Does START triage work? The answer is clear!

Computer-assisted diagnostics

Healthcare is at the edge of a profound renovation or collapse due to the rapid inflow of machine learning protocols and procedures able to optimize several processes. Clinical trials are key for the progress of science and the correct interpretation of data. Rickard et al., in this journal, report that data on misidentification rates in medical trials are scarce. In five trials involving more than 800 blood or histology specimens examined, data clarification forms (DCFs) were issued for 21% of instances, and 67% were related to sample identification. The authors suggest that a suitable number of de- recognized data points is critical. Moreover, a formalized process involving the specimen accession employed in routine care is key to mitigate recognition errors and their potential profound impact on clinical research and outcome. We fully agree with the authors and their report is highly relevant today that we face transformation in healthcare. We suggest that 3D barcoding may mitigate several issues on misidentification.

The Impact of In-Event Health Services at Europe's Largest Electronic Dance Music Festival on Ems and Ed in the Host Community

BACKGROUND

Electronic dance music festivals (EDMF) can cause a significant disruption in the standard operational capacity of emergency medical services (EMS) and hospitals. We determined whether or not the presence of in-event health services (IEHS) can reduce the impact of Europe's largest EDMF on the host community EMS and local emergency departments (EDs).

METHODS

We conducted a pre-post analysis of the impact of Europe's largest EDMF in July 2019, in Boom, Belgium, on the host community EMS and local EDs. Statistical analysis included descriptive statistics, independent t-tests, and χ2 analysis.

RESULTS

Of 400,000 attendees, 12,451 presented to IEHS. Most patients only required in-event first aid, but 120 patients had a potentially life-threatening condition. One hundred fifty-two patients needed to be transported by IEHS to nearby hospitals, resulting in a transport-to-hospital rate of 0.38/1000 attendees. Eighteen patients remained admitted to the hospital for >24 h; one died after arrival in the ED. IEHS limited the overall impact of the MGE on regular EMS and nearby hospitals. No predictive model proved optimal when proposing the optimal number and level of IEHS members.

CONCLUSIONS

This study shows that IEHS at this event limited ambulance usage and mitigated the event's impact on regular emergency medical and health services.

Promptly reporting of critical laboratory values in pediatrics: A work in progress

In the 21^st century, the determination of alert thresholds remains the most challenging and controversial issue in clinical pediatrics. Pre-analytical, analytical, and post-analytical matters will consolidate or undermine the fate of any laboratory process. Pre-analytical issues need to be cleared off before the laboratory physician can dispatch the result to the pediatrician in charge. Once it is cleared off, the classification of essential laboratory results is paramount. It is more than an academic exercise and may be subdivided in the order of priority we handle it to inform promptly and safely the primary physicians. Currently, we are applying new modes of making sure relevant information is transmitted without interrupting the standard workflow of the primary physicians in charge for the child, who eventually need a fast line of action for results that may be life-threatening.

A better START for low-acuity victims: data-driven refinement of mass casualty triage

OBJECTIVE

Methods currently used to triage patients from mass casualty events have a sparse evidence basis. The objective of this project was to assess gaps of the widely used Simple Triage and Rapid Transport (START) algorithm using a large database when it is used to triage low-acuity patients. Subsequently, we developed and tested evidenced-based improvements to START.

METHODS

Using the National Trauma Database (NTDB), a large set of trauma victims were assigned START triage levels, which were then compared to recorded patient mortality outcomes using area under the receiver-operator curve (AUC). Subjects assigned to the "Minor/Green" level who nevertheless died prior to hospital discharge were considered mistriaged. Recursive partitioning identified factors associated with of these mistriaged patients. These factors were then used to develop candidate START models of improved triage, whose overall performance was then re-evaluated using data from the NTDB. This process of evaluating performance, identifying errors, and further adjusting candidate models was repeated iteratively.

RESULTS

The study included 322,162 subjects assigned to "Minor/Green" of which 2,046 died before hospital discharge. Age was the primary predictor of under-triage by START. Candidate models which re-assigned patients from the "Minor/Green" triage level to the "Delayed/Yellow" triage level based on age (either for patients >60 or >75), reduced mortality in the "Minor/Green" group from 0.6% to 0.1% and 0.3%, respectively. These candidate START models also showed net improvement in the AUC for predicting mortality overall and in select subgroups.

CONCLUSION

In this research model using trauma registry data, most START under-triage errors occurred in elderly patients. Overall START accuracy was improved by placing elderly but otherwise minimally injured-mass casualty victims into a higher risk triage level. Alternatively, such patients would be candidates for closer monitoring at the scene or expedited transport ahead of other, younger "Minor/Green" victims.

An Analysis of Patient Presentations at a 2-Day Mass-participation Cycling Event: The Ride to Conquer Cancer Case Series, 2010-2012

Objective

To analyze the unique factors involved in providing medical support for a long-distance, cross-border, cycling event, and to describe patient presentations and event characteristics for the British Columbia (BC) Ride to Conquer Cancer from 2010 through 2012.

Methods

This study was a 3-year, descriptive case series report. Medical encounters were documented, prospectively, from 2010-2012 using an online registry. Data for event-related variables also were reported.

Results

Providing medical support for participants during the 2-day ride was complicated by communication challenges, weather conditions, and cross-border issues. The total number of participants for the ride increased from 2,252 in 2010 to 2,879 in 2011, and 3,011 in 2012. Patient presentation rates (PPRs) of 125.66, 155.26, and 198.93 (per 1,000 participants) were documented from 2010 through 2012. Over the course of three years, and not included in the PPR, an additional 3,840 encounters for “self-treatment” were documented.

