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Bartenschlager CC, Brunner JO, Kubiciel M, Heller AR. Evaluation of score-based tertiary triage policies during the COVID-19 pandemic: simulation study with real-world intensive care data. Med Klin Intensivmed Notfmed 2024:10.1007/s00063-024-01162-8. [PMID: 39093430 DOI: 10.1007/s00063-024-01162-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/20/2024] [Accepted: 06/11/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVE The explicit prohibition of discontinuing intensive care unit (ICU) treatment that has already begun by the newly established German Triage Act in favor of new patients with better prognoses (tertiary triage) under crisis conditions may prevent saving as many patients as possible and therefore may violate the international well-accepted premise of undertaking the "best for the most" patients. During the COVID-19 pandemic, authorities set up lockdown measures and infection-prevention strategies to avoid an overburdened health-care system. In cases of situational overload of ICU resources, when transporting options are exhausted, the question of a tertiary triage of patients arises. METHODS We provide data-driven analyses of score- and non-score-based tertiary triage policies using simulation and real-world electronic health record data in a COVID-19 setting. Ten different triage policies, for example, based on the Simplified Acute Physiology Score (SAPS II), are compared based on the resulting mortality in the ICU and inferential statistics. RESULTS Our study shows that score-based tertiary triage policies outperform non-score-based tertiary triage policies including compliance with the German Triage Act. Based on our simulation model, a SAPS II score-based tertiary triage policy reduces mortality in the ICU by up to 18 percentage points. The longer the queue of critical care patients waiting for ICU treatment and the larger the maximum number of patients subject to tertiary triage, the greater the effect on the reduction of mortality in the ICU. CONCLUSION A SAPS II score-based tertiary triage policy was superior in our simulation model. Random allocation or "first come, first served" policies yield the lowest survival rates, as will adherence to the new German Triage Act. An interdisciplinary discussion including an ethical and legal perspective is important for the social interpretation of our data-driven results.
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Affiliation(s)
- Christina C Bartenschlager
- Applied Data Science in Healthcare, Nürnberg School of Health, Ohm University of Applied Sciences Nuremberg, 90489, Nürnberg, Germany.
- Anaesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, University Hospital of Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
| | - Jens O Brunner
- Decision Science in Healthcare, Department of Technology, Management, and Economics, Technical University of Denmark, Akademivej, Kongens Lyngby, 2800, Denmark
| | - Michael Kubiciel
- Chair of German, European and International Criminal, Medical and Economic Law, University of Augsburg, Universitätsstraße 24, 86159, Augsburg, Germany
| | - Axel R Heller
- Anaesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, University Hospital of Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
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Ikram F, Sukhia RH, Fida M. Knowledge and Awareness of the orthodontic triage and its uses among dental healthcare professionals - a cross-sectional study. BMC Oral Health 2024; 24:863. [PMID: 39080667 PMCID: PMC11288081 DOI: 10.1186/s12903-024-04593-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 07/09/2024] [Indexed: 08/03/2024] Open
Abstract
INTRODUCTION In orthodontics, the triage system is used to assess the preadolescents to rule out interventions needed earlier and to assess the nature of orthodontic problems as complex or moderate. The objective of this study was to determine the knowledge and awareness of orthodontic triage and its uses among dental healthcare professionals (DHCP). MATERIALS AND METHODS A triage awareness questionnaire (TAQ) was formulated and validated as reliable by a panel of five orthodontic specialists which was then circulated online among 400 DHCP. The questionnaire consisted of nine sections that assessed the current knowledge and usage of orthodontic triage among the dental community. Frequencies and percentages were reported for all categorical variables. Chi-square was used to assess the association among the variables. RESULTS The response rate was 28.2% with the majority of participants being general dentists. Regarding the knowledge and use of triage, 40% of DHCP were only familiar with the word "orthodontic triage" while being unaware of how it works and 79% denied using orthodontic triage. Regarding the management of anomalies, 42% of DHCP preferred extraction as the management of supernumerary teeth (p = 0.013). Practitioners belonging to private setups performed visual inspection in growing patients for assessment of their facial features (p = 0.012). Clinicians with more than one year of experience referred young patients to orthodontic specialists for the management of crossbite (p = 0.024). Younger clinicians (25-35 years) with more than one year of experience referred adult patients to orthodontists for correction of their unesthetic smile (p = 0.013). CONCLUSIONS This paper provides foundational data for the development of future policies and protocols supporting structured, evidence-based approaches to patient management via use of orthodontic triage. This study underscores the importance of targeted educational interventions to enhance understanding and implementation of orthodontic triage principles in clinical practice. Further probing is necessary to discern the disparity between understanding the orthodontic triage and effective employment of its components among practicing dental healthcare professionals.
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Affiliation(s)
- Fizzah Ikram
- Department of Surgery, The Aga Khan University Hospital, Stadium Road, P.O Box 3500, Karachi, 74800, Pakistan
| | - Rashna Hoshang Sukhia
- Department of Surgery, The Aga Khan University Hospital, Stadium Road, P.O Box 3500, Karachi, 74800, Pakistan.
| | - Mubassar Fida
- Department of Surgery, The Aga Khan University Hospital, Stadium Road, P.O Box 3500, Karachi, 74800, Pakistan
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Karwa ML, Naqvi AA, Betchen M, Puri AK. In-Hospital Triage. Crit Care Clin 2024; 40:533-548. [PMID: 38796226 DOI: 10.1016/j.ccc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.
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Affiliation(s)
- Manoj L Karwa
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Weiler Hospital, 4th Floor, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Ali Abbas Naqvi
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Melanie Betchen
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Ajay Kumar Puri
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
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Meral G, Ateş S, Günay S, Öztürk A, Kuşdoğan M. Comparative analysis of ChatGPT, Gemini and emergency medicine specialist in ESI triage assessment. Am J Emerg Med 2024; 81:146-150. [PMID: 38728938 DOI: 10.1016/j.ajem.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/21/2024] [Accepted: 05/02/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION The term Artificial Intelligence (AI) was first coined in the 1960s and has made significant progress up to the present day. During this period, numerous AI applications have been developed. GPT-4 and Gemini are two of the best-known of these AI models. As a triage system The Emergency Severity Index (ESI) is currently one of the most commonly used for effective patient triage in the emergency department. The aim of this study is to evaluate the performance of GPT-4, Gemini, and emergency medicine specialists in ESI triage against each other; furthermore, it aims to contribute to the literature on the usability of these AI programs in emergency department triage. METHODS Our study was conducted between February 1, 2024, and February 29, 2024, among emergency medicine specialists in Turkey, as well as with GPT-4 and Gemini. Ten emergency medicine specialists were included in our study but as a limitation the emergency medicine specialists participating in the study do not frequently use the ESI triage model in daily practice. In the first phase of our study, 100 case examples related to adult or trauma patients were extracted from the sample and training cases found in the ESI Implementation Handbook. In the second phase of our study, the provided responses were categorized into three groups: correct triage, over-triage, and under-triage. In the third phase of our study, the questions were categorized according to the correct triage responses. RESULTS In the results of our study, a statistically significant difference was found between the three groups in terms of correct triage, over-triage, and under-triage (p < 0.001). GPT-4 was found to have the highest correct triage rate with an average of 70.60 (±3.74), while Gemini had the highest over-triage rate with an average of 35.2 (±2.93) (p < 0.001). The highest under-triage rate was observed in emergency medicine specialists (32.90 (±11.83)). In the ESI 1-2 class, Gemini had a correct triage rate of 87.77%, GPT-4 had 85.11%, and emergency medicine specialists had 49.33%. CONCLUSION In conclusion, our study shows that both GPT-4 and Gemini can accurately triage critical and urgent patients in ESI 1&2 groups at a high rate. Furthermore, GPT-4 has been more successful in ESI triage for all patients. These results suggest that GPT-4 and Gemini could assist in accurate ESI triage of patients in emergency departments.
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Affiliation(s)
- Gürbüz Meral
- Department of Emergency Medicine, Specialist in Emergency Medicine, Hitit University Çorum Erol Olçok Education and Research Hospital, Çorum, Turkey.
| | - Serdal Ateş
- Department of Emergency Medicine, Specialist in Emergency Medicine, Hitit University Çorum Erol Olçok Education and Research Hospital, Çorum, Turkey
| | - Serkan Günay
- Department of Emergency Medicine, Specialist in Emergency Medicine, Hitit University Çorum Erol Olçok Education and Research Hospital, Çorum, Turkey
| | - Ahmet Öztürk
- Department of Emergency Medicine, Specialist in Emergency Medicine, Hitit University Çorum Erol Olçok Education and Research Hospital, Çorum, Turkey
| | - Mikail Kuşdoğan
- Department of Emergency Medicine, Specialist in Emergency Medicine, Hitit University Çorum Erol Olçok Education and Research Hospital, Çorum, Turkey
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Liu X, Lai R, Wu C, Yan C, Gan Z, Yang Y, Zeng X, Liu J, Liao L, Lin Y, Jing H, Zhang W. Assessing the utility of artificial intelligence throughout the triage outpatients: a prospective randomized controlled clinical study. Front Public Health 2024; 12:1391906. [PMID: 38873307 PMCID: PMC11171710 DOI: 10.3389/fpubh.2024.1391906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/08/2024] [Indexed: 06/15/2024] Open
Abstract
Currently, there are still many patients who require outpatient triage assistance. ChatGPT, a natural language processing tool powered by artificial intelligence technology, is increasingly utilized in medicine. To facilitate and expedite patients' navigation to the appropriate department, we conducted an outpatient triage evaluation of ChatGPT. For this evaluation, we posed 30 highly representative and common outpatient questions to ChatGPT and scored its responses using a panel of five experienced doctors. The consistency of manual triage and ChatGPT triage was assessed by five experienced doctors, and statistical analysis was performed using the Chi-square test. The expert ratings of ChatGPT's answers to these 30 frequently asked questions revealed 17 responses earning very high scores (10 and 9.5 points), 7 earning high scores (9 points), and 6 receiving low scores (8 and 7 points). Additionally, we conducted a prospective cohort study in which 45 patients completed forms detailing gender, age, and symptoms. Triage was then performed by outpatient triage staff and ChatGPT. Among the 45 patients, we found a high level of agreement between manual triage and ChatGPT triage (consistency: 93.3-100%, p<0.0001). We were pleasantly surprised to observe that ChatGPT's responses were highly professional, comprehensive, and humanized. This innovation can help patients win more treatment time, improve patient diagnosis and cure rates, and alleviate the pressure of medical staff shortage.
