TRIAGE IN THE EMERGENCY DEPARTMENT (The Australasian Triage Scale)
The Canadian Pre-hospital Acuity Scale (CPAS): What is it and … · 2011. 10. 14. · National...
Transcript of The Canadian Pre-hospital Acuity Scale (CPAS): What is it and … · 2011. 10. 14. · National...
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1
The Canadian Pre-hospital Acuity Scale (CPAS): What is it and How does it help?
EMSCC Webinar
May 25th, 2011 Rob Grierson MD, FRCPC
Medical Director – Winnipeg Fire Paramedic Service
Assistant Professor – Dept. of Emergency Medicine, University of Manitoba
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Presentation Objectives
Brief overview of the development of The Canadian Triage and
Acuity Scale (CTAS)
Explain how and why The Canadian Pre-hospital Acuity Scale
(CPAS) was developed
Explanation of the process for CPAS determination
Identify the projected benefits and challenges
Real-time CPAS determination using an electronic patient care
(ePCR) system
Address questions and concerns
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Introduction
5-level CTAS was introduced to Canada in 1999 to help
nurses prioritize patients based on acuity
Developments since have incorporated a (CEDIS)
complaint list, well defined modifiers, & an educational
package to improve standardization in all aspects of the
tool
This has led to expanding interest among EMS directors
and providers to apply CTAS acuity in the field to allow for
better communication between the pre-hospital and the
emergency department by sharing a common language,
understanding, and evaluation tool
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A national standard for triage
Improved patient care
Increased triage reliability and validity
Site & personal performance indicators
National benchmarks
Rationale for the Development
of CTAS
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Origins of CTAS
National Triage Scale – Australia ACEM 1994
CAEP Triage and Acuity Scale – Canada 1995
CTAS – Canada (CAEP, NENA, AMUQ ) 1999
Paediatric CTAS (above + CPS, SRPC) 2001
Adult CTAS revision 2004
CEDIS Complaint list (+ revision) 2003 & 2008
Adult CTAS revision 2008
Paediatric CTAS revision 2008
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Prehospital CTAS Concerns
CTAS was developed as a triage tool, based on acuity, to be applied
in the ED to:
„prioritize‟ patients as to who is next to be seen and who can
most “safely wait”
screen for communicable disease to protect other patients and
staff
CTAS educational materials reflect the realities of the ED workplace,
resources, and nursing training
Both content and cases
CTAS research both reliability, usability, & validity testing has
focused on use in the ED
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Several EMS jurisdictions already adapting CTAS
Aligning with but separating from ED triage (reduces confusion)
Allows for minor revisions based on environmental and work processes
Common language for EMS and ED personnel
Create a national standard
Opportunity for QI and research projects
Support regional and national benchmarks
Rationale for the Development
of CPAS
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Unique features of CPAS CPAS, while consistent with CTAS, is slightly streamlined for
adoption by EMS Providers:
CEDIS complaint list shortened from 167 to 112
Options for fever measurement modified for EMS
Pain scales for children limited to 2
Applied as part of the assess/stabilization/treatment process
(parallel process compared to the serial process in the ED)
Expectation that CPAS will be assigned based on findings at the
scene and again en route or nearing the hospital – the change in
CPAS acuity may be important to hospital decision making and
patient outcome
Example: Asthmatic who starts as a CPAS level 2, but improves to a
level 4 with pre-hospital treatment
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The CEDIS Categories Cardiovascular (CVS)
ENT – Ears (ENT-E)
ENT – Mouth, throat, neck (ENT-MTN)
ENT – Nose (ENT-N)
Environmental (ENV)
Gastrointestinal (GI)
Genitourinary (GU)
Mental Health (MH)
Neurologic (CNS)
OB – GYN (OB-GYN)
Opthamology (OPTH)
Orthopedic (ORTHO)
Respiratory (RESP)
Skin (SKIN)
Substance Misuse (SUBST)
Trauma (T)
General and Minor (GEN)
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Determining the CPAS Level
1. Select appropriate CEDIS complaint
2. Apply appropriate 1st order modifiers
3. Select relevant complaint-specific 2nd order
modifiers
CRITICAL
LOOK
INFECTION
CONTROL
PRESENTING
COMPLAINT
VITAL
SIGNS
OTHER
MODIFIERS
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First Order Modifiers
1st Step
Respiratory Distress…..............Airway
……………Breathing
Hemodynamic Status………….Circulation
Level of Consciousness……….Disability
Temperature
2nd Step
Pain Score
Bleeding Disorder
Mechanism of Injury
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Assessing Acuity Process Critical Look - rapid visual assessment
Presenting Complaint - Hx / Infection Control
Vitals – physiologic parameter assessment (1st order modifiers: 1st step)
Additional Keys - non physiologic parameters (1st order modifiers: 2nd step)
Special Modifiers - complaint-based (2nd order modifiers)
CPAS Level – Assign Acuity Level
Reassessment
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Level 1 - Resuscitation
Level 2 - Emergent
Level 3 - Urgent
Level 4 - Less Urgent
Level 5 - Non-Urgent
CPAS Five Level Acuity
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Level 1 - Resuscitation
“Conditions that are
threats to life or limb
(or imminent risk of
deterioration)
requiring immediate
aggressive
interventions.”
