Is a mobile emergency severity index (ESI) triage better than the paper ESI?

Outcome After Self-Triage App Referral in Urgent Direct-to-Consumer Telemedicine Encounter

Background: The quantification of self-triage effectiveness, guided by mobile applications, in urgent direct-to-consumer telemedicine (TM) encounters requires further investigation. The objective of this study was to evaluate the outcomes of referral guidance provided by a symptom-based self-management mobile application decision algorithm in the context of remote urgent care assessments. Methods: An observational retrospective single-center study was conducted from May 2022 to December 2023. The inclusion criteria encompassed individuals aged >18 years old, and those spontaneously seeking virtual emergency care through the EINSTEIN CONECTA application. Patients experiencing connectivity issues, preventing completion of the encounter, were excluded. The primary outcomes included the rate of patient concurrence with the algorithm's recommendation for seeking in-person emergency care and the referral rate to face-to-face assessment among cases evaluated through TM. The application's algorithm employs scientific evidence based on symptoms to recommend referrals to emergency departments (EDs). Results: Out of 88,834 patients connected to the TM Center, self-triage obviated the need for virtual physician assessment in 53,302 (60%) encounters. A total of 35,532 patients were remotely evaluated by 316 on-duty physicians, resulting in 1,125 ICD-coded diagnoses. Among these, 21,722 (61.1%) were initially advised by self-triage to visit the ED, with subsequent medical assessment leading to in-person referrals in 6,354 (29.3%) of the evaluations. Of the 13,810 patients recommended to continue with virtual care post-self-triage, 157 (1.1%) were referred for in-person assessment. Conclusions: Self-triage effectively reduced the need for physician encounters in approximately three-fifths of TM consultations. Despite being based on scientific evidence, symptom-based referral algorithms demonstrated high sensitivity but poor correlation with physician decision-making.

Usability evaluation of a glove-type wearable device for efficient biometric collection during triage

To efficiently allocate medical resources at disaster sites, medical workers perform triage to prioritize medical treatments based on the severity of the wounded or sick. In such instances, evaluators often assess the severity status of the wounded or sick quickly, but their measurements are qualitative and rely on experience. Therefore, we developed a wearable device called Medic Hand in this study to extend the functionality of a medical worker's hand so as to measure multiple biometric indicators simultaneously without increasing the number of medical devices to be carried. Medic Hand was developed to quantitatively and efficiently evaluate "perfusion" during triage. Speed is essential during triage at disaster sites, where time and effort are often spared to attach medical devices to patients, so the use of Medic Hand as a biometric measurement device is more efficient for collecting biometric information. For Medic Hand to be handy during disasters, it is essential to understand and improve upon factors that facilitate its public acceptance. To this end, this paper reports on the usability evaluation of Medic Hand through a questionnaire survey of nonmedical workers.

The Role of Telemedicine in Prehospital Traumatic Hand Injury Evaluation

Unnecessary ED visits and transfers to hand clinics raise treatment costs and patient burden at trauma centers. In the present COVID-19 pandemic, needless transfers can increase patients' risk of viral exposure. Therefore, this review analyzes different aspects of the remote diagnosis and triage of traumatic hand injuries. The most common file was photography, with the most common devices being cell phone cameras. Treatment, triage, diagnosis, cost, and time outcomes were assessed, showing concordance between teleconsultation and face-to-face patient evaluations. We conclude that photography and video consultations are feasible surrogates for ED visits in patients with traumatic hand injuries. These technologies should be leveraged to decrease treatment costs and potentially decrease the time to definitive treatment after initial evaluation.

Feasibility study of using mobile application to support triage and diagnosis clinical decisions for pediatricians: User-centered design approach

Background

While there is some evidence in the literature demonstrating success in using a triage software application in ED, none of the solution was developed specifically to support a holistic decision of pediatricians in triage and diagnosis purposes to initiate the first treatment properly. To explore the usefulness and possibility of employing a digital-based solution to enhance clinician performance, the mobile application was developed and then assessed in different perspectives.

Objective

The primary objective of this study is to contribute implementation practice of an application to support pediatric triage and diagnoses. The secondary objective is to present the results of the preliminary evaluation of the application.