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Affiliation(s)
- Xiaoni Liu
- Department of Hematology, Lymphoma Research Center, Peking University Third Hospital, Beijing, China
- Department of Respiratory Medicine, First Affiliated Hospital Gannan Medical University, Ganzhou, China
| | - Rui Lai
- Department of Respiratory Medicine, The People's Hospital of Ruijin City, Ruijin, China
| | - Chaoling Wu
- Department of Respiratory Medicine, Affiliated Hospital of Jiujiang University, Jiujiang, China
| | - Changjian Yan
- The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Zhe Gan
- Gannan Medical University, Ganzhou, China
| | - Yaru Yang
- Department of Hematology, Lymphoma Research Center, Peking University Third Hospital, Beijing, China
| | - Xiangtai Zeng
- Department of Thyroid and Hernia Surgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Jin Liu
- Department of Respiratory Medicine, Longnan First People's Hospital, Longnan, China
| | - Liangliang Liao
- Department of Respiratory Medicine, Longnan First People's Hospital, Longnan, China
| | - Yuansheng Lin
- Department of Emergency and Critical Care Medicine, Suzhou Hospital, Affiliated Hospital of Medical School, Nanjing University, Suzhou, China
| | - Hongmei Jing
- Department of Hematology, Lymphoma Research Center, Peking University Third Hospital, Beijing, China
| | - Weilong Zhang
- Department of Hematology, Lymphoma Research Center, Peking University Third Hospital, Beijing, China
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Behzadi Koochnai N, Muñoz Romo R, Riera López N, Caballero Cubedo R, Gómez de la Oliva S, Martin de Rosales Cabrera T, Castaño Reguillo A. Digitalisation of information and management optimisation in Multiple Victim Incidents. Analytical study. PLoS One 2024; 19:e0303247. [PMID: 38743753 PMCID: PMC11093311 DOI: 10.1371/journal.pone.0303247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/22/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Triage is a crucial tool for managing a Multiple Victim Incident (MVI). One particularly problematic issue is the communication of results to the chain of command and control. Favourable data exists to suggest that digital triage can improve some features of analogue triage. Within this context we have witnessed the emergence of the Valkyries Project, which is working to develop strategies to respond to MVIs, and especially cross-border incidents. To that end, an IT platform called "SIGRUN" has been created which distributes, in real time, all the information to optimise MVI management. A full-scale simulation, held on the Spain-Portugal border and featuring contributions from different institutions on both sides of the border, put to the test the role of information digitalisation in this type of incidents. OBJECTIVE To evaluate the impact of the synchronous digitalisation of information on the optimal management of Multiple Victim Incidents. METHOD Clinical evaluation study carried out on a cross-border simulation between Spain and Portugal. A Minimum Data Set (MDS) was established by means of a modified Delphi by a group of experts. The digital platform "SIGRUN" integrated all the information, relaying it in real time to the chain of command and control. Each country assigned two teams that would carry out digital and analogue triage synchronously. Analogue triage variables were gathered by observers accompanying the first responders. Digital triage times were recorded automatically. Each case was evaluated and classified simultaneously by the two participating teams, to carry out a reliability study in a real time scenario. RESULTS The total duration of the managing of the incident in the A group of countries involved compared to the B group was 72.5 minutes as opposed to 73 minutes. The total digital assistance triage (AT) time was 37.5 seconds in the digital group, as opposed to 32 minutes in the analogue group. Total evacuation (ET) time was 28 minutes in the digital group compared with 65 minutes in the analogue group. The average differences in total times between the analogue and the digital system, both for primary and secondary evaluation, were statistically significant: p = 0.048 and p = 0.000 respectively. For the "red" category, AT obtained a sensitivity of 100%, also for ET, while with regard to AT safety it obtained a PPV of 61.54% and an NPV of 100%, and for ET it obtained a PPV of 83.33% and an NPV of 100%. For the analogue group, for AT it obtained a sensitivity of 62.50%, for ET, 70%, for AT safety it obtained a PPV of 45.45% and an NPV of 92.31%, while for ET it obtained a PPV of 70% and an NPV of 92.50%. The gap analysis obtained a Kappa index of 0.7674. CONCLUSION The triage system using the developed digital tool demonstrated its validity compared to the analogue tool, as a result of which its use is recommended.
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Affiliation(s)
- Navid Behzadi Koochnai
- Servicio de Urgencias Médicas de la Comunidad de Madrid (SUMMA112), Madrid, Spain
- Fundación para la Investigación e Innovación Biosanitarias en Atención Primaria (FIIBAP), Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Camilo José Cela de Madrid, Madrid, Spain
| | - Raúl Muñoz Romo
- Servicio de Urgencias Médicas de la Comunidad de Madrid (SUMMA112), Madrid, Spain
| | - Nicolás Riera López
- Servicio de Urgencias Médicas de la Comunidad de Madrid (SUMMA112), Madrid, Spain
| | | | | | | | - Almudena Castaño Reguillo
- Fundación para la Investigación e Innovación Biosanitarias en Atención Primaria (FIIBAP), Madrid, Spain
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Açıksarı K, Koçak M, Solakoğlu GA, Bodas M. The effect of multiple triage points on the outcomes (time and accuracy) of hospital triage during mass casualty incidents. Injury 2024; 55:111318. [PMID: 38238120 DOI: 10.1016/j.injury.2024.111318] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 12/27/2023] [Accepted: 01/07/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION During mass casualty incidents (MCIs), the accuracy and timing of the triage of patients by the emergency department (ED) triage officers are essential. The primary triage is performed at the event's location by paramedics and intends a quick evaluation of the victims. Secondary triage may be used when the transfer of the victim is delayed. In this study, we aimed to investigate the effectiveness of two-point triage in a simulated environment of an MCI in the hospital setting. MATERIALS AND METHODS In this case-control study, we used an online test module to assess single triage points (Group 1, n = 41) and two triage points (Group 2, n = 40). 60 vignettes for Group 1 and 55 vignettes (5 deceased cases removed) for Group 2 were used. The assessment utilized clinical MCI scenarios in a scheduled online meeting by using the Simple Triage and Rapid Treatment (START) system. Triage time and accuracy of the triage, along with the experience, and previous training of the participants, were assessed. RESULTS A total of 81 triage officers participated in this study. The participants were divided into two independent groups homogenously according to their profession and experience. Groups were comparable primarily without any statistically significant difference in terms of the profession (p = 0.101), sex (p = 0.923), and MCI experience (p = 0.785). The difference between the two groups was not significant with regard to having received practical or theoretical triage training (p = 0.099). The mean time of a single vignette triage was 19.2 (SD 6.5) seconds and mean percentage of correct triage score was 65.0 (SD 12.6). The participants had a statistically significantly better performance in the single-point triage group regarding the median triage time (p < 0.001) and median percentages of under triage (p = 0.001), but a worse median percentage of over triage (p < 0.001). However, there was no significant difference between the two groups in terms of the percentage of accurate triage. Emergency residents performed better in accuracy and triage time than their non-physician colleagues (p = 0.019). CONCLUSIONS Two-point triage does not demonstrate better outcomes in terms of accuracy and timing. Triage officers should be trained frequently with the preferred training methodology to prevent improper triage accuracy and timing. Well-defined medical disaster planning should include frequent training of the triage officers with case scenarios.
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Affiliation(s)
- Kurtulus Açıksarı
- Department of Emergency Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Mehmet Koçak
- Department of Emergency Medicine, Primary Health Care Corporation, Doha, Qatar.
| | - Görkem Alper Solakoğlu
- Department of Emergency Medicine, Faculty of Medicine, Istanbul Medeniyet University Istanbul, Turkey
| | - Moran Bodas
- Department of Emergency & Disaster Management, School of Public Health, Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, Israel
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Alchikh M, Conrad TOF, Obermeier PE, Ma X, Schweiger B, Opota O, Rath BA. Disease Burden and Inpatient Management of Children with Acute Respiratory Viral Infections during the Pre-COVID Era in Germany: A Cost-of-Illness Study. Viruses 2024; 16:507. [PMID: 38675850 PMCID: PMC11054359 DOI: 10.3390/v16040507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/06/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Respiratory viral infections (RVIs) are common reasons for healthcare consultations. The inpatient management of RVIs consumes significant resources. From 2009 to 2014, we assessed the costs of RVI management in 4776 hospitalized children aged 0-18 years participating in a quality improvement program, where all ILI patients underwent virologic testing at the National Reference Centre followed by detailed recording of their clinical course. The direct (medical or non-medical) and indirect costs of inpatient management outside the ICU ('non-ICU') versus management requiring ICU care ('ICU') added up to EUR 2767.14 (non-ICU) vs. EUR 29,941.71 (ICU) for influenza, EUR 2713.14 (non-ICU) vs. EUR 16,951.06 (ICU) for RSV infections, and EUR 2767.33 (non-ICU) vs. EUR 14,394.02 (ICU) for human rhinovirus (hRV) infections, respectively. Non-ICU inpatient costs were similar for all eight RVIs studied: influenza, RSV, hRV, adenovirus (hAdV), metapneumovirus (hMPV), parainfluenza virus (hPIV), bocavirus (hBoV), and seasonal coronavirus (hCoV) infections. ICU costs for influenza, however, exceeded all other RVIs. At the time of the study, influenza was the only RVI with antiviral treatment options available for children, but only 9.8% of influenza patients (non-ICU) and 1.5% of ICU patients with influenza received antivirals; only 2.9% were vaccinated. Future studies should investigate the economic impact of treatment and prevention of influenza, COVID-19, and RSV post vaccine introduction.
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Affiliation(s)
- Maren Alchikh
- Vaccine Safety Initiative, 10437 Berlin, Germany; (M.A.); (P.E.O.)
- Laboratoire Chrono-Environnement, Université Bourgogne Franche-Comté, 25030 Besançon, France
- ESGREV (ESCMID Respiratory Virus Study Group), 4001 Basel, Switzerland;
| | | | - Patrick E. Obermeier
- Vaccine Safety Initiative, 10437 Berlin, Germany; (M.A.); (P.E.O.)
- ESGREV (ESCMID Respiratory Virus Study Group), 4001 Basel, Switzerland;
| | - Xiaolin Ma
- Department of Pulmonology, Capital Institute of Pediatrics, Beijing 100005, China;
| | - Brunhilde Schweiger
- Unit 17, Influenza and Other Respiratory Viruses, Department of Infectious Diseases, National Reference Centre for Influenza, Robert Koch-Institute, 13353 Berlin, Germany;
| | - Onya Opota
- ESGREV (ESCMID Respiratory Virus Study Group), 4001 Basel, Switzerland;
- Institute of Microbiology, University of Lausanne, 1011 Lausanne, Switzerland
| | - Barbara A. Rath
- Vaccine Safety Initiative, 10437 Berlin, Germany; (M.A.); (P.E.O.)