Conclusions

The Ride to Conquer Cancer Series has shown that medical coverage at multi-day, cross-national cycling events must be planned carefully to face a unique set of circumstances, including legislative issues, long-distance communication capabilities, and highly mobile participants. This combination of factors leads to potentially higher PPRs than have been reported for noncycling events. This study also illuminates the additional workload “self-treatment” visits place on the medical team.

LundA, TurrisSA, WangP, MuiJ, LewisK, GutmanSJ. An analysis of patient presentations at a 2-day mass-participation cycling event: The Ride to Conquer Cancer Case Series, 2010-2012. Prehosp Disaster Med. 2014;29(4):1-8.

Mass-Gathering Medicine: Creation of an Online Event and Patient Registry

Introduction/Problem

A review of the mass-gathering medicine literature confirms that the research community currently lacks a standardized approach to data collection and reporting in relation to large-scale community events. This lack of consistency, particularly with regard to event characteristics, patient characteristics, acuity determination, and reporting of illness and injury rates makes comparisons between and across events difficult. In addition, a lack of access to good data across events makes planning medical support on-site, for transport, and at receiving hospitals, challenging. This report describes the development of an Internet-hosted, secure registry for event and patient data in relation to mass gatherings.

Methods

Descriptive; development and pilot testing of a Web-based event and patient registry.

Results

Several iterations of the registry have resulted in a cross-event platform for standardized data collection at a variety of events. Registry and reporting field descriptions, successes, and challenges are discussed based on pilot testing and early implementation over two years of event enrollment.

Conclusion

The Mass-Gathering Medicine Event and Patient Registry provides an effective tool for recording and reporting both event and patient-related variables in the context of mass-gathering events. Standardizing data collection will serve researchers and policy makers well. The structure of the database permits numerous queries to be written to generate standardized reports of similar and dissimilar events, which supports hypothesis generation and the development of theoretical foundations in mass-gathering medicine.

LundA,TurrisSA,AmiriN,LewisK,CarsonM.Mass-gathering medicine: creation of an online event and patient registry.Prehosp Disaster Med.2012;27(6):1-11.

Triage During Mass Gatherings

Triage is a complex process and is one means for determining which patients most need access to limited resources. Triage has been studied extensively, particularly in relation to triage in overcrowded emergency departments, where individuals presenting for treatment often are competing for the available stretchers. Research also has been done in relation to the use of prehospital and field triage during mass-casualty incidents and disasters.

In contrast, scant research has been done to develop and test an effective triage approach for use in mass-gathering and mass-participation events, although there is a growing body of knowledge regarding the health needs of persons attending large events. Existing triage and acuity scoring systems are suboptimal for this unique population, as these events can involve high patient presentation rates (PPR) and, occasionally, critically ill patients. Mass-gathering events are dangerous; a higher incidence of injury occurs than would be expected from general population statistics.

The need for an effective triage and acuity scoring system for use during mass gatherings is clear, as these events not only create multiple patient encounters, but also have the potential to become mass-casualty incidents. Furthermore, triage during a large-scale disaster or mass-casualty incident requires that multiple, local agencies work together, necessitating a common language for triage and acuity scoring.

In reviewing existing literature with regard to triage systems that might be employed for this population, it is noted that existing systems are biased toward traumatic injuries, usually ignoring mitigating factors such as alcohol and drug use and environmental exposures. Moreover, there is a substantial amount of over-triage that occurs with existing prehospital triage systems, which may lead to misallocation of limited resources. This manuscript presents a review of the available literature and proposes a triage system for use during mass gatherings that also may be used in the setting of mass-casualty incidents or disaster responses.

TurrisSA, LundA. Triage during mass gatherings. Prehosp Disaster Med. 2012;27(6):1-5.

Independent Application of the Sacco Disaster Triage Method to Pediatric Trauma Patients

Introduction

Though many mass-casualty triage methods have been proposed, few have been validated in an evidence-based manner. The Sacco Triage Method (STM) has been shown to accurately stratify adult victims of blunt and penetrating trauma into groups of increasing mortality risk. However, it has not been validated for pediatric trauma victims.

Purpose

Evaluate the STM's performance in pediatric trauma victims.

Methods

Records from the United States’ National Trauma Data Base, a registry of trauma victims developed by the American College of Surgeons, were extracted for the 2007-2009 reporting years. Patients ≤18 years of age transported from a trauma scene with complete initial scene data were included in the analysis. Sacco triage scores were assigned to each registry patient, and receiver-operator curves were developed for predicting mortality, along with several secondary outcomes. Area under the receiver-operator curve (AUC) was the main outcome statistic. Sensitivity analysis was performed using a Sacco score without age adjustment, using blunt versus penetrating trauma, and using patients <12 years of age.

Results

There were 210,175 pediatric records, of which 90,037 had complete data for analysis. The STM with age adjustment predicted pediatric trauma mortality with an AUC of 0.933 (95% CI: 0.925-0.940). Without the age adjustment term, it predicted mortality with an AUC of 0.924 (95% CI: 0.916-0.933). The STM with age adjustment predicted blunt trauma mortality in 72,467 patients with an AUC of 0.938 (95% CI: 0.929-0.947) and penetrating trauma mortality in 10,099 patients with an AUC of 0.927 (95% CI: 0.911-0.943). These findings did not change significantly when analysis was limited to patients <12 years of age. The Sacco Triage Method was also predictive of some secondary outcomes, such as major injury and death on arrival to the emergency department.

Conclusion

The Sacco Triage Method, with or without its age adjustment term, was a highly accurate predictor of mortality in pediatric trauma patients in this registry database. This triage method appears to be a valid strategy for the prioritization of injured children.

Cross KP, Cicero MX. Independent application of the Sacco Disaster Triage Method to pediatric trauma patients. Prehosp Disaster Med. 2012;27(4):1-6.