Methods

The application called Pedicmeter was developed. Formative tests with revisions were applied throughout the development phase. A number of summative extensive evaluations were also conducted to investigate the efficacy of the proposed method. The evaluation focused on measuring the ability of an application to support a pediatric staff's decision to determine an overall severity level and disease diagnosis. Finally, the user's (clinician's) satisfaction of using the application was measured.

Results

The application Pedicmeter enables clinicians to make more accurate decisions in determining emergency level of pediatric patients by 6.66%. The application accurately diagnosed a disease with 73.08% accuracy and 66.67% accuracy for respiratory and infectious diseases, respectively. The diagnostic information that the application suggested shows that it does have an influence on a clinician's diagnosis. Using the app showed improvements in diagnostic accuracy for asthma, croup, sepsis, but it showed a decrease in the accuracy of a clinician's decision for pneumonia. The benefit of the application that satisfies the pediatricians the most is the helpfulness of the features of the application (86%), while the least satisfying factor was the required number of inputs (63%).

Conclusion

The developed application conceptually shows a promising opportunity to enhance clinicians' decisions from the pilot study. However, the study also reveals further tweaks are required and unveils challenging issues and the concerns of clinician users when use the application. Further research will be conducted to investigate and determine the limiting factors and specific issues revealed by this study. Longitudinal data collection and analysis also need to be conducted to investigate the clinical implications.

The prognostic value of sepsis scores and dichotomized triage score in patients presenting to the emergency department with fever: A prospective, observational study

BACKGROUND

The performance of the Quick Sequential Organ Failure Assessment (qSOFA) score needs to be explored further in the emergency triage room. This study aims to explore the performance of triage (tqSOFA) versus the dichotomized triage score (DTS) in patients admitted to the emergency room triage with fever.

METHODS

This research was designed as a prospective, observational study within a six-month period, including patients who presented to the emergency room triage with infrared fever ≥ 37.5 °C.

RESULTS

771 patients were analyzed.The highest sensitivity for predicting overall hospitalization and intensive care admission was seen for DTS (95.4 %, 100 %; p < 0.0001, p < 0.0001, respectively) (AUC:0.697, 95 % CI 0.663 to 0.730; AUC:0.684, 95 % CI 0.650 to 0.717, respectively). The highest sensitivity for predicting 1st week and 1st month mortality was found for DTS (100 %, 96.3 %; p < 0.0001, p < 0.0001, respectively). However, the highest specificity for predicting 1st week and 1st month mortality was observed in tqSOFA (94.1 %, 95.16; p = 0.0845, p < 0.0001, respectively) (AUC:0.658, 95 % CI 0.623 to 0.691; AUC:0.698, 95 % CI 0.664 to 0.730, respectively).

CONCLUSION

We found DTS to be as effective as tqSOFA and SIRS in determining all hospitalization times and mortality.

Educational intervention in triage with the Swedish triage scale RETTS©, with focus on specialist nurse students in ambulance and emergency care - A cross-sectional study

AIM

To determine the reliability of application of the RETTS© triage scale after an educational intervention using paper-based scenarios in emergency care education.

BACKGROUND

Knowledge about and education in triage are important factors in triagescale implementation. Presenting students with a large number of triage scenarios is a common part of triage education.

METHODS

In this prospective cross-sectional study at two universities students undergoing education in emergency care used RETTS© to assess triage level in 46 paper-based scenarios.

RESULTS

57 students in the study made 2590 final triage decisions. Fleiss Kappa for final triage was 0.411 which is in the lower range of moderate agreement. In 25 of 46 (53.4%) scenarios, final triage levels did not agree about whether the case was stable or unstable.

CONCLUSION/IMPLICATIONS

Application of the RETTS© triage scale after an educational intervention with paper-based simulation in emergency care education resulted in moderate agreement about the final levels of triage.

Comparing the prehospital NEWS with in-hospital ESI in predicting 30-day severe outcomes in emergency patients

BACKGROUND

In Iran, the emergency departments (EDs) have largely adopted the emergency severity index (ESI) to prioritize the emergency patients, however emergency medical services (EMS) mainly triage the patients based on the paramedics' gestalt. The National Early Warning Score (NEWS) is a recommended prehospital triage in the UK. We aimed to compare prehospital NEWS and ED ESI for predicting severe outcomes in emergency patients.