- Laboratoire Chrono-Environnement, Université Bourgogne Franche-Comté, 25030 Besançon, France
- ESGREV (ESCMID Respiratory Virus Study Group), 4001 Basel, Switzerland;
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Savioli G, Ceresa IF, Bressan MA, Bavestrello Piccini G, Novelli V, Cutti S, Ricevuti G, Esposito C, Longhitano Y, Piccioni A, Boudi Z, Venturi A, Fuschi D, Voza A, Leo R, Bellou A, Oddone E. Geriatric Population Triage: The Risk of Real-Life Over- and Under-Triage in an Overcrowded ED: 4- and 5-Level Triage Systems Compared: The CREONTE (Crowding and R E Organization National TriagE) Study. J Pers Med 2024; 14:195. [PMID: 38392628 PMCID: PMC10890089 DOI: 10.3390/jpm14020195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/18/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
Elderly patients, when they present to the emergency department (ED) or are admitted to the hospital, are at higher risk of adverse outcomes such as higher mortality and longer hospital stays. This is mainly due to their age and their increased fragility. In order to minimize this already increased risk, adequate triage is of foremost importance for fragile geriatric (>75 years old) patients who present to the ED. The admissions of elderly patients from 1 January 2014 to 31 December 2020 were examined, taking into consideration the presence of two different triage systems, a 4-level (4LT) and a 5-level (5LT) triage system. This study analyzes the difference in wait times and under- (UT) and over-triage (OT) in geriatric and general populations with two different triage models. Another outcome of this study was the analysis of the impact of crowding and its variables on the triage system during the COVID-19 pandemic. A total of 423,257 ED presentations were included. An increase in admissions of geriatric, more fragile, and seriously ill individuals was observed, and a progressive increase in crowding was simultaneously detected. Geriatric patients, when presenting to the emergency department, are subject to the problems of UT and OT in both a 4LT system and a 5LT system. Several indicators and variables of crowding increased, with a net increase in throughput and output factors, notably the length of stay (LOS), exit block, boarding, and processing times. This in turn led to an increase in wait times and an increase in UT in the geriatric population. It has indeed been shown that an increase in crowding results in an increased risk of UT, and this is especially true for 4LT compared to 5LT systems. When observing the pandemic period, an increase in admissions of older and more serious patients was observed. However, in the pandemic period, a general reduction in waiting times was observed, as well as an increase in crowding indices and intrahospital mortality. This study demonstrates how introducing a 5LT system enables better flow and patient care in an ED. Avoiding UT of geriatric patients, however, remains a challenge in EDs.
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Affiliation(s)
- Gabriele Savioli
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | - Iride Francesca Ceresa
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Maria Antonietta Bressan
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Viola Novelli
- Medical Direction, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | - Sara Cutti
- Medical Direction, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy
| | - Yaroslava Longhitano
- Residency Program in Emergency Medicine, Department of Emergency Medicine, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates
| | - Alessandro Venturi
- Department of Political and Social Sciences, University of Pavia, 27100 Pavia, Italy
- Bureau of the Presidency, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | - Damiano Fuschi
- Department of Italian and Supranational Public Law, Faculty of Law, University of Milan, 20133 Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Roberto Leo
- Department of Systems Medicine, University of Rome "Tor Vergata", 00133 Rome, Italy
| | - Abdelouahab Bellou
- Global Network on Emergency Medicine, Brookline, MA 02446, USA
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Institute of Sciences in Emergency Medicine, Department of Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
- Occupational Medicine Unit (UOOML), ICS Maugeri IRCCS, 27100 Pavia, Italy
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10
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Moon SH, Cho IY. Development of a Competency-Based Triage Education Application and Usability Testing for Triage Training Based on the Korean Triage and Acuity Scale. J Contin Educ Nurs 2024; 55:33-41. [PMID: 37921476 DOI: 10.3928/00220124-20231030-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
BACKGROUND Improving the quality of emergency nursing care requires enhancing triage competency through education programs that integrate the content of the Korean Triage and Acuity Scale, a triage system specifically developed for the Korean context. Thus, this study developed a competency-based triage education application (CTEA), based on the Korean Triage and Acuity Scale, and evaluated its effectiveness through usability testing. METHOD The CTEA used various teaching methods and game mechanisms, including lectures, case studies, and video-based scenarios, to improve triage competency. RESULTS In the usability testing phase, the CTEA was refined through expert heuristic evaluation and user interviews conducted with the think-aloud method. Six themes were derived from the interviews, highlighting the need for a well-structured program with realistic scenarios, easy accessibility, gamification, functional improvements, and future triage educational applications. CONCLUSION These findings suggest that the CTEA is effective and satisfactory for users and can contribute to improving the triage competency of emergency nurses. [J Contin Educ Nurs. 2024;55(1):33-41.].
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11
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Garber S, Brunner JO, Heller AR, Marckmann G, Bartenschlager CC. Simulation of the mortality after different ex ante (secondary) and ex post (tertiary) triage methods in people with disabilities and pre-existing diseases. DIE ANAESTHESIOLOGIE 2023; 72:10-18. [PMID: 37733034 PMCID: PMC10692011 DOI: 10.1007/s00101-023-01336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/22/2023]
Abstract
The significant increase in patients during the COVID-19 pandemic presented the healthcare system with a variety of challenges. The intensive care unit is one of the areas particularly affected in this context. Only through extensive infection control measures as well as an enormous logistical effort was it possible to treat all patients requiring intensive care in Germany even during peak phases of the pandemic, and to prevent triage even in regions with high patient pressure and simultaneously low capacities. Regarding pandemic preparedness, the German Parliament passed a law on triage that explicitly prohibits ex post (tertiary) triage. In ex post triage, patients who are already being treated are included in the triage decision and treatment capacities are allocated according to the individual likelihood of success. Legal, ethical, and social considerations for triage in pandemics can be found in the literature, but there is no quantitative assessment with respect to different patient groups in the intensive care unit. This study addressed this gap and applied a simulation-based evaluation of ex ante (primary) and ex post triage policies in consideration of survival probabilities, impairments, and pre-existing conditions. The results show that application of ex post triage based on survival probabilities leads to a reduction in mortality in the intensive care unit for all patient groups. In the scenario close to a real-world situation, considering different impaired and prediseased patient groups, a reduction in mortality of approximately 15% was already achieved by applying ex post triage on the first day. This mortality-reducing effect of ex post triage is further enhanced as the number of patients requiring intensive care increases.
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Affiliation(s)
- Sara Garber
- Working Group for Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstr. 16, 86159, Augsburg, Germany
| | - Jens O Brunner
- Working Group for Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstr. 16, 86159, Augsburg, Germany
- Professor of Decision Science in Healthcare, Department of Technology, Management, and Economics, Technical University of Denmark, Lyngby, Denmark
| | - Axel R Heller
- Clinic for Anaesthesiology and Operative Intensive Care, Medical Faculty, University Hospital of Augsburg, University of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany.
| | - Georg Marckmann
- Institute for Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München, Lessingstr. 2, 80336, Munich, Germany
| | - Christina C Bartenschlager
- Working Group for Health Care Operations/Health Information Management, Faculty of Business and Economics, Faculty of Medicine, University of Augsburg, Universitätsstr. 16, 86159, Augsburg, Germany
- Professor of Applied Data Science in Healthcare, Nürnberg School of Health, Klinikum Nürnberg and Ohm University of Applied Sciences Nuremberg, Keßlerplatz 12, Nuremberg, Germany
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12
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Khorram-Manesh A, Carlström E, Burkle FM, Goniewicz K, Gray L, Ratnayake A, Faccincani R, Bagaria D, Phattharapornjaroen P, Sultan MAS, Montán C, Nordling J, Gupta S, Magnusson C. The implication of a translational triage tool in mass casualty incidents: part three: a multinational study, using validated patient cards. Scand J Trauma Resusc Emerg Med 2023; 31:88. [PMID: 38017553 PMCID: PMC10683288 DOI: 10.1186/s13049-023-01128-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/09/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Mass casualty incidents (MCI) pose significant challenges to existing resources, entailing multiagency collaboration. Triage is a critical component in the management of MCIs, but the lack of a universally accepted triage system can hinder collaboration and lead to preventable loss of life. This multinational study uses validated patient cards (cases) based on real MCIs to evaluate the feasibility and effectiveness of a novel Translational Triage Tool (TTT) in primary triage assessment of mass casualty victims. METHODS Using established triage systems versus TTT, 163 participants (1575 times) triaged five patient cases. The outcomes were statistically compared. RESULTS TTT demonstrated similar sensitivity to the Sieve primary triage method and higher sensitivity than the START primary triage system. However, the TTT algorithm had a lower specificity compared to Sieve and higher over-triage rates. Nevertheless, the TTT algorithm demonstrated several advantages due to its straightforward design, such as rapid assessment, without the need for additional instrumental interventions, enabling the engagement of non-medical personnel. CONCLUSIONS The TTT algorithm is a promising and feasible primary triage tool for MCIs. The high number of over-triages potentially impacts resource allocation, but the absence of under-triages eliminates preventable deaths and enables the use of other personal resources. Further research involving larger participant samples, time efficiency assessments, and real-world scenarios is needed to fully assess the TTT algorithm's practicality and effectiveness in diverse multiagency and multinational contexts.
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Affiliation(s)
- Amir Khorram-Manesh
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 405 30, Gothenburg, Sweden.
- Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden.
- Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg University, 405 30, Gothenburg, Sweden.
- Center for Disaster Medicine, Gothenburg University, 405 30, Gothenburg, Sweden.
| | - Eric Carlström
- Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, Gothenburg University, 405 30, Gothenburg, Sweden
- USN School of Business, University of South-Eastern Norway, 3199, Borre, Norway
| | | | | | - Lesley Gray
- Department of Primary Health Care & General Practice, University of Otago, Wellington, New Zealand
- Joint Centre for Disaster Research, Massey University, Wellington, New Zealand
| | - Amila Ratnayake
- Sri Lanka Army Hospital, Narahenpita, Colombo, 08, Sri Lanka
| | - Roberto Faccincani
- Emergency Department, Humanitas Mater Domini, 210 53, Castellanza, Italy
| | - Dinesh Bagaria
- Division of Trauma Surgery & Critical Care, J.P.N. Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Carl Montán
- Karolinska MRMID-International Association for Medical Response to Major Incidents, Stockholm, Sweden
- Disasters, and Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Johan Nordling
- Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden
| | - Shailly Gupta
- Division of Trauma Surgery & Critical Care, J.P.N. Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Carl Magnusson
- Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg University, 405 30, Gothenburg, Sweden
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13
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Larangeira AS, Mezzaroba AL, Morakami FK, Cardoso LTQ, Matsuo T, Grion CMC. Improved performance of an intensive care unit after changing the admission triage model. Sci Rep 2023; 13:17043. [PMID: 37813948 PMCID: PMC10562408 DOI: 10.1038/s41598-023-44184-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 10/04/2023] [Indexed: 10/11/2023] Open
Abstract
The aim of this study is to analyze the effect of implementing a prioritization triage model for admission to an intensive care unit on the outcome of critically ill patients. Retrospective longitudinal study of adult patients admitted to the Intensive Care Unit (ICU) carried out from January 2013 to December 2017. The primary outcome considered was vital status at hospital discharge. Patients were divided into period 1 (chronological triage) during the years 2013 and 2014 and period 2 (prioritization triage) during the years 2015-2017. A total of 1227 patients in period 1 and 2056 in period 2 were analyzed. Patients admitted in period 2 were older (59.8 years) compared to period 1 (57.3 years; p < 0.001) with less chronic diseases (13.6% vs. 19.2%; p = 0.001), and higher median APACHE II score (21.0 vs. 18.0; p < 0.001)) and TISS 28 score (28.0 vs. 27.0; p < 0.001). In period 2, patients tended to stay in the ICU for a shorter time (8.5 ± 11.8 days) compared to period 1 (9.6 ± 16.0 days; p = 0.060) and had lower mortality at ICU (32.8% vs. 36.9%; p = 0.016) and hospital discharge (44.2% vs. 47.8%; p = 0.041). The change in the triage model from a chronological model to a prioritization model resulted in improvement in the performance of the ICU and reduction in the hospital mortality rate.
