Color-coding triage and allergic reactions in an Italian ED.

Emergency Department (ED) crowding is an international public health problem. Moreover, it is associated with prolonged stay and increased risk of adverse drug events (ADEs). Adverse drug reactions (ADRs) account for 3-6% of all hospital admissions, and occur in 10-15% of hospitalized patiens. An ADE should be differentiated from ADR, the latter including harm related to medication errors and drug/food medications. Only few studies have focused prevalence and incidence of drug allergy in hospital-based populations. We were interested to drug allergy, defined as an immunologically-mediated drug hypersensitivity reaction, characterized by either IgE or non-IgE mediated mechanism. In particular, we aimed to focus on drug allergies referring to the ED and requiring hospitalization, to evaluate type and prevalence, and relationships between initial triage assessment and hospital lenght of stay (LOS). This study was conducted, between January and December 2009, at the Emergency Department of St. Anna Hospital of Ferrara, a 863-bed tertiary care teaching hospital, with a yearly patient flow in the ED of approximately 76 000. Allergic reactions were defined as erythema, exanthema, urticaria and angioedema. Age, sex, triage assessment colour code, history, body temperature, drugs involved, LOS, and therapy were evaluated. Descriptive analysis and chi-square test were performed, and triage assessment represented the grouping variable. Multivariate analysis was not performed due to the limited sample size. Out of 75 966 patients arrived to the ED in the year 2009, 2842 (3.7%) were admitted to the ED ward. Of these, 58 (2%) presented a drug-related allergic reaction. Mean age was 58±5 years (range 18-88), 62% were female. Comorbilities included metabolic, heart, bone, infectious, gastric, vascular, neurologic, renal, and bowel diseases; 14% had a history of cancer. Allergic reactions were due to several kind of medications: anti-infective, anti-inflammatory, endocrine, cardiovascular, antineoplastic, and other. Triage assessment showed colour code green in 26% of cases, yellow in 55% and red in 19%. LOS was 6-12 hours in 19% of cases, between 12 hours and 3 days in 41%, and >3 days in 40%. Therapy at first evaluation included antihistaminics, steroids, non-steroidal-anti-inflammatory drugs, plasma expanders, and oxygen. Triage assessment colour code red was associated with history of heart disease, lung disease and vascular disease, whereas only allergic reactions defined as urticaria were related to the green code. The red code was significantly associated with longer LOS >3 days. Allergic reactions are very frequent among ED attenders: national data in the USA estimated incidence of ADRs as 2.4 visits x 1000 population. Of these, 33.5% were drug allergies, and 11.3% required hospitalization. Although triage represents a highly useful tool to prioritize patients’s care in EDs, very limited data relating triage assessment colour code for allergic reactions are available. The importance of a correct triage is important, since it has been shown that ED patients presenting with ADEs incurred great health services utilization and costs of hospital care. To the best of our knowledge, this is the first study evaluating the relationship between triage colour code, clinical features, and LOS in subjects with allergic reactions presenting to the ED. Patients’ age was younger compared with previous reports, and LOS exceeded 3 days in more than 40% of cases, with a good correspondence with the triage colour code assigned upon ED arrival. EDs could represent optimal settings for research, and support important translational knowledge.