METHODS

An observational study was conducted in a university-affiliated ED between January and April 2021. Adult patients who arrived in the ED by EMS were included. EMS providers calculated the patients' NEWS upon arriving on the scene using an Android NEWS application. In the ED, triage nurses utilized the ESI algorithm to prioritize patients with higher clinical risk. Then, Research nurses recorded patients' 30-day severe outcomes (death or ICU admission). Finally, The prognostic properties of ESI and NEWS were evaluated.

RESULTS

One thousand forty-eight cases were included in the final analysis, of which 29 (2.7%) patients experienced severe outcomes. The difference between the prehospital NEWS and ED ESI in predicting severe outcomes was not statistically significant (AUC = 0.825, 95% CI: 0.74-0.91 and 0.897, 95% CI, 0.83-0.95, for prehospital NEWS and ESI, respectively).

CONCLUSION

Our findings indicated that prehospital NEWS compares favorably with ED ESI in predicting 30-day severe outcomes in emergency patients.

Mobile Triage Applications: A Systematic Review in Literature and Play Store

The main objective of this paper is to review and analysis of the state of the art regarding triage applications (apps) for health emergencies. This research is based on a systematic review of the literature in scientific databases from 2010 to early 2021, following a prism methodology. In addition, a Google Play Store search of the triage apps found in the literature was performed for further evaluation. A total of 26 relevant papers were obtained for this study, of which 13 apps were identified. After searching for each of these apps in the Google Play Store platform, only 2 of them were obtained, and these were subsequently evaluated together with another app obtained from the link provided in the corresponding paper. In the analysis carried out, it was detected that from 2019 onwards there has been an increase in research interest in this area, since the papers obtained from this year onwards represent 38.5% of the relevant papers. This increase may be caused by the need for early selection of the most serious patients in such difficult times for the health service. According to the review carried out, an increase in mobile app research focused on Emergency Triage and a decrease in app studies for triage catastrophe have been identified. In this study it was also observed that despite the existence of many researches in this sense, only 3 apps contained in them are accessible. "TRIAGIST" does not allow the entry of an unidentified user, "Major Trauma Triage Tool" presents negative comments from users who have used it and "ESITriage" lacks updates to improve its performance.

The effects of mobile health on emergency care in low- and middle-income countries: A systematic review and narrative synthesis

BACKGROUND

In resource-constrained settings, mobile health (mHealth) has varied applications. While there is strong evidence for its use in chronic disease management, the applications of mHealth for management of acute illness in low- and middle-income countries (LMICs) are not as well described. This review systematically explores current available evidence on the effectiveness of mHealth interventions at improving health outcomes in emergency care settings in LMICs.

METHODS

A systematic search of the literature was performed in accordance with PRISMA guidelines, utilizing seven electronic databases and manual searches to identify peer-reviewed literature containing each of three search elements: mHealth, emergency care (EC), and LMICs. Articles quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

After removing duplicates, 6498 studies met initial search criteria; 108 were eligible for full text review and 46 met criteria for inclusion. Thirty-six pertained to routine emergency care, and 10 involved complex humanitarian emergencies. Based on the GRADE criteria, 15 studies were rated as "Very Low" quality, 24 as "Low" quality, 6 as "Moderate" quality, and 1 as "High" quality. Eight studied data collection, 9 studied decision support, 15 studied direct patient care, and 14 studied health training. All 46 studies reported positive impacts of mHealth on EC in LMICs.

CONCLUSIONS

Mobile health interventions can be effective in improving provider-focused and patient-centered outcomes in both routine and complex EC settings. Future investigations focusing on patient-centered outcomes are needed to further validate these findings.

Assessment of Interrater Reliability of the Emergency Severity Index After Implementation in Emergency Departments in Jamaica Using a Learning Collaborative Approach

INTRODUCTION

In 2016, the Ministry of Health in Jamaica selected the Emergency Severity Index as the triage tool to be used nationally. This study evaluated the effectiveness of this approach by assessing the interrater reliability among new users trained with minimal resources by 2 experienced trainers, 1 local and 1 international.

