The timeliness of ED care:
The structured five-level triage has proven to be a useful tool to organize care and determine the timeliness for medical evaluation in the ED –, , . Timeliness is an indicator of the quality of care in the ED , since a poor timeliness in care is associated with adverse outcomes , – and “time-sensitive” diseases – such as CVA – present more frequent adverse outcomes when there is poor timeliness of ED care.
CVA requires timely attention and management. Saver et al. found that when an ischemic CVA occurs due to the obstruction of large vessels, an average of 1.9 million neurons, 14 billion synapses and 12 kilometers of myelin fibers are lost for every minute that passes since the beginning of the vascular obstruction . Further, Meretoja et al. show that – for every minute saved when performing reperfusion therapy with rTPA – 1.8 extra days of healthy life are provided . The American Heart Association and the American Stroke Association, recommend the implementation of triage protocol as a good practice to improve timelines of care in ED for patients with CVA . Xian et al. evidenced that the implementation of a triage protocol in the ED decreased the acute door-to-needle time (DTN) by an average of 8.1 minutes . Another study conducted by Xian et al. evidenced that the implementation of triage in hospitals defined as reference centers for the management of CVA decreases − 2.6 (CI -4-0 a -1.3) times the time to perform reperfusion therapy compared to those centers that had not implemented a triage protocol . Likewise, Lindsberg et al. demonstrated that the updating of triage improves the DTN by approximately 38 minutes, and evidenced an increase in the reperfusion therapy .
Identifying the probable case is part of the chain of interventions in the care of CVA , . In addition to the early identification of the case, triage allows notifying the medical staff and improves the timeliness of ED care and management to reduce the risks associated with the disease . Our study showed a non-statistically significant downward trend in post-intervention mortality. This may be explained by the post intervention observation time of our study, possibly short to evaluate this outcome.
There is variable evidence regarding mortality in the population with ischemic CVA , , . In a meta-analysis, Emberson found that performing reperfusion therapy increases the risk of fatal parenchymal hemorrhage in the first seven days of treatment . In another study, Fonarow et al. evidenced an 11% decrease in in-hospital mortality due to any cause (OR 0.89 95% CI 0.83–0.94), after implementing good-practice measures, including triage protocols, to improve the quality of care in the management of CVA .
Increase in the Reperfusion Therapy:
Reperfusion therapy has modified the evolution of ischemic CVA, reducing the risk of death, disability and other adverse outcomes , . One of the great challenges is the detection of the probable case during triage, to accelerate attention, define reperfusion therapy and reduce DTN . Douglas et al. evidenced an increase in the frequency of use of rTPA in ischemic CVA when institutional protocols for care – including triage protocols – existed . Fonarow et al. also evidenced that, by implementing an institutional good-practice program in the management of CVA – including triage protocols – the proportion of patients receiving rTPA with DTN of less than 60 minutes increases, and the improvement of the state of independence was presented at hospital discharge, and decreased in-hospital mortality due to any cause . Lindsberg et al. also evidenced a 20% increase in the use of rTPA in the population with CVA after having updated the triage protocol in an ED .
In our study, we evidence improvement in the timeliness of ED care, and an increase in the use of rTPA in the population evaluated, after the implementation of the triage policy, a statistically significant finding. Although the goal of implementing reperfusion therapy in the population with CVA is still far away, the impact of triage is evident.
STRENGTHS AND LIMITATIONS:
To carry out the study, we defined a methodology that minimizes the risk of confusion bias due to variables related to the individual , , and a quality control was established to reduce confusion due to unmeasured variables .
The implementation of the TP proposed by the Colombian Ministry of Health was the only intervention of a regulatory order identified in the periods of time studied, related to the care of patients who consulted the EDs. However, during the time period of the study, the criteria for performing reperfusion therapy with rTPA were extended in Colombia, which may have predisposed to more timely care. And although the determination to receive the treatment does not necessarily depend on the TP, the use of rTPA can be considered as a co-intervention, since it is related to the outcome and its use was increased at the same time as the policy was implemented. This effect was controlled with a quality control group, in which there were no changes in these outcomes.
The intervention (the TP) did not affect the manner in which information was collected and stored in the institution. The data were collected electronically and automatically by the Information Management Office.
The main outcome (opportunity in care) was measured objectively, since it is a quantitative variable, and this was extracted directly from the hospital database. However, this information may be inaccurate in some circumstances, given that the recording of systematized attention times may be an unreliable representation of the actual care. And the size of the effect for the intervention was pre-specified, according to the simulation proposed by Zhang  in the determination of the sample size.
The limitations presented were the source of information was secondary, since it was recorded automatically in the electronic clinical history, from the completion of the triage to the beginning of the medical care, which can lead to an under-registration of this information; and second, the data in the control were only available as of January 2013.
IMPLICATIONS FOR PRACTICE:
The timeliness of ED care is critical in time-sensitive diseases, given that it can minimize the risk of adverse outcomes. Triage is the tool to determine this timeliness of ED care. Although the implementation of the structured five-level triage proposed by the Colombian Ministry of Health allowed improving timeliness of care in the ED for patients with ischemic CVA classified as Triage I and II, compared to Triage III, IV and V Categories. Strategies for quantification and improvement of the timeliness of ED care must be implemented.
IMPLICATIONS FOR OTHER RESEARCH
Although one of the critical times in the chain of care of the patient with CVA (from triage to medical care) was evaluated, it is necessary to quantify in greater depth the times of other moments in this same population (Door-CT Time; Door-to-Needle Time), which will permit establishing the quality of care for this population with greater precision. Other research derived from this work includes performing an ITS analysis with the CVA mortality data from across the country. This would increase the number of observations in each month by decreasing the variability of the estimate at each time point. Regarding the evaluation of the outcomes, in a future study it would be important to evaluate disability after the implementation of the triage policy.