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Affiliation(s)
| | - Ana Luiza Mezzaroba
- Internal Medicine Department, Londrina State University, Rua Robert Koch 60, Vila Operária, Londrina, Paraná, 86038-440, Brazil
| | | | - Lucienne T Q Cardoso
- Internal Medicine Department, Londrina State University, Rua Robert Koch 60, Vila Operária, Londrina, Paraná, 86038-440, Brazil
| | - Tiemi Matsuo
- Statistics Department, Londrina State University, Londrina, Brazil
| | - Cintia M C Grion
- Internal Medicine Department, Londrina State University, Rua Robert Koch 60, Vila Operária, Londrina, Paraná, 86038-440, Brazil.
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14
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Laxar D, Eitenberger M, Maleczek M, Kaider A, Hammerle FP, Kimberger O. The influence of explainable vs non-explainable clinical decision support systems on rapid triage decisions: a mixed methods study. BMC Med 2023; 21:359. [PMID: 37726729 PMCID: PMC10510231 DOI: 10.1186/s12916-023-03068-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND During the COVID-19 pandemic, a variety of clinical decision support systems (CDSS) were developed to aid patient triage. However, research focusing on the interaction between decision support systems and human experts is lacking. METHODS Thirty-two physicians were recruited to rate the survival probability of 59 critically ill patients by means of chart review. Subsequently, one of two artificial intelligence systems advised the physician of a computed survival probability. However, only one of these systems explained the reasons behind its decision-making. In the third step, physicians reviewed the chart once again to determine the final survival probability rating. We hypothesized that an explaining system would exhibit a higher impact on the physicians' second rating (i.e., higher weight-on-advice). RESULTS The survival probability rating given by the physician after receiving advice from the clinical decision support system was a median of 4 percentage points closer to the advice than the initial rating. Weight-on-advice was not significantly different (p = 0.115) between the two systems (with vs without explanation for its decision). Additionally, weight-on-advice showed no difference according to time of day or between board-qualified and not yet board-qualified physicians. Self-reported post-experiment overall trust was awarded a median of 4 out of 10 points. When asked after the conclusion of the experiment, overall trust was 5.5/10 (non-explaining median 4 (IQR 3.5-5.5), explaining median 7 (IQR 5.5-7.5), p = 0.007). CONCLUSIONS Although overall trust in the models was low, the median (IQR) weight-on-advice was high (0.33 (0.0-0.56)) and in line with published literature on expert advice. In contrast to the hypothesis, weight-on-advice was comparable between the explaining and non-explaining systems. In 30% of cases, weight-on-advice was 0, meaning the physician did not change their rating. The median of the remaining weight-on-advice values was 50%, suggesting that physicians either dismissed the recommendation or employed a "meeting halfway" approach. Newer technologies, such as clinical reasoning systems, may be able to augment the decision process rather than simply presenting unexplained bias.
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Affiliation(s)
- Daniel Laxar
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Ludwig Boltzmann Gesellschaft, Vienna, Austria
| | - Magdalena Eitenberger
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Ludwig Boltzmann Gesellschaft, Vienna, Austria
| | - Mathias Maleczek
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Ludwig Boltzmann Gesellschaft, Vienna, Austria.
| | - Alexandra Kaider
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Fabian Peter Hammerle
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Oliver Kimberger
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Digital Health and Patient Safety, Ludwig Boltzmann Gesellschaft, Vienna, Austria
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15
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Salis F, Pili D, Collu M, Serchisu L, Laconi R, Mandas A. Six-item cognitive impairment test (6-CIT)'s accuracy as a cognitive screening tool: best cut-off levels in emergency department setting. Front Med (Lausanne) 2023; 10:1186502. [PMID: 37547596 PMCID: PMC10401263 DOI: 10.3389/fmed.2023.1186502] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Background Nowadays, elderly patients represent a significant number of accesses to the Emergency Department (ED). Working rhythms do not allow to perform complete cognitive analysis, which would, however, be useful for the health care. This study aims to define the optimal cut-off values of the six-item Cognitive Impairment Test (6-CIT) as a cognitive screening tool in ED. Methods This study included 215 subjects, evaluated at the Emergency Department of the University Hospital of Monserrato, Cagliari, Italy, from July to December 2021. The accuracy of 6-CIT as a cognitive screening tool was assessed by comparison with Mini Mental State Examination (MMSE). Results The correlation coefficient between the two tests was -0.836 (CI: -0.87 to -0.79; p < 0.0001), and 6-CIT showed AUC = 0.947 (CI: 0.908-0.973; p < 0.0001). The 8/9 6-CIT cut-off score presented 86.76% sensitivity (CI: 76.4-93.8) and 91.84% specificity (CI: 86.2-95.7), and Youden index for this score was 0.786. Conclusion Our study demonstrates that 6-CIT is a reliable cognitive screening tool in ED, offering excellent sensitivity and specificity with a 8/9 points cut-off score.
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Affiliation(s)
- Francesco Salis
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Daniela Pili
- University Hospital “Azienda Ospedaliero-Universitaria” of Cagliari, Cagliari, Italy
| | - Manuel Collu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Luca Serchisu
- University Hospital “Azienda Ospedaliero-Universitaria” of Cagliari, Cagliari, Italy
| | - Rosanna Laconi
- University Hospital “Azienda Ospedaliero-Universitaria” of Cagliari, Cagliari, Italy
| | - Antonella Mandas
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- University Hospital “Azienda Ospedaliero-Universitaria” of Cagliari, Cagliari, Italy
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16
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Garber S, Brunner JO, Heller AR, Marckmann G, Bartenschlager CC. [Simulation of mortality after different ex-ante and ex-post-triage methods in people with disabilities and comorbidities]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01302-3. [PMID: 37358616 PMCID: PMC10400691 DOI: 10.1007/s00101-023-01302-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/24/2023] [Accepted: 05/10/2023] [Indexed: 06/27/2023]
Abstract
The significant increase in patients during the COVID-19 pandemic presented the healthcare system with a variety of challenges. The intensive care unit is one of the areas particularly affected in this context. Only through extensive infection control measures as well as an enormous logistical effort was it possible to treat all patients requiring intensive care in Germany even during peak phases of the pandemic, and to prevent triage even in regions with high patient pressure and simultaneously low capacities. Regarding pandemic preparedness, the German Parliament passed a law on triage that explicitly prohibits ex post (tertiary) triage. In ex post triage, patients who are already being treated are included in the triage decision and treatment capacities are allocated according to the individual likelihood of success. Legal, ethical, and social considerations for triage in pandemics can be found in the literature, but there is no quantitative assessment with respect to different patient groups in the intensive care unit. This study addressed this gap and applied a simulation-based evaluation of ex ante (primary) and ex post triage policies in consideration of survival probabilities, impairments, and pre-existing conditions. The results show that application of ex post triage based on survival probabilities leads to a reduction in mortality in the intensive care unit for all patient groups. In the scenario close to a real-world situation, considering different impaired and prediseased patient groups, a reduction in mortality of approximately 15% was already achieved by applying ex post triage on the first day. This mortality-reducing effect of ex post triage is further enhanced as the number of patients requiring intensive care increases.
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Affiliation(s)
- Sara Garber
- Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland
| | - Jens O Brunner
- Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland
- Professor of Decision Science in Healthcare, Department of Technology, Management, and Economics, Technical University of Denmark, Lyngby, Dänemark
| | - Axel R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät, Universitätsklinikum Augsburg, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - Georg Marckmann
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, Lessingstr. 2, 80336, München, Deutschland
| | - Christina C Bartenschlager
- Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland
- Professur für Angewandte Datenwissenschaften im Gesundheitswesen, Nürnberg School of Health, Technische Hochschule Nürnberg Georg Simon Ohm, Klinikum Nürnberg, Nürnberg, Deutschland
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17
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Bushuven S, Bentele M, Gerber B, Michalsen A, Ilkilic I, Inthorn J. Single-rater reliability of a three-dimensional instrument for decision-making in tertiary triage and ICU- prioritization-a case vignette simulation study. BMC Anesthesiol 2023; 23:215. [PMID: 37340343 DOI: 10.1186/s12871-023-02173-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 06/09/2023] [Indexed: 06/22/2023] Open
Abstract
Disconcerting reports from different EU countries during the first wave of the COVID-19 pandemic demonstrated the demand for supporting decision instruments and recommendations in case tertiary triage is needed. COVID-19 patients mainly present sequentially, not parallelly, and therefore ex-post triage scenarios were expected to be more likely than ex-ante ones. Decision-makers in these scenarios may be highly susceptible to second victim and moral injury effects, so that reliable and ethically justifiable algorithms would have been needed in case of overwhelming critical cases.To gather basic information about a potential tertiary triage instrument, we designed a three-dimensional instrument developed by an expert group using the Delphi technique. The instrument focused on three parameters: 1) estimated chance of survival, 2) estimated prognosis of regaining autonomy after treatment, and 3) estimated length of stay in the ICU. To validate and test the instrument, we conducted an anonymous online survey in 5 German hospitals addressing physicians that would have been in charge of decision-making in the case of a mass infection incident. Of about 80 physicians addressed, 47 responded. They were presented with 16 fictional ICU case vignettes (including 3 doublets) which they had to score using the three parameters of the instrument.We detected a good construct validity (Cronbach's Alpha 0.735) and intra-reliability (p < 0.001, Cohens Kappa 0.497 to 0.574), but a low inter-reliability (p < 0.001, Cohen's Kappa 0.252 to 0.327) for the three parameters. The best inter-reliability was detected for the estimated length of stay in the ICU. Further analysis revealed concerns in assessing the prognosis of the potentially remaining autonomy, especially in patients with only physical impairment.In accordance with German recommendations, we concluded that single-rater triage (which might happen in stressful and highly resource-limited situations) should be avoided to ensure patient and health care provider safety. Future work should concentrate on reliable and valid group decision instruments and algorithms and question whether the chance of survival as a single triage parameter should be complemented with other parameters, such as the estimated length of stay in the ICU.
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Affiliation(s)
- Stefan Bushuven
- Institute for Hospital Hygiene and Infection Prevention, Hegau-Jugendwerk Hospital Gailingen, Health Care Association District of Constance, Hausherrenstrasse 12, 78315, Radolfzell, Germany.
- Institute for Medical Education, University Hospital, LMU Munich, Munich, Germany.