METHODS

A retrospective case series review was conducted within an online learning collaborative framework. After completion of the training, the participants from each of the 19 clinical sites were asked to submit 2 triage cases per month for blinded review by the expert trainers. The triage categories assigned by each reviewer were compared with those assigned by the newly trained Emergency Severity Index providers. A weighted kappa value was calculated to assess the degree of agreement between the sites and the expert trainers.

RESULTS

A total of 166 cases were received over the study period. Participation in the learning collaborative was consistently below 50%. The interrater reliability between the expert trainers (κ = 0.48) as well as between each scorer and each accident and emergency department site (κ_SF = 0.33, κ_PT = 0.26) was low, although there was improvement over the study period. Incomplete triage documentation limited raters' ability to assign triage categories and assess interrater reliability.

DISCUSSION

Despite a rigorous implementation process, the interrater reliability of the Emergency Severity Index skills of Jamaican emergency nurses and doctors when compared with that of the 2 experts was poor. Several areas were identified for strengthening. Considerations for the implementation of the Emergency Severity Index in countries outside of the US were also discussed.

Emergency Severity Index as a predictor of in-hospital mortality in suspected sepsis patients in the emergency department

OBJECTIVES

To demonstrate the accuracy, sensitivity, and specificity of the Emergency Severity Index (ESI), quick Sepsis-related Organ Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome (SIRS) criteria, and National Early Warning Score (NEWS) for predicting in-hospital mortality and intensive care unit (ICU) admission in suspected sepsis patients.

METHODS

A retrospective cohort study conducted at a tertiary care hospital, Thailand. Suspected sepsis was defined by a combination of (1) hemoculture collection and (2) the initiation of intravenous antibiotics therapy during the emergency department (ED) visit. The accuracy of each scoring system for predicting in-hospital mortality and ICU admission was analyzed.

RESULTS

A total of 8177 patients (median age: 62 years, 52.3% men) were enrolled in the study, 509 (6.2%) of whom died and 1810 (22.1%) of whom were admitted to the ICU. The ESI and NEWS had comparable accuracy for predicting in-hospital mortality (AUC of 0.70, 95% confidence interval [CI] 0.68 to 0.73 and AUC of 0.73, 95% CI 0.70 to 0.75) and ICU admission (AUC of 0.75, 95% CI 0.74 to 0.76 and AUC of 0.74, 95% CI 0.72 to 0.75). The ESI level 1-2 had the highest sensitivity for predicting in-hospital mortality (96.7%), and qSOFA ≥2 had the highest specificity (86.6%).

CONCLUSION

The ESI was accurate and had the highest sensitivity for predicting in-hospital mortality and ICU admission in suspected sepsis patients in the ED. This confirms that the ESI is useful in both ED triage and predicting adverse outcomes in these patients.

Thailand medical mobile application for patients triage base on criteria based dispatch protocol

BACKGROUND

Before patients are admitted into the emergency department, it is important to undertake a pre-hospital process, both in terms of treatment performance and a request for resources from an emergency unit. The existing system to triage patients in Thailand is not functioning to its full capacity in either the primary medical system or pre-hospital treatment with shortcomings in the areas of speed, features, and appropriate systems. There is a high possibility of issuing a false Initial Dispatch Code (IDC), which will cause the over or underutilisation of emergency resources, such as rescue teams, community hospitals and emergency medical volunteers.

METHODS

A usability system design, together with a reliability test, was applied to develop an application to optimise the pre-hospital process, specifically to sort patients, using an IDC to improve the request for emergency resources. The triage mobile application was developed on both iOS and Android operating systems to support patient triage based on Criteria Based Dispatch (CBD). The 25 main symptom categories covered by CBD were used to design and develop the application, and 12 emergency medical staff, including doctors and nurses, were asked to test the system in the aspects of triage protocol correction, triage reliability, usability and user satisfaction.

RESULTS

The results of testing the proposed triage application were compared with the time used to triage by experienced staff and it was found that, in non-trauma cases, it was faster and more effective to use the application for emergency operations and to correct the IDC code representation.

CONCLUSIONS

The triage application will be utilised to support the pre-hospital process and to classify patients' conditions before they are admitted to the Emergency Department (ED). The application is suitable for users who are not medical emergency staff. Patients with non-trauma symptoms may be a suitable group to use the application in terms of time used to identify IDC for their own symptoms. The use of the application can be beneficial for those who wish to self-identify their symptoms before requesting medical services.