Ontario devises cloud-based triage system for EDs

TORONTO – Cancer Care Ontario is in the process of rolling out a cloud-based system for Emergency Department triage to hospitals across the province. The computerized system uses algorithms that lead to more consistent assessments of patients who present in Emergency Rooms, resulting in higher quality triage and ultimately, increased patient safety.

“We’re now live in six hospitals and by 2018, the system will be in 100 hospitals,” said Steve Scott, Director of eCTAS, Analytics & Informatics at Cancer Care Ontario.

Scott added that over 100,000 patients have been triaged using the system, so far. Called eCTAS, short for the Electronic Canadian Triage and Acuity Scale, the system also provides real-time reporting of patient loads in Emergency Departments.

This data will be useful for the hospitals using the system, as well as planners in Local Health Information Networks (LHINs) and by the Ministry of Health.

The eCTAS solution also shows ER nurses if the patient presenting has been at other emergency departments, and provides the record of triage, but not the diagnostic record.

The rollout comes after an intensive period of design and testing. A key factor in the design was the involvement of nurses, who worked closely with technologists and designers.

“We asked for nurses to volunteer [in the design stage] and expected eight to 10 to sign on,” said Scott. “It turned out that we got 90 volunteers.” Many nurses saw the creation of a shared eCTAS system as an important project and wanted to be involved, he said.

“The reaction and involvement was incredible.”

By having the nurses working in design and education, CCO was able to produce a highly usable solution that meets the needs of frontline professionals, said Scott.

Moreover, the design process itself used an iterative model, meaning it was constantly tweaked, tested by users and then modified once more. Indeed, there were six waves of testing and modifications.

One of the major requirements, it turned out, was to have all the information needed by triage nurses on a single screen. That reduces the number of clicks needed and cuts down on navigation.

Another important feature: while cloud-based (it makes use of Microsoft Azure), the system can be downloaded to run locally. This means if there is an outage of a connection to the Internet, for whatever reason, the solution can still be used in the ER.

“This is a real technological innovation,” said Scott. “Even if access to the Internet is spotty, patients will still be coming in, and ED staff can continue working. High availability was critical.”

“You don’t want to experience any disruptions in service.”

The system works on any platform – desktop, tablet or smartphone. Staff can be sitting at a workstation or walking around the unit and have access to the information they need.

Cancer Care Ontario was chosen for the task of leading the project as it is already heavily involved in data collection across the province. Moreover, it produced and manages the Ontario Wait Time Information System (WTIS) and already has links to all hospitals and Emergency Departments.

Giving the agency responsibility for deploying eCTAS made sense and was a natural fit.

Scott noted eCTAS is based on research from the University of Alberta and the algorithm was built in collaboration with the Canadian Association of Emergency Physicians. Cancer Care Ontario created a delivery system for it, ensuring that it is in a practical and easy-to-access format.

As part of the approach in building the solution, CCO also conducted a Privacy Impact Assessment to ensure any PHI data would be secure in the cloud.

It is available to Ontario hospitals via the web, or they can integrate eCTAS into their own hospital information systems. So far, the majority of participating hospitals have opted to use the cloud-based version via the web.

“It’s good to see healthcare organizations moving to leverage cloud to deliver and build for the future,” commented Peter Jones, healthcare industry lead at Microsoft Canada. “Because of the broad use across the province, Azure is an ideal solution.”

Earlier this year, the Ross Memorial Hospital in Lindsay, Ont., became the first to make use of the solution. Scott said that Ross Memorial has been a major supporter of the project and was of enormous help in the design and testing stages.

The solution has already helped Ross Memorial. “Before, triage was paper-based,” said Jennifer Burns-West, ED unit manager. “With eCTAS, it’s all on computer, and the system flags nurses about modifiers, so the scoring is more accurate.”

She noted that when calculating a triage score, modifiers have to be taken into account. For example, for a patient who suffered a car crash, nurses must account for the speed of the car in the crash and the pain level of the patient.

“A lot more is automated, and our nurses love it,” said Burns-West, noting the hospital has 70 ED nurses, with two triage stations in the department. The system makes triage faster, and because nurses are alerted about modifiers, the quality of triage has gone up.

“Honestly, it’s so easy to navigate,” said Burns-West. “This is going to help nurses across the province.”

The implementation at Ross Memorial was soon followed by Cambridge Memorial, Mount Sinai, in Toronto; Southlake Regional Health Centre, in Newmarket; the Norfolk General Hospital, in Simcoe; and Lake-of-the-Woods District Hospital, in Kenora.

The impetus for eCTAS can be linked to a study done by Ontario’s Auditor General, who examined three hospital EDs and determined that only 37 percent of patients were appropriately triaged.

The ministry then commissioned the creation of a computerized tool that would help ED staff produce more consistent and accurate assessments, and directed Cancer Care Ontario to develop the web-based delivery system.

Already it has been found that EDs using eCTAS are assessing patients much more consistently than before, when measured against the way an expert in triage determines a triage score.

Initial results are showing that the number of patients who are under-triaged has dropped from 13 percent to just 3 percent in hospitals using eCTAS. “We’ve potentially improved patient safety for 10 percent of the ED patients, or one in 10,” said Scott.

Speaking online in a web-video, Dr. Howard Ovens, provincial clinical lead for ER medicine, said: “Applying this project will give us an opportunity to make sure that every hospital is consistent and using best practices in making this initial assessment, which is such a key part of the patient journey.”

Dr. Ovens is also the chief medical strategy officer for the Sinai Health System in Toronto.

Another useful feature of the system has been the inclusion of an infection control screen. Before patients are triaged, nurses see the screen and can determine whether patients may be infectious.