- Institute for Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Hegau Bodensee Hospital, Singen, Germany.
| | - Michael Bentele
- Institute for Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Hegau Bodensee Hospital, Singen, Germany
| | - Bianka Gerber
- Institute for Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Hegau Bodensee Hospital, Singen, Germany
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine and Pain Therapy, Konstanz Hospital, Constance, Germany
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18
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Heller AR, Bartenschlager C, Brunner JO, Marckmann G. [German "Triage Act"-Regulation with fatal consequences]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01286-0. [PMID: 37233790 DOI: 10.1007/s00101-023-01286-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 05/27/2023]
Abstract
With the coming into force of § 5c of the Infection Protection Act (IfSG), the so-called Triage Act, on 14 December 2022, a protracted discussion has come to a provisional conclusion, the result of which physicians and social associations but also lawyers and ethicists are equally dissatisfied. The explicit exclusion of the discontinuation of treatment that has already begun in favor of new patients with better chances of success (so-called tertiary or ex-post triage) prevents allocation decisions with the aim of enabling as many patients as possible to beneficially participate in medical care under crisis conditions. The result of the new regulation is de facto a first come first served allocation, which is associated with the highest mortality even among individuals with limitations or disabilities and was rejected by a large margin as unfair in a population survey. Mandating allocation decisions based on the likelihood of success but which are not permitted to be consistently implemented and prohibiting, for example the use of age and frailty as prioritization criteria, although both factors most strongly determine the short-term probability of survival according to evident data, shows the contradictory and dogmatic nature of the regulation. The only remaining possibility is the consistent termination of treatment that is no longer indicated or desired by the patient, regardless of the current resource situation; however, if a different decision is made in a crisis situation than in a situation without a lack of resources, this practice would not be justified and would be punishable. Accordingly, the highest efforts must be set on legally compliant documentation, especially in the stage of decompensated crisis care in a region. The goal of enabling as many patients as possible to beneficially participate in medical care under crisis conditions is in any case thwarted by the new German Triage Act.
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Affiliation(s)
- A R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - C Bartenschlager
- Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Augsburg, Deutschland
| | - J O Brunner
- Zentrum für Interdisziplinäre Gesundheitsforschung, Universität Augsburg, Augsburg, Deutschland
| | - G Marckmann
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, München, Deutschland
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19
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Zhao F, Zhao C, Bai S, Yao L, Zhang Y. Triage Algorithms for Mass-Casualty Bioterrorism: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20065070. [PMID: 36981980 PMCID: PMC10049471 DOI: 10.3390/ijerph20065070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To understand existing triage algorithms, propose improvement measures through comparison to better deal with mass-casualty incidents caused by bioterrorism. STUDY DESIGN Systematic review. METHODS Medline, Scopus and Web of Science were searched up to January 2022. The studies investigating triage algorithms for mass-casualty bioterrorism. Quality assessment was performed using the International Narrative Systematic Assessment tool. Data extractions were performed by four reviewers. RESULTS Of the 475 titles identified in the search, 10 studies were included. There were four studies on triage algorithms for most bioterrorism events, four studies on triage algorithms for anthrax and two studies on triage algorithms for mental or psychosocial problems caused by bioterrorism events. We introduced and compared 10 triage algorithms used for different bioterrorism situations. CONCLUSION For triage algorithms for most bioterrorism events, it is necessary to determine the time and place of the attack as soon as possible, control the number of exposed and potentially exposed people, prevent infection and determine the type of biological agents used. Research on the effects of decontamination on bioterrorism attacks needs to continue. For anthrax triage, future research should improve the distinction between inhalational anthrax symptoms and common disease symptoms and improve the efficiency of triage measures. More attention should be paid to triage algorithms for mental or psychosocial problems caused by bioterrorism events.
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Affiliation(s)
- Feida Zhao
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
| | - Chao Zhao
- Center for Biosafety Research and Strategy, Tianjin University, Tianjin 300072, China
| | - Song Bai
- Evaluation and Optimization of Health Emergency Response Capacity, Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
| | - Lulu Yao
- Emergency Medicine, Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
| | - Yongzhong Zhang
- Epidemiology and Health Statistics, Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
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Pantileeva D, Rangelova D, Atanasov P, Mircheva S, Ivanov I, Chaneva M, Obreshkova D, Ivanova S, Milanov S, Kazalakova K, Dimitrov V, Petkova V, Baltov A, Petrov S. Logistical challenges with an emphasis on organizing specialized triage in the conditions of a newly emerging, epidemiologically significant infectious pathogen for humans – SARS-CoV2. PHARMACIA 2023. [DOI: 10.3897/pharmacia.70.e101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Background: UMHATEM „N.I. Pirogov“ Sofia, is one of the largest and busiest hospitals for emergency medical care in Bulgaria. It is the legal successor of the former Institute of Emergency Medicine „N.I. Pirogov“, and it can be said that at the moment it is the only diagnostic- therapeutic, prophylactic and scientific-educational structure of this type within the Bulgarian healthcare system. The concept of adequate functioning and development of this type of hospital does not consider structuring an Infectious Diseases diagnostic-treatment unit. This reality makes necessary the formation of a radically different organization for the admission and treatment of patients in the hospital, both for those with symptoms of Covid 19 and for all other emergency patients. The organization created in this way must absolutely guarantee safety for both streams of patients.
In the conditions of a pandemic, in case of a real threat to public health, the main task of triage in the Emergency Department is to establish indications for urgent hospitalization, or to refuse it in the absence of indications. The characteristic course of the disease, the prolonged treatment, the manifestations within the so-called „post-Covid syndrome“, require serious planning not only of the diagnostic-treatment and rehabilitation period, but also adequate monitoring in the first months after the patient‘s discharge.
Within the national reorganization measures, during the determined periods, the main changes concerning the MED (Multi-profile emergency department) of Pirogov are implemented, with an emphasis on the formation of a specialized triage for the diagnosis and clinical evaluation of patients with a coronavirus infection. The main goal is the adequate diagnosis, treatment and follow-up of patients with coronavirus infection who have passed through the organized Covid-triage in a period of extreme pressure on the emergency structures and on the hospital system in the country as a whole.
Objective: For a MED, which at the time of declaring an epidemic situation does not have a concept for the diagnosis and treatment of infectious diseases, to systematize the main urgently implemented organizational and structural changes, which turned out to be absolutely necessary to meet a newly emerging epidemiologically significant infectious disease.
Aims: To systematize the organizational changes imposed by the situation and urgently implemented in the MED (multi-profile emergency department).
To systematize the structural changes imposed by the situation and urgently implemented in the work of the MED.
To analyze the organizational and structural changes carried out in this way and to differentiate the main difficulties caused by the regulations existing at the time of the announcement of the epidemic situation.
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Lu J, Wang X, Chen L, Sun X, Li R, Zhong W, Fu Y, Yang L, Liu W, Han W. Unmanned aerial vehicle based intelligent triage system in mass-casualty incidents using 5G and artificial intelligence. World J Emerg Med 2023; 14:273-279. [PMID: 37425090 PMCID: PMC10323497 DOI: 10.5847/wjem.j.1920-8642.2023.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/02/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Rapid on-site triage is critical after mass-casualty incidents (MCIs) and other mass injury events. Unmanned aerial vehicles (UAVs) have been used in MCIs to search and rescue wounded individuals, but they mainly depend on the UAV operator's experience. We used UAVs and artificial intelligence (AI) to provide a new technique for the triage of MCIs and more efficient solutions for emergency rescue. METHODS This was a preliminary experimental study. We developed an intelligent triage system based on two AI algorithms, namely OpenPose and YOLO. Volunteers were recruited to simulate the MCI scene and triage, combined with UAV and Fifth Generation (5G) Mobile Communication Technology real-time transmission technique, to achieve triage in the simulated MCI scene. RESULTS Seven postures were designed and recognized to achieve brief but meaningful triage in MCIs. Eight volunteers participated in the MCI simulation scenario. The results of simulation scenarios showed that the proposed method was feasible in tasks of triage for MCIs. CONCLUSION The proposed technique may provide an alternative technique for the triage of MCIs and is an innovative method in emergency rescue.
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Affiliation(s)
- Jiafa Lu
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Xin Wang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen 518055, China
| | - Linghao Chen
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen 518060, China
| | - Xuedong Sun
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Rui Li
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Wanjing Zhong
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Yajing Fu
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Le Yang
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
| | - Weixiang Liu
- School of Biomedical Engineering, Health Science Center, Shenzhen University, Shenzhen 518060, China
| | - Wei Han
- Emergency Department of Shenzhen University General Hospital, Shenzhen 518055, China
- Tianjin University, Tianjin 300072, China
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22
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Schreiber E, Gaebel J, de Hoop T, Neumuth T. The Emergency Medical Team Operating System: design, implementation, and evaluation of a field hospital information management system. JAMIA Open 2022; 5:ooac106. [PMID: 36589211 PMCID: PMC9789890 DOI: 10.1093/jamiaopen/ooac106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 11/23/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022] Open
Abstract
In case of sudden-onset disasters (SODs), the World Health Organization deploys specialized emergency medical teams (EMTs); yet, the coordination and operation of such teams pose significant challenges. One issue is the lack of digital information systems and standards. We developed a highly customizable and scalable electronic medical record (EMR) system, tailored to EMT requirements, called the "Emergency Medical Team Operating System" (EOS). EOS was successfully tested through 9 realistic clinical tasks during a full-scale EU Module Exercise. During the initial evaluation, 21 team members from 9 countries evaluated the system positively, stressing the urgent need for an EMR for EMTs. EMTs face unique challenges during disaster relief missions. To provide an effective and coordinated delivery of care, there is a great need for an EMR tailored to the specific needs of EMTs. EOS may serve as an effective EMR during SOD missions.
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Affiliation(s)
- Erik Schreiber
- Corresponding Author: Erik Schreiber, Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Semmelweisstr. 14, 04103 Leipzig, Germany;
| | - Jan Gaebel
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Tom de Hoop
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
| | - Thomas Neumuth
- Innovation Center Computer Assisted Surgery (ICCAS), Faculty of Medicine, Leipzig University, Leipzig, Germany
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Zhang A, Lou J, Pan Z, Luo J, Zhang X, Zhang H, Li J, Wang L, Cui X, Ji B, Chen L. Prediction of anemia using facial images and deep learning technology in the emergency department. Front Public Health 2022; 10:964385. [PMID: 36438300 PMCID: PMC9682145 DOI: 10.3389/fpubh.2022.964385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/03/2022] [Indexed: 11/11/2022] Open
Abstract
Background According to the WHO, anemia is a highly prevalent disease, especially for patients in the emergency department. The pathophysiological mechanism by which anemia can affect facial characteristics, such as membrane pallor, has been proven to detect anemia with the help of deep learning technology. The quick prediction method for the patient in the emergency department is important to screen the anemic state and judge the necessity of blood transfusion treatment. Method We trained a deep learning system to predict anemia using videos of 316 patients. All the videos were taken with the same portable pad in the ambient environment of the emergency department. The video extraction and face recognition methods were used to highlight the facial area for analysis. Accuracy and area under the curve were used to assess the performance of the machine learning system at the image level and the patient level. Results Three tasks were applied for performance evaluation. The objective of Task 1 was to predict patients' anemic states [hemoglobin (Hb) <13 g/dl in men and Hb <12 g/dl in women]. The accuracy of the image level was 82.37%, the area under the curve (AUC) of the image level was 0.84, the accuracy of the patient level was 84.02%, the sensitivity of the patient level was 92.59%, and the specificity of the patient level was 69.23%. The objective of Task 2 was to predict mild anemia (Hb <9 g/dl). The accuracy of the image level was 68.37%, the AUC of the image level was 0.69, the accuracy of the patient level was 70.58%, the sensitivity was 73.52%, and the specificity was 67.64%. The aim of task 3 was to predict severe anemia (Hb <7 g/dl). The accuracy of the image level was 74.01%, the AUC of the image level was 0.82, the accuracy of the patient level was 68.42%, the sensitivity was 61.53%, and the specificity was 83.33%. Conclusion The machine learning system could quickly and accurately predict the anemia of patients in the emergency department and aid in the treatment decision for urgent blood transfusion. It offers great clinical value and practical significance in expediting diagnosis, improving medical resource allocation, and providing appropriate treatment in the future.
