The PAndemic INfluenza Triage in the Emergency Department (PAINTED) pilot cohort study

Background: Research needs to be undertaken rapidly in the event of an influenza pandemic to develop and evaluate triage methods for people presenting to the emergency department with suspected pandemic influenza. Objectives: We aimed to pilot a research study to be undertaken in a pandemic to identify the most accurate triage method for patients presenting to the emergency department with suspected pandemic influenza. The objectives of the pilot study were to develop a standardised clinical assessment form and secure online database; test both using data from patients with seasonal influenza; seek clinician views on the usability of the form; and obtain all regulatory approvals required for the main study. Design: Study methods were piloted using an observational cohort study and clinician views were sought using qualitative, semistructured interviews. Setting: Six acute hospital emergency departments. Participants: Patients attending the emergency department with suspected seasonal influenza during winter 2012–13 and clinicians working in the emergency departments. Main outcome measures: Adverse events up to 30 days were identified, but analysis of the pilot data was limited to descriptive reporting of patient flow, data completeness and patient characteristics. Results: Some 165 patients were identified, of whom 10 withdrew their data, leaving 155 (94%) for analysis. Follow-up data were available for 129 of 155 (83%), with 50 of 129 (39%) being admitted to hospital. Three cases (2%) were recorded as having suffered an adverse outcome. There appeared to be variation between the hospitals, allowing for small numbers. Three of the hospitals identified 150 of 165 (91%) of the patients, and all 10 withdrawing patients were at the same hospital. The proportion with missing follow-up data varied from 8% to 31%, and the proportion admitted varied from 4% to 85% across the three hospitals with meaningful numbers of cases. All of the deaths were at one hospital. There was less variation between hospitals in rates of missing data, and for most key variables missing rates were between 5% and 30%. Higher missing rates were recorded for blood pressure (39%), inspired oxygen (43%), capillary refill (36%) and Glasgow Coma Scale score (43%). Chest radiography was performed in 51 of 118 cases, and electrocardiography in 40 of 111 cases with details recorded. Blood test results were available for 32 of 155 cases. The qualitative interviews revealed generally positive views towards the standardised assessment form. Concerns about lack of space for free text were raised but counterbalanced by appreciation that it fitted on to one A4 page. A number of amendments were suggested but only three of these were suggested by more than one participant, and no suggestions were made by more than two participants. Conclusions: A standardised assessment form is acceptable to clinicians and could be used to collect research data in an influenza pandemic, but analysis may be limited by missing data. Future work: An observational cohort study to identify the most accurate triage method for predicting severe illness in emergency department attendees with suspected pandemic influenza is set up and ready to activate if, or when, a pandemic occurs. Trial registration: Current Controlled Trials ISRCTN56149622. Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 3. See the NIHR Journals Library website for further project information