an obvious way to reduce the pressure on the ED and “solve” the overcrowding problem.

To quantify the resource implications, in terms of stretcher use and waiting times, related to non-urgent patient visits and to estimate the potential impact on ED flow of redirecting these patients to alternate primary care settings.

Retrospective database audit in an urban referral hospital ED. For this study, patients triaged as either CTAS Levels IV or V were considered “non-urgent.”

Non-urgent patients comprised 30% of ED visits, but less than 5% of all those needing stretchers, along with their associated nursing resources. The longer waits consisted almost entirely of waits for available stretchers and would therefore have remained essentially unaffected. In spite of being labelled “non-urgent” by CTAS criteria, 7.3% of all patients requiring admission came from this group.

Non-urgent patients consume a small fraction of the ED stretchers and acute-care resources; therefore, strategies aimed at diverting non-urgent patients are unlikely to improve access for more urgent patients. Using the CTAS to identify patients for diversion away from the ED is measurably unsafe and will lead to inappropriate refusal of care for many patients requiring hospital treatment.

Triage reliability studies typically use hypothetical scenarios and weighted kappa scores where agreement within one level is considered satisfactory. But if triage category is used to help define ED case-mix groups for comparative or benchmarking processes, agreement on exact triage level and major system involved is important. Our hypothesis was that a computerized menu that links presenting complaints to preferred triage levels (PC-linked triage) would provide high triage reliability.

Our objective was to assess inter-rater reliability of PC-linked triage using the Canadian Emergency Department Triage and Acuity Scale (CTAS) in a real-time clinical setting, considering agreement on exact triage level and primary body system involved.

On duty triage nurses entered patient presenting complaint and PC-linked triage level as per standard procedure. In a convenience sample of patients, a second nurse, blinded to triage assignment, observed the triage interaction and independently entered presenting complaint and triage level on a dummy terminal.

During the study, 15 nurse pairs triaged 266 patients. Study patients matched actual emergency department case mix closely. Triage nurses agreed exactly in 74% of cases and within one level in 94% of cases. The unweighted kappa value was 0.66 (95% confidence interval [CI], 0.60–0.73) and the quadratic weighted kappa value was 0.75 (95% CI, 0.68–0.81). Kappa for agreement on major system involved was 0.80 (95% CI, 0.69–0.91).

PC-linked triage has high inter-rater reliability in a real-time clinical setting. PC-linked triage may be useful as one factor in defining case-mix groups for benchmarking and comparative purposes.

To assess the performance of the newly implemented Canadian Emergency Department Triage and Acuity Scale (CTAS) triage system in a redesigned 200-bed community hospital emergency department (ED) and to evaluate the predictive validity of CTAS in this setting.

Triage system performance was analyzed on the basis of 4 quality indicators: time to triage; triage duration; proportion of patients who left without being seen by a physician; and waiting time to nurse and physician, stratified by triage level and reported as fractile response rates. The predictive validity of CTAS was evaluated by investigating the relationship between CTAS level, hospitalization index, ED length of stay (LOS) and diagnostic test utilization.

During the study period, 32 574 patients were triaged and 32 261 were eligible for study. Eighty-five percent were triaged within 10 minutes, and 98% had a triage duration of ≤5 minutes. Waiting times to nurse and physician were within CTAS time objectives in 96.3% and 92.3% of cases respectively. The left without being seen (LWBS) rate was 0.96%. Hospitalization rates were compatible with CTAS standards for adults in Levels I, II, III and V and for children in Level V. Median LOS and laboratory test utilization were highly correlated with CTAS Levels II to V (p < 0.01), and similar correlation between triage acuity and imaging utilization was noted in adult patients with non-traumatic non-musculoskeletal complaints (p < 0.01).

The CTAS is adaptable to countries beyond Canada and its operating objectives are achievable. Time to triage and fractile response rates can be considered indicators of triage quality and ED performance. CTAS is a valid instrument for predicting admission rates, hospital LOS and diagnostic utilization.

Length of stay (LOS) is a key measure of emergency department (ED) throughput and a marker of overcrowding. Time studies that assess key ED processes will help clarify the causes of patient care delays and prolonged LOS. The objectives of this study were to identify and quantify the principal ED patient care time intervals, and to measure the impact of important service processes (laboratory testing, imaging and consultation) on LOS for patients in different triage levels.

In this retrospective review, conducted at a large urban tertiary care teaching hospital and trauma centre, investigators reviewed the records of 1047 consecutive patients treated during a continuous 7-day period in January 1999. Key data were recorded, including patient characteristics, ED process times, tests performed, consultations and overall ED LOS. Of the 1047 patient records, 153 (14.6%) were excluded from detailed analysis because of incomplete documentation. Process times were determined and stratified by triage level, using the Canadian Emergency Department Triage and Acuity Scale (CTAS). Multiple linear regression analysis was performed to determine which factors were most strongly associated with prolonged LOS.

Patients in intermediate triage Levels III and IV generally had the longest waiting times to nurse and physician assessment, and the longest ED lengths of stay. CTAS triage levels predicted laboratory and imaging utilization as well as consultation rate. The use of diagnostic imaging and laboratory tests was associated with longer LOS, varying with the specific tests ordered. Specialty consultation was also associated with prolonged LOS, and this effect was highly variable depending on the service consulted.

Triage level, investigations and consultations are important independent variables that influence ED LOS. Future research is necessary to determine how these and other factors can be incorporated into a model for predicting LOS. Improved information systems will facilitate similar ED time studies to assess key processes, lengths of stay and clinical efficiency.