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Affiliation(s)
- Aixian Zhang
- Medical School of the Chinese PLA, Beijing, China,Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Jingjiao Lou
- Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China,School of Control Science and Engineering, Shandong University, Jinan, Shandong, China
| | - Zijie Pan
- Luoyang Outpatient Department of 63650 Army Hospital of the Chinese PLA, Luoyang, China
| | - Jiaqi Luo
- Medical School of the Chinese PLA, Beijing, China
| | - Xiaomeng Zhang
- Medical School of the Chinese PLA, Beijing, China,Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Han Zhang
- Medical School of the Chinese PLA, Beijing, China,Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Jianpeng Li
- Medical School of the Chinese PLA, Beijing, China,Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Lili Wang
- Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Xiang Cui
- Department of Orthopedics, Chinese PLA General Hospital, National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Bing Ji
- School of Control Science and Engineering, Shandong University, Jinan, Shandong, China,*Correspondence: Bing Ji
| | - Li Chen
- Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China,Li Chen
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Halvachizadeh S, Leibovitz D, Held L, Jensen KO, Pape HC, Muller D, Neuhaus V. The number of beds occupied is an independent risk factor for discharge of trauma patients. Medicine (Baltimore) 2022; 101:e31024. [PMID: 36221382 PMCID: PMC9542835 DOI: 10.1097/md.0000000000031024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Reducing the burden of limited capacity on medical practitioners and public health systems requires a time-dependent characterization of hospitalization rates, such that inferences can be drawn about the underlying causes for hospitalization and patient discharge. The aim of this study was to analyze non-medical risk factors that lead to the discharge of trauma patients. This retrospective cohort study includes trauma patients who were treated in Switzerland between 2011 and 2018. The national Swiss database for quality assurance in surgery (AQC) was reviewed for trauma diagnoses according to the ICD-10 code. Non-medical risk factors include seasonal changes, daily changes, holidays, and number of beds occupied by trauma patients across Switzerland. Individual patient information was aggregated into counts per day of total patients, as well as counts per day of levels of each categorical variable of interest. The ARIMA-modeling was utilized to model the number of discharges per day as a function of auto aggressive function of all previously mentioned risk factors. This study includes 226,708 patients, 118,059 male (age 48.18, standard deviation (SD) 22.34 years) and 108,649 female (age 62.57, SD 22.89 years) trauma patients. The mean length of stay was 7.16 (SD 14.84) days and most patients were discharged home (n = 168,582, 74.8%). A weekly and yearly seasonality trend can be observed in admission trends. The mean number of occupied trauma beds ranges from 3700 to 4000 per day. The number of occupied beds increases on weekdays and decreases on holidays. The number of occupied beds is a positive, independent risk factor for discharge in trauma patients; as the number of occupied beds increases at any given time, so does the risk for discharge. The number of beds occupied represents an independent non-medical risk factor for discharge. Capacity determines triage of hospitalized patients and therefore might increase the risk of premature discharge.
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Affiliation(s)
- Sascha Halvachizadeh
- University Hospital Zurich, Department of Trauma, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zürich, Switzerland
- * Correspondence: Sascha Halvachizadeh, University Hospital Zurich, Department of Trauma, Raemistrasse 100, Zurich 8091, Switzerland (e-mail: )
| | - Daniel Leibovitz
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Zurich, Switzerland
- Cantonal Hospital Thurgau, Frauenfeld, Department of Surgery, Frauenfeld, Switzerland
| | - Leonhard Held
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Zurich, Switzerland
- Cantonal Hospital Thurgau, Frauenfeld, Department of Surgery, Frauenfeld, Switzerland
| | - Kai Oliver Jensen
- University Hospital Zurich, Department of Trauma, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zürich, Switzerland
| | - Hans-Christoph Pape
- University Hospital Zurich, Department of Trauma, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zürich, Switzerland
| | - Dominik Muller
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Zurich, Switzerland
- Cantonal Hospital Thurgau, Frauenfeld, Department of Surgery, Frauenfeld, Switzerland
| | - Valentin Neuhaus
- University Hospital Zurich, Department of Trauma, Zurich, Switzerland
- University of Zurich, Faculty of Medicine, Zürich, Switzerland
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Developing a translational triage research tool: part two-evaluating the tool through a Delphi study among experts. Scand J Trauma Resusc Emerg Med 2022; 30:48. [PMID: 35907858 PMCID: PMC9338674 DOI: 10.1186/s13049-022-01035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background There are different prehospital triage systems, but no consensus on what constitutes the optimal choice. This heterogeneity constitutes a threat in a mass casualty incident in which triage is used during multiagency collaboration to prioritize casualties according to the injuries’ severity. A previous study has confirmed the feasibility of using a Translational Triage Tool consisting of several steps which translate primary prehospital triage systems into one. This study aims to evaluate and verify the proposed algorithm using a panel of experts who in their careers have demonstrated proficiency in triage management through research, experience, education, and practice. Method Several statements were obtained from earlier reports and were presented to the expert panel in two rounds of a Delphi study. Results There was a consensus in all provided statements, and for the first time, the panel of experts also proposed the manageable number of critical victims per healthcare provider appropriate for proper triage management. Conclusion The feasibility of the proposed algorithm was confirmed by experts with some minor modifications. The utility of the translational triage tool needs to be evaluated using authentic patient cards used in simulation exercises before being used in actual triage scenarios.
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Azizpour I, Mehri S, Soola AH. Disaster preparedness knowledge and its relationship with triage decision-making among hospital and pre-hospital emergency nurses - Ardabil, Iran. BMC Health Serv Res 2022; 22:934. [PMID: 35854268 PMCID: PMC9296334 DOI: 10.1186/s12913-022-08311-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/07/2022] [Indexed: 11/17/2022] Open
Abstract
Background Hospital and pre-hospital emergency nurses are at the forefront of disaster response. Disaster incidents continue to pose a threat to healthcare systems by exposing them to an overwhelming surge of patients. Methods This descriptive cross-sectional study was performed on 472 hospital and pre-hospital emergency nurses in Ardabil province, in the northwest Iran, from March to April 2021, were recruited by convenience sampling method. Data were collected using valid and reliable self-reported questionnaires, including the Emergency Preparedness Information questionnaire (EPIQ) and Triage Decision-making Inventory (TDMI). Data were analyzed using SPSS (Version 22) software using descriptive statistics, Pearson correlation coefficient test, t-test, ANOVA test, and multiple linear regression analysis. Results Emergency nurses’ disaster preparedness knowledge was low according to the mean score of total disaster preparedness knowledge. Furthermore, multiple linear regression analysis showed triage decision-making, age, residence, disaster preparedness training, working on duty during a disaster, and training organization variables were predictors of disaster preparedness knowledge in hospital and pre-hospital emergency nurses (p < 0.05). Conclusion Emergency nurses who have higher disaster preparedness knowledge have higher triage decision-making skills. It is suggested that the managers of educational and medical centres and professional organizations provide favourable conditions for training and increasing disaster preparedness of emergency nurses according to their age and residence.
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Affiliation(s)
- Islam Azizpour
- Department of Emergency nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Saeid Mehri
- Department of Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Aghil Habibi Soola
- Department of Nursing, School of Nursing and Midwifery, Ardabil University of Medical Sciences, Ardabil, Iran.
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Triaje en la pandemia COVID-19: un abordaje con perspectiva de derechos humanos. ACTA COLOMBIANA DE CUIDADO INTENSIVO 2022. [PMCID: PMC8801254 DOI: 10.1016/j.acci.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
El triaje es un sistema de selección y clasificación de pacientes en los servicios de urgencia, basado en las necesidades terapéuticas y los recursos disponibles para una adecuada atención. Además, diferencia a los pacientes, en tiempos de normalidad en donde aplica la justicia igualitaria y en tiempos de emergencia aplica la justicia equitativa. El triaje mantiene siempre los criterios médicos, científicos y éticos aun en tiempos de excepción o urgencia sanitaria, como en la pandemia COVID-19 evitando injusticias, discriminaciones, vulneraciones o exclusiones de pacientes; respetando siempre el derecho fundamental a la salud y la vida. No cambia su nombre ni su denominación en tiempos de emergencia, solo la estrategia ante el recurso escaso, estableciendo prioridades para la distribución y asignación adecuada del recurso. Aplica la justicia distributiva o justicia social y el principio de proporcionalidad; lo útil y beneficioso para quien más se beneficie. Tiene siempre en cuenta la ética de salud pública como el máximo bien social que debe estar presente en las acciones y decisiones de quien lo realiza. El objetivo de este artículo de reflexión es establecer tres preguntas que den respuestas a la importancia del triaje en la pandemia COVID-19, relacionadas con: selección y clasificación; respeto de los derechos humanos, y denominación del triaje.
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Sensitivity and Specificity of Spanish Prehospital Advanced Triage Method (META). Prehosp Disaster Med 2022; 37:321-326. [PMID: 35379369 DOI: 10.1017/s1049023x22000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Mass-casualty incident (MCI) triage systems aim to provide the best possible health care to the greatest number of affected people with the available resources in the context of a mass-casualty event. The Spanish Prehospital Advanced Triage Method (Modelo Extrahospitalario de Triaje Avanzado; META) was designed to improved patient sorting in MCIs. OBJECTIVE The aim of this study was to estimate and compare sensitivity and specificity of META and the Manchester Triage System (MTS) in MCIs by retrospectively applying both triage algorithms to real MCI patients from the Emergency and Disaster Research Unit (Unidad de Investigación en Emergencia y Desastres; UIED) MCI database. METHOD This was a comparative study of two triage methods using sensitivity and specificity with the Revised Trauma Score (RTS) as the gold standard. A total of 134 MCI patients from the UIED database were included. An MCI in Asturias is defined as an incident that involves four or more victims that require ambulance mobilization. RESULTS Patients mean age was 39.85 years (95% CI, 35.9-43.8) with an age range from one to 88 years old. In total, 54.4% of the patients were female. The most common types of MCI involved were fires (51.0%), followed by road traffic accident (43.3%) and street fight (3.7%). For MTS, the overall sensitivity was 30.6% (95% CI, 22.9-39.1) and specificity was 66.0% (95% CI, 60.0-71.7). For META triage algorithm, the overall sensitivity was 79.9% (95% CI, 72.1-86.3) and specificity was 89.9% (95% CI, 85.7-93.3). CONCLUSION The META triage algorithm is a reliable triage system; thus, it can be recommended to be used in an MCI.
