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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

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

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

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

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

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

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

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

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)

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

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

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

Level 1 - Resuscitation

Level 2 - Emergent

Level 3 - Urgent

Level 4 - Less Urgent

Level 5 - Non-Urgent

CPAS Five Level Acuity

Level 1 - Resuscitation

“Conditions that are

threats to life or limb

(or imminent risk of

deterioration)

requiring immediate

aggressive

interventions.”

Level 1 - Presentations

Cardiac arrest

Seizures (actively seizing)

Respiratory arrest

Major trauma (in shock)

Shortness of breath (severe)

Unconscious (GCS 3-9)

Level 2 - Emergent

“Conditions that are a potential threat to life, limb or function, requiring rapid intervention”

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)

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)

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.”

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)

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)

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.”

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)

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.”

Level 5 - Presentations

Diarrhea (mild, no dehydration)

Minor bites (+/- mild acute peripheral pain)

Dressing changes (uncomplicated)

Medication request

Laceration/puncture (no

sutures required)

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

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)

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

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

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%.

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

Acknowledgements

Questions?

Please feel free to e-mail me at RGrierson@winnipeg.ca.

It may take a few days for me to respond.