Abstract. Objectives: Triage is the initial clinical sorting process in hospital emergency departments (EDs). Because of poor reproducibility and validity of three-level triage, the authors developed and validated a new five-level triage instrument, the Emergency Severity Index (ESI). The study objectives were: 1) to validate the triage instrument against ED patients' clinical resource and hospitalization needs, and 2) to measure the interrater reliability (reproducibility) of the instrument. Methods: This was a prospective, observational cohort study of a population-based convenience sample of adult patients triaged during 100 hours at two urban referral hospitals. Validation by resource use and hospitalization (criterion standards) and reproducibility by blinded paired triage assignments compared with weighted kappa analysis were assessed. Results: Five hundred thirty-eight patients were enrolled; 45 were excluded due to incomplete evaluations. The resulting cohort of 493 patients was 52% female, was 26% nonwhite, and had a median age of 40 years (range 16-95); overall, 159 (32%) patients were hospitalized. Weighted kappa for triage assignment was 0.80 (95% CI = 0.76 to 0.84). Resource use and hospitalization rates were strongly associated with triage level. For patients in category 5, only one-fourth (17/67) required any diagnostic test or procedure, and none were hospitalized (upper confidence limit, 5%). Conversely, in category 1, one of twelve patients was discharged (upper confidence limit, 25%), and none required fewer than two resources. Conclusions: This five-level triage instrument was shown to be both valid and reliable in the authors' practice settings. It reproducibly triages patients into five distinct strata, from very high hospitalization/resource intensity to very low hospitalization/resource intensity. Keywords: triage; emergency service, hospital; clinical protocols; nursing assessment. ACADEMIC EMER-GENCY MEDICINE 2000; 7:236-242 T HERE were 95 million hospital emergency department (ED) visits in 1997.1 For more than 30 years, literature reports indicate that as many as one-half of ED visits are for minor health problems. [2][3][4][5][6][7][8] Triage is the preliminary clinical assessment process that sorts patients prior to full ED diagnosis and treatment, so that in the setting of resource constraints (i.e., limited beds, staff, and equipment), patients with the highest acuity are treated first. Most U.S. hospitals use three triage categories, 9 whereas five-level triage prevails in Canada, 10 and health insurers use triage data when reviewing the ''medical necessity'' of ED services for reimbursement purposes.14 Such decision making depends on reproducible and valid triage classifications. Unfortunately, existing ED triage methods are flawed, particularly for identification of nonurgent patients who may be referred for care elsewhere. 14-21Because of limitations in existing triage processes, we developed and validated a five-level triage instrument, based on an expanded conceptual model:...

These recommendations are intended to provide certified athletic trainers and others participating in the health maintenance and performance enhancement of athletes with specific knowledge and problem-solving skills to better prevent, detect, and manage DE. The individual biological, psychological, sociocultural, and familial factors for each athlete with DE result in widely different responses to intervention strategies, challenging the best that athletics programs have to offer in terms of resources and expertise. The complexity, time intensiveness, and expense of managing DE necessitate an interdisciplinary approach representing medicine, nutrition, mental health, athletic training, and athletics administration in order to facilitate early detection and treatment, make it easier for symptomatic athletes to ask for help, enhance the potential for full recovery, and satisfy medicolegal requirements. Of equal importance is establishing educational initiatives for preventing DE.

IMPORTANCE Each year, cellulitis leads to 650 000 hospital admissions and is estimated to cost $3.7 billion in the United States. Previous literature has demonstrated a high misdiagnosis rate for cellulitis, which results in unnecessary antibiotic use and health care cost. OBJECTIVE To determine whether dermatologic consultation decreases duration of hospital stay or intravenous antibiotic treatment duration in patients with cellulitis. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted in a large urban tertiary care hospital between October 2012 and January 2017, with 1-month follow-up duration. Patients were randomized to the control group, which received the standard of care (ie, treatment by primary medicine team), or the intervention group, which received dermatology consultation. Medical chart review of demographic information and hospital courses was performed. Adult patients hospitalized with presumed diagnosis of cellulitis were eligible. A total of 1300 patients were screened, 1125 were excluded, and 175 were included. Statistical analysis was employed to identify significant outcome differences between the 2 groups. INTERVENTIONS Dermatology consultation within 24 hours of hospitalization. MAIN OUTCOMES AND MEASURES Length of hospital stay and duration of intravenous antibiotic treatment. RESULTS Of 175 participants, 70 (40%) were women and 105 (60%) were men. The mean age was 58.8 years. Length of hospital stay was not statistically different between the 2 groups. The duration of intravenous antibiotic treatment (<4 days: 86.4% vs 72.5%; absolute difference, 13.9%; 95% CI, 1.9%-25.9%; P = .04) and duration of total antibiotic treatment was significantly lower in patients who had early dermatology consultation (<10 days: 50.6% vs 32.5%; absolute difference, 18.1%; 95% CI, 3.7%-32.5%; P = .01). Clinical improvement at 2 weeks was significantly higher for those in the intervention group (79 [89.3%] vs 59 [68.3%]; absolute difference, 21.0%; 95% CI, 9.3%-32.7%; P < .001). There was no significant difference in 1-month readmission rate between the groups (4 [4.5%] vs 6 [6.9%]; absolute difference, −2.4%; 95% CI, −9.3% to 4.5%; P = .54). In the intervention group, the rate of cellulitis misdiagnosis was 30.7% (27 of 88 participants). Among the entire cohort, 101 (57.7%) patients were treated with courses of antibiotics longer than what is recommended by guidelines. CONCLUSIONS AND RELEVANCE Early dermatologic consultation can improve outcomes in patients with suspected cellulitis by identifying alternate diagnoses, treating modifiable risk factors, and decreasing length of antibiotic treatment. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01706913

No abstract