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Fadare JO, Adeoti AO, Dada SA, Dele-Ojo BF, Raimi TH, Isikekpei B, Ajayi AO, Ajayi EA. COVID-19 Pandemic- Ethical Challenges for Healthcare Workers Practicing in Resource-Limited Settings. Niger Med J 2022; 63:1-9. [PMID: 38798972 PMCID: PMC11117041 DOI: 10.60787/nmj-63-1-116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
In this review, the ethical issues peculiar to the COVID-19 pandemics and the role of healthcare workers, especially those in resource-limited settings are x-rayed. We contend that there is a pressing ethical issue that needs urgent clarification on the rights and responsibilities of healthcare workers, especially in the current context of COVID-19 pandemic preparedness and responsiveness. We searched MEDLINE, Web of Science, EMBASE, Google Scholar, PUBMED related articles, newspaper articles, and online news sources for relevant information. The various professional codes of conduct (World Medical Association, Medical and Dental Council of Nigeria) were also consulted. The ethical principles of equitable distribution of healthcare resources, confidentiality with associated stigmatization, issues relating to duty to care by the healthcare workers and those pertaining to conduct of clinical trials and access to approved therapies or vaccines were highlighted in this study. We agree with the submission that healthcare workers only have a moral duty to treat patients with COVID-19 if the necessary protective equipment and adequate compensation are not provided. We argue that the duty of physicians and other healthcare workers to care for patients during pandemics such as COVID-19 is obligatory in the absence of required protective equipment and other forms of compensation. There is a need for the government and other stakeholders to put in place a National Pandemic /Epidemic Ethical Framework to address these identified ethical challenges.
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Affiliation(s)
| | | | - Samuel Ayokunle Dada
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | | | - Taiwo Hussean Raimi
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Brenda Isikekpei
- Department of Community Health and Primary Care, Lagos University Teaching Hospital, Lagos, Nigeria
| | | | - Ebenezer Adekunle Ajayi
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
- Department of Medicine, Federal Teaching Hospital, Ido-Ekiti, Nigeria
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Simple triage and rapid treatment protocol for emergency department mass casualty incident victim triage. Am J Emerg Med 2021; 53:99-103. [PMID: 35007873 DOI: 10.1016/j.ajem.2021.12.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Triage plays an essential role in emergency medical care. It is crucial to adopt appropriate triage in a mass casualty incident (MCI) when resources are limited. The simple triage and rapid treatment (START) protocol is commonly used worldwide; however, the effectiveness of the START protocol for emergency department (ED) triage is unclear. This study aimed to examine the accuracy of START for the ED triage of victims following a MCI. METHODS We retrospectively reviewed the records of victims who presented to our ED during a MCI response after a train crash. The ED nurses applied the START protocol upon patient arrival, and we used a consensus-based standard to determine the outcome-based categories of these same patients. We compared the START protocol and outcome-based categories. In addition, the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of START in terms of predicting surgery and ED disposition were determined. RESULTS This study enrolled 47 patients (predominantly women, 68.1%; median age: 39.0years). Most victims were triaged into the START minor category (61.7%) and discharged from the ED (68.1%). Twenty-nine patients had matched START and outcome-based categories, whereas 2 patients were over-triaged and 16 patients were under-triaged. Additionally, the START system had acceptable AUC and sensitivities for predicting surgery and ED disposition (AUC/sensitivity/specificity for surgery: 0.850/100%/69.1%; AUC/sensitivity/specificity for admission: 0.917/93.3%/87.5%; AUC/sensitivity/specificity for intensive care unit (ICU)/ED death: 0.994/100%/97.8%). CONCLUSIONS This study demonstrated poor agreement between START categories, as determined in the ED, and the consensus-based standard categories. However, the START protocol was acceptable in terms of identifying emergent patients (100% sensitivity for the immediate and deceased categories) and predicting ED disposition (surgery, admission, and ICU/ED mortality). Although START is not perfect, our findings suggest that it could be used for the ED triage of trauma-related MCI victims.
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Paediatric patients in mass casualty incidents: a comprehensive review and call to action. Br J Anaesth 2021; 128:e109-e119. [PMID: 34862001 DOI: 10.1016/j.bja.2021.10.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 12/16/2022] Open
Abstract
The paediatric population is disproportionately affected during mass casualty incidents (MCIs). Several unique characteristics of children merit special attention during natural and man-made disasters because of their age, physiology, and vulnerability. Paediatric anaesthesiologists play a critical part of MCI care for this population, yet there is a deficit of publications within the anaesthesia literature addressing paediatric-specific MCI concerns. This narrative review article analyses paediatric MCI considerations and compares differing aspects between care provision in Australia, the UK, and the USA. We integrate some of the potential roles for anaesthesiologists with paediatric experience, which include preparation, command consultation, in-field care, pre-hospital transport duties, and emergency department, operating theatre, and ICU opportunities. Finally, we propose several methods by which anaesthesiologists can improve their contribution to paediatric MCI care through personal education, training, and institutional involvement.
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Tallach R, Einav S, Brohi K, Abayajeewa K, Abback PS, Aylwin C, Batrick N, Boutonnet M, Cheatham M, Cook F, Curac S, Davidson S, Eason H, Fiore N, Gaarder C, Garusinghe S, Goralnick E, Grimaldi D, Kritayakirana K, Levraut J, Lindner T, Märdian S, Padayachee A, Qureshi S, Ramessur S, Raux M, Ratnayake A, Römer M, Roy H, Tole E, Tose S, Fuentes FT, Gauss T. Learning from terrorist mass casualty incidents: a global survey. Br J Anaesth 2021; 128:e168-e179. [PMID: 34749991 DOI: 10.1016/j.bja.2021.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses. METHODS We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale. RESULTS Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement). CONCLUSION This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.
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Affiliation(s)
- Rosel Tallach
- Royal London Hospital, London, UK; Raigmore Hospital, Inverness, UK.
| | | | | | | | | | | | | | | | | | | | | | | | - Hilary Eason
- Royal Manchester Children's Hospital, Manchester, UK
| | - Nick Fiore
- Sunrise Children's Hospital, Las Vegas, NV, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eunice Tole
- Aga Khan University Hospital, Nairobi, Kenya
| | - Sheila Tose
- Salford Royal Foundation Trust Hospital, Manchester, UK
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Mansab F, Bhatti S, Goyal D. Reliability of COVID-19 symptom checkers as national triage tools: an international case comparison study. BMJ Health Care Inform 2021; 28:bmjhci-2021-100448. [PMID: 34663637 PMCID: PMC8523957 DOI: 10.1136/bmjhci-2021-100448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/30/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives Triage is a critical component of the pandemic response. It affects morbidity, mortality and how effectively the available healthcare resources are used. In a number of nations the pandemic has sponsored the adoption of novel, online, patient-led triage systems—often referred to as COVID-19 symptom checkers. The current safety and reliability of these new automated triage systems remain unknown. Methods We tested six symptom checkers currently in use as triage tools at a national level against 52 cases simulating COVID-19 of various severities to determine if the symptom checkers appropriately triage time-critical cases onward to healthcare contact. We further analysed and compared each symptom checker to determine the discretionary aspects of triage decision-making that govern the automated advice generated. Results Of the 52 clinical presentations, the absolute rate of onward referral to any form of healthcare contact was: Singapore 100%, the USA 67%, Wales 65%, England 62%, Scotland 54% and Northern Ireland 46%. Triage decisions were broadly based on either estimates of ‘risk’ or ‘disease severity’. Risk-based symptom checkers were more reliable, with severity-based symptom checkers often triaging time-critical cases to stay home without clinical contact or follow-up. Conclusion The COVID-19 symptom checkers analysed here were unable to reliably discriminate between mild and severe COVID-19. Risk-based symptom checkers may hold some promise of contributing to pandemic case management, while severity-based symptom checkers—the CDC and NHS 111 versions—confer too much risk to both public and healthcare services to be deemed a viable option for COVID-19 triage.
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Affiliation(s)
- Fatma Mansab
- School of Postgraduate Medicine, University of Gibraltar, Gibraltar, Gibraltar.,Department of Public Health, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - Sohail Bhatti
- School of Postgraduate Medicine, University of Gibraltar, Gibraltar, Gibraltar.,Department of Public Health, Gibraltar Health Authority, Gibraltar, Gibraltar
| | - Daniel Goyal
- School of Postgraduate Medicine, University of Gibraltar, Gibraltar, Gibraltar .,Department of Medicine, Lorn and Islands Hospital, Oban, UK
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Abstract
The COVID-19 pandemic has led to new ethical challenges and exposed or exacerbated others that were already present. Through the lens of pediatric surgery, this article aims to discuss issues that have been impacted by the pandemic including triage of care and allocation of scarce resources, equity and access to care, and a physician's competing responsibilities to their patients, families, and selves.
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Affiliation(s)
- Jason Sulkowski
- Children's Hospital of Richmond at Virginia Commonwealth University, United States
| | - Sophie Mayeux
- NYP-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, Children's North 216-B, 3959 Broadway, New York, NY 10032, United States,NewYork-Presbyterian Hospital, United States
| | - William Middlesworth
- NYP-Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, Children's North 216-B, 3959 Broadway, New York, NY 10032, United States; NYP-Morgan Stanley Children's Hospital, United States.
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Goyal DK, Mansab F, Naasan AP, Iqbal A, Millar C, Franklin G, Thomas S, McFadden J, Burke D, Lasserson D. Restricted access to the NHS during the COVID-19 pandemic: Is it time to move away from the rationed clinical response? THE LANCET REGIONAL HEALTH. EUROPE 2021; 8:100201. [PMID: 34423329 PMCID: PMC8372453 DOI: 10.1016/j.lanepe.2021.100201] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Daniel K Goyal
- Consultant Physician & COVID Co-Lead, Lorn & Islands Hospital, Oban, NHS Highlands, Scotland, UK; Clinical Lecturer, Health Systems, University of Gibraltar, Gibraltar
- Corresponding author.
| | - Fatma Mansab
- Researcher, COVID-19 Team, Public Health Gibraltar; Clinical Lecturer, Postgraduate Medical School, University of Gibraltar
| | - Adeeb P Naasan
- Senior House Officer in General Internal Medicine and Covid-19 Response Co-ordinator, Lorn & Islands Hospital, Oban, NHS Highlands, Scotland, UK
| | - Amir Iqbal
- Senior Clinical Lead, Covid-19 Remote Monitoring of Patients During Response & Recovery, NHS Grampian, Scotland, UK
| | - Colin Millar
- Consultant Physician, Covid Co-Lead, Lorn & Islands Hospital, Oban, NHS Highlands, Scotland, UK
| | - Grant Franklin
- Consultant Acute Medicine, Raigmore Hospital, NHS Highlands, Inverness, Scotland, UK
| | - Stephen Thomas
- Consultant Respiratory Physician, Raigmore Hospital, NHS Highlands, Inverness, Scotland, UK
| | - John McFadden
- General Practitioner, Burnfield Medical Practice, NHS Highlands, Scotland, UK
| | - Derek Burke
- Head of Clinical Governance and GMC Suitable Person, Gibraltar Health Authority, Gibraltar (formerly Consultant in Paediatric Emergency Medicine and Medical Director Sheffield Children's NHS FT)
| | - Daniel Lasserson
- Professor of Acute Ambulatory Care, University of Warwick; Clinical Lead for Ambulatory Outreach Team, Oxford University Hospital, Oxford, UK
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Khorram-Manesh A, Nordling J, Carlström E, Goniewicz K, Faccincani R, Burkle FM. A translational triage research development tool: standardizing prehospital triage decision-making systems in mass casualty incidents. Scand J Trauma Resusc Emerg Med 2021; 29:119. [PMID: 34404443 PMCID: PMC8369703 DOI: 10.1186/s13049-021-00932-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background There is no global consensus on the use of prehospital triage system in mass casualty incidents. The purpose of this study was to evaluate the most commonly used pre-existing prehospital triage systems for the possibility of creating one universal translational triage tool. Methods The Rapid Evidence Review consisted of (1) a systematic literature review (2) merging and content analysis of the studies focusing on similarities and differences between systems and (3) development of a universal system. Results There were 17 triage systems described in 31 eligible articles out of 797 identified initially. Seven of the systems met the predesignated criteria and were selected for further analysis. The criteria from the final seven systems were compiled, translated and counted for in means of 1/7’s. As a product, a universal system was created of the majority criteria. Conclusions This study does not create a new triage system itself but rather identifies the possibility to convert various prehospital triage systems into one by using a triage translational tool. Future research should examine the tool and its different decision-making steps either by using simulations or by experts’ evaluation to ensure its feasibility in terms of speed, continuity, simplicity, sensitivity and specificity, before final evaluation at prehospital level. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00932-z.
