由于儿科急诊患者分诊不足导致的治疗和处置延误。

Delays in treatment and disposition attributable to undertriage of pediatric emergency medicine patients.

机构信息

Division of Emergency Medicine, Children's National Hospital, Washington, DC, United States of America; The George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America.

Division of Pediatric Emergency Medicine, Johns Hopkins University, United States of America; Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.

出版信息

Am J Emerg Med. 2023 Dec;74:130-134. doi: 10.1016/j.ajem.2023.09.054. Epub 2023 Oct 2.

DOI:10.1016/j.ajem.2023.09.054

PMID:37826993

Abstract

BACKGROUND

Triage, the initial assessment and sorting of patients in the Emergency Department (ED), determines priority of evaluation and treatment. Little is known about the impact of undertriage, the underestimation of disease severity at triage, on clinical care in pediatric ED patients. We evaluate the impact of undertriage on time to disposition and treatment decisions in pediatric ED patients.

METHODS

This was a case control study of ED visits for patients <22 years of age, with an assigned Emergency Severity Index (ESI) score of 4 or 5, and associated hospital admission, nebulized treatment, supplemental oxygen, and/or intravenous (IV) line placement, between January 1, 2018, to June 30, 2022. Controls were sampled from a pool of patient visits with an ESI score of 3, matched by intervention, disposition, and date and hour of arrival. Primary outcome measures were time to order of intervention (nebulized treatment, oxygen administration, or IV placement) and time to disposition decision. A secondary outcome measure was return visits requiring admission or emergency intervention within 14 days of the index visit. Continuous variables (time to orders) were analyzed using Wilcoxon rank sum test and dichotomous outcomes (return visits) were compared using odds ratios with 95% confidence intervals. Analysis was performed with Python v3.10.

RESULTS

The final analysis included 7245 undertriaged patients. Undertriaged patients had longer times to orders for nebulized treatments, (p < 0.001) IV placement, (p < 0.001) and admission (p < 0.001) when compared to controls. There were no significant differences in time to supplemental oxygen delivery and time to discharge compared to controls. Undertriaged patients were more likely to experience a return visit requiring admission or emergency intervention (OR 3.74, 95% CI 3.32,4.22).

CONCLUSIONS

Undertriage in the pediatric ED is associated with delays in care and disposition decisions and increases likelihood of return visits.

摘要

背景

分诊是对急诊科（ED）患者进行的初步评估和分类，决定了评估和治疗的优先级。对于分诊低估疾病严重程度（即分诊不足）对儿科 ED 患者临床护理的影响，我们知之甚少。我们评估了分诊不足对儿科 ED 患者处置和治疗决策时间的影响。

方法

这是一项病例对照研究，纳入了 2018 年 1 月 1 日至 2022 年 6 月 30 日期间就诊于 ED 的年龄<22 岁的患者，其急诊严重指数（ESI）评分为 4 或 5，且存在住院、雾化治疗、补充氧气和/或静脉（IV）置管等相关治疗，对照组从 ESI 评分为 3 的患者就诊池中随机抽取，匹配干预措施、处置和到达时间及小时。主要结局指标为干预（雾化治疗、吸氧或 IV 置管）医嘱下达时间和处置决策时间。次要结局指标为就诊后 14 天内再次就诊需要住院或急诊干预。连续变量（医嘱下达时间）采用 Wilcoxon 秩和检验分析，二分类结局（再次就诊）采用比值比（95%CI）比较。使用 Python v3.10 进行分析。

结果

最终分析纳入了 7245 例分诊不足的患者。与对照组相比，分诊不足的患者接受雾化治疗、IV 置管和住院的医嘱下达时间更长（p<0.001）。与对照组相比，分诊不足的患者接受补充氧气的时间和出院时间没有显著差异。与对照组相比，分诊不足的患者再次就诊需要住院或急诊干预的可能性更高（OR 3.74，95%CI 3.32，4.22）。