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Level 1 - Presentations
Cardiac arrest
Seizures (actively seizing)
Respiratory arrest
Major trauma (in shock)
Shortness of breath (severe)
Unconscious (GCS 3-9)
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Level 2 - Emergent
“Conditions that are a potential threat to life, limb or function, requiring rapid intervention”
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Level 2 - Presentations
Chest pain with cardiac features
Chest pain, non cardiac features (other
significant chest pain ripping or tearing)
Hypertension (SBP >220 or DBP >130 with
symptoms)
Hypothermia (core temperature <32C)
Fever (>38C), Looks septic (3 SIRS criteria)
Headache (sudden, severe, worst ever)
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Level 2 - Presentations continued
Depression / Suicidal / Deliberate self harm (attempted suicide or clear plan)
Bizarre behavior (uncertain flight or safety risk)
Chemical exposure to eye
Shortness of breath (moderate respiratory distress)
Abdominal pain (severe acute pain 8/10)
Altered Level of Consciousness (GCS 10-13)
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Level 3 - Urgent
“Conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living.”
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Level 3 - Presentations
Hypertension (SBP >220 or DBP >130
with no symptoms)
Seizures (resolved, normal level of
alertness)
Diarrhea (uncontrolled bloody diarrhea)
Active labor (contractions >2 min)
Depression / Suicidal / Deliberate self
harm (suicidal ideation, no plan)
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Level 3 - Presentations continued
Shortness of breath (mild respiratory
distress)
Abdominal pain (moderate acute pain 4 -
7/10)
Headache (moderate acute pain 4 - 7/10)
Upper extremity injury (obvious deformity)
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Level 4 - Less Urgent
“Conditions that relate to
patient age, distress, or
potential for deterioration or
complications, which would
benefit from intervention or
reassurance within 1-2 hours.”
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Level 4 - Presentations
Upper extremity injury (tight cast with no neuro-vascular symptoms)
UTI complaints/symptoms (with mild dysuria)
Constipation (with mild pain)
Confusion (chronic, no change from usual state)
Vaginal bleed (minor spotting)
Laceration/puncture (sutures required)
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Level 5 - Non-Urgent
“Conditions that may be acute but non-urgent, as well as conditions which may be part of a chronic problem, with or without evidence of deterioration. The investigation or interventions for some of these illnesses or injuries could be delayed or even referred to other areas of the hospital or health care system.”
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Level 5 - Presentations
Diarrhea (mild, no dehydration)
Minor bites (+/- mild acute peripheral pain)
Dressing changes (uncomplicated)
Medication request
Laceration/puncture (no
sutures required)
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Key Points to Assigning a CPAS Level
in Adults
The CPAS level is assigned based upon:
1. First look
2. Selection of the most appropriate chief
complaint (CEDIS) and
3. Application of modifiers to more accurately
reflect acuity
CRITICAL
LOOK INFECTION
CONTROL
PRESENTING
COMPLAINT
VITAL
SIGNS
OTHER
MODIFIERS
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Destination Decision Making CPAS level 1 – generally the closest ED
Exceptions include: designated trauma centers, stroke centers,
Paediatric EDs., etc.
May require algorithms or on-line decision making
CPAS level 2 – nearest appropriate ED
Destination protocols often established based on patient
complaint & hospital specific specialized services
May need on-line communication with dispatch or facility
CPAS level 3,4,5 – patient stability allows more options
Nearest appropriate (based on complaint & specific resources)
Hospital of most recent admission, own FP, or patient request
Central destination coordination based on site availability or an
equitable rotation (compensating for overcrowding)
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Current and Future Challenges Education
Development and maintenance of CPAS Instructors
Classroom versus on-line teaching vs combined
Will require an evaluation process
Hoping to encourage provinces to take educational responsibility
Feedback from students & instructors important
Dissemination & Adoption
Ontario already proposed to adopt CTAS (CPAS) as a means of
measuring and documenting pre hospital acuity & complaint
Other provinces looking to also adopt CPAS
Computer aided vs. manual CPAS determination
Time constraints of CPAS determination
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Current and Future Challenges Research and Evaluation
Very exciting opportunities
Comparing to RTS, PHI looking at sensitivity & specificity for
trauma and critical care decision making
Looking at the impact of CPAS on scene & transfer times
Integrating with Cincinnati Stroke Scale or LAPSS
Evaluating the importance of CPAS acuity change during
transport for a variety of patients and their outcomes (ie
trauma, asthma/COPD, altered LOC, etc.)
Comparing utility in rural and urban systems
Measuring interrater reliability
Optimizing education and uptake by providers
Linking of CPAS score to MPDS determinant to develop a
national database for benchmarking of response profiles
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CPAS Example
63 y/o male c/o palpitations and lightheadedness Denies chest pain, no nausea, no SOB, no diaphoresis. In no distress. Speaking in full sentences.
Appears well. PMHx: ICD due to previous VT. Family MD
told pt to go to hospital if he has palpitations.
Vital Signs: RR 20, P 168 and regular, BP 138/78, GCS of 15, Temp 37.6C, O2 Sat 96%.
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Answer to Example
1. Chief Complaint
Palpitations / Irregular Heartbeat (4)
Syncope, Pre-Syncope (4)
2. Complaint Specific Modifier
History or documented lethal dysrhythmia (2)
New onset of dysrhythmia, irregular pulse &/or change in rate (2)
First Order Modifiers
Hemodynamic compromise (unexplained tachycardia) (2) Evidence of borderline perfusion - pale, history of
diaphoresis, unexplained tachycardia, postural hypotension (by history = feeling faint on sitting or standing) or suspected hypotension (BP lower than patient normal or expected for a given patient).
FINAL SCORE 2
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Acknowledgements
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Questions?
Please feel free to e-mail me at [email protected].
It may take a few days for me to respond.
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