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Affiliation(s)
- Amir Khorram-Manesh
- Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 413 45, Gothenburg, Sweden. .,Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden. .,Department of Research and Development, Armed Forces Center for Defense Medicine, 426 76, Västra Frölunda, Gothenburg, Sweden.
| | - Johan Nordling
- Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 413 45, Gothenburg, Sweden
| | - Eric Carlström
- Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden.,Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden.,USN School of Business, University of South-Eastern Norway, 3616, Kongsberg, Norway
| | - Krzysztof Goniewicz
- Department of Aviation Security, Military University of Aviation, 08-521, Dęblin, Poland
| | - Roberto Faccincani
- Emergency Department, Humanitas Mater Domini, 210 53, Castellanza, Italy
| | - Frederick M Burkle
- T.H. Chan School of Public Health, Harvard Humanitarian Initiative, Harvard University, Boston, MA, 02115, USA
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L’éthique clinique en temps de pandémie Covid-19 : le triomphe de l’utilitarisme. LA PRESSE MÉDICALE FORMATION 2021. [PMCID: PMC8177499 DOI: 10.1016/j.lpmfor.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Carson RC, Forzley B, Thomas S, Preto N, Hargrove G, Virani A, Antonsen J, Brown M, Copland M, Michaud M, Singh A, Levin A. Balancing the Needs of Acute and Maintenance Dialysis Patients during the COVID-19 Pandemic: A Proposed Ethical Framework for Dialysis Allocation. Clin J Am Soc Nephrol 2021; 16:1122-1130. [PMID: 33558254 PMCID: PMC8425609 DOI: 10.2215/cjn.07460520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The COVID-19 pandemic continues to strain health care systems and drive shortages in medical supplies and equipment around the world. Resource allocation in times of scarcity requires transparent, ethical frameworks to optimize decision making and reduce health care worker and patient distress. The complexity of allocating dialysis resources for both patients receiving acute and maintenance dialysis has not previously been addressed. Using a rapid, collaborative, and iterative process, BC Renal, a provincial network in Canada, engaged patients, doctors, ethicists, administrators, and nurses to develop a framework for addressing system capacity, communication challenges, and allocation decisions. The guiding ethical principles that underpin this framework are (1) maximizing benefits, (2) treating people fairly, (3) prioritizing the worst-off individuals, and (4) procedural justice. Algorithms to support resource allocation and triage of patients were tested using simulations, and the final framework was reviewed and endorsed by members of the provincial nephrology community. The unique aspects of this allocation framework are the consideration of two diverse patient groups who require dialysis (acute and maintenance), and the application of two allocation criteria (urgency and prognosis) to each group in a sequential matrix. We acknowledge the context of the Canadian health care system, and a universal payer in which this framework was developed. The intention is to promote fair decision making and to maintain an equitable reallocation of limited resources for a complex problem during a pandemic.
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Affiliation(s)
- Rachel C. Carson
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Brian Forzley
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Sarah Thomas
- BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Nina Preto
- BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Gaylene Hargrove
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Alice Virani
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Antonsen
- BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Melanie Brown
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Michael Copland
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Marie Michaud
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Anurag Singh
- BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
| | - Adeera Levin
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada,BC Renal, British Columbia Provincial Health Services Authority, British Columbia, Canada
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Mulcahy Symmons S, Fox R, Mannion M, Joyce D, De Brún A, Glynn L, Ryan D, Keane N, McAuliffe E. A mixed methods protocol to evaluate the effectiveness and acceptability of COVID-19 Community Assessment Hubs. HRB Open Res 2021; 4:16. [PMID: 34056538 PMCID: PMC8136252 DOI: 10.12688/hrbopenres.13217.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Ireland's health system has been under significant strain due to staff shortages and inadequate capacity. Critical care bed capacity per capita in Ireland is among the lowest in Europe, thus, the coronavirus disease 2019 (COVID-19) pandemic has put additional strain on an over-stretched system. COVID-19 Community Assessment Hubs (CAHs) were established to mitigate unnecessary admission to acute hospitals, and reduce infection spread by supporting COVID-19 positive or suspected positive patients to isolate at home, or in isolation facilities. There is some evidence that similar assessment centres may be a successful triage strategy to reduce burden on hospital and acute care. Aim : The aim of this study is to evaluate the impact of COVID-19 Community Assessment Hubs on service delivery in two regions in Ireland during the pandemic. Methods: A mixed-methods approach will be used, incorporating co-design to engage stakeholders and ensure informed data capture and analysis. Online surveys will assess CAH patients' experiences of access to and quality of care. Clinical patient data from CAHs will be collected and analysed using multinomial logistic regression to check for association with patient demographics and COVID-19 symptoms, and CAH early warning scores and outcomes (Transfer to Emergency Department, Transfer to isolation unit, Sent home with care plan). Semi-structured interviews will be conducted with: patients to elicit an in-depth understanding of experiences and acceptability of attending CAHs; and staff to understand challenges, benefits, and effectiveness of CAHs. Interview data will be analysed using thematic analysis. Discussion: This study will provide valuable insights from both patient and staff perspectives on the operation of CAHs. We will evaluate the effectiveness and acceptability of CAHs and propose areas for improvement of the service. This will contribute to international literature on the use of community assessment centres during infectious disease pandemics.
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Affiliation(s)
- Sophie Mulcahy Symmons
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Robert Fox
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Marese Mannion
- School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland
| | - David Joyce
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Aoife De Brún
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Liam Glynn
- School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland
- HRB Primary Care Clinical Trials Network Ireland, Galway, Ireland
| | - Damien Ryan
- School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland
- ALERT, Emergency Department, University Hospital Limerick, Limerick, V94 F858, Ireland
| | - Niamh Keane
- Department of Public health Nursing, Health Service Executive, Dublin, Ireland
| | - Eilish McAuliffe
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
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40
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The pandemic’s effect on discharge against medical advice from the emergency department. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.907496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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41
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Mulcahy Symmons S, Fox R, Mannion M, Joyce D, De Brún A, Glynn L, Ryan D, Keane N, McAuliffe E. A mixed methods protocol to evaluate the effectiveness and acceptability of COVID-19 Community Assessment Hubs. HRB Open Res 2021; 4:16. [PMID: 34056538 PMCID: PMC8136252 DOI: 10.12688/hrbopenres.13217.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 04/03/2024] Open
Abstract
Background: Ireland's health system has been under significant strain due to staff shortages and inadequate capacity. Critical care bed capacity per capita in Ireland is among the lowest in Europe, thus, the coronavirus disease 2019 (COVID-19) pandemic has put additional strain on an over-stretched system. COVID-19 Community Assessment Hubs (CAHs) were established to mitigate unnecessary admission to acute hospitals, and reduce infection spread by supporting COVID-19 positive or suspected positive patients to isolate at home, or in isolation facilities. There is some evidence that similar assessment centres may be a successful triage strategy to reduce burden on hospital and acute care. Aim : The aim of this study is to evaluate the impact of COVID-19 Community Assessment Hubs on service delivery in one region in Ireland. Methods: A mixed-methods approach will be used, incorporating co-design to engage stakeholders and ensure informed data capture and analysis. Online surveys will assess CAH patients' experiences of access to and quality of care. Clinical patient data from CAHs will be collected and analysed using multinomial logistic regression to check for association with patient demographics and COVID-19 symptoms, and CAH early warning scores and outcomes (Transfer to Emergency Department, Transfer to isolation unit, Sent home with care plan). Semi-structured interviews will be conducted with: patients to elicit an in-depth understanding of experiences and acceptability of attending CAHs; and staff to understand challenges, benefits, and effectiveness of CAHs. Interview data will be analysed using a thematic analysis approach. Discussion: This study will provide valuable insights from both patient and staff perspectives on the operation of CAHs. We will evaluate the effectiveness and acceptability of CAHs and propose areas for improvement of the service. This will contribute to international literature on the use of community assessment centres during infectious disease pandemics.
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Affiliation(s)
- Sophie Mulcahy Symmons
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Robert Fox
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Marese Mannion
- School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland
| | - David Joyce
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Aoife De Brún
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Liam Glynn
- School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland
- HRB Primary Care Clinical Trials Network Ireland, Galway, Ireland
| | - Damien Ryan
- School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland
- ALERT, Emergency Department, University Hospital Limerick, Limerick, V94 F858, Ireland
| | - Niamh Keane
- Department of Public health Nursing, Health Service Executive, Dublin, Ireland
| | - Eilish McAuliffe
- Centre for Interdisciplinary Research Education and Innovation in Health Systems (IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, D04 V1W8, Ireland
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Di Lorenzo R, Frattini N, Dragone D, Farina R, Luisi F, Ferrari S, Bandiera G, Rovesti S, Ferri P. Psychiatric Emergencies During the Covid-19 Pandemic: A 6-Month Observational Study. Neuropsychiatr Dis Treat 2021; 17:1763-1778. [PMID: 34113107 PMCID: PMC8184244 DOI: 10.2147/ndt.s307128] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/22/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The new SARS-CoV-2 has caused an ongoing pandemic. Health prevention measures to contain the outbreak are profoundly affecting the physical and mental health as well as personal freedom of the population. AIM To evaluate psychiatric emergencies in a 6-month period during the COVID-19 pandemic in 2020 compared to those of the corresponding period of the previous year. METHODS This monocentric observational study preliminarily collected variables of the urgent psychiatric consultations (UPCs) carried out in emergency room (ER) from 1-3-2020 to 31-8-2020 and the socio-demographic and clinical characteristics of patients who required UPCs in the 6-month period, comparing these data with those collected from 1-3-2019 to 31-8-2019. The data, collected in alpha-numeric code, were statistically analyzed through STATA 12-2011. RESULTS This research reported a reduction of both UPCs and hospital psychiatric admissions. Concomitantly, we observed an increase of UPCs required by people already being treated by psychiatric and other health services, residents in psychiatric facilities and non-Italians. In 2020, differently from 2019, the most frequent reasons for urgent psychiatric consultations were aggressive behavior and adjustment disorders with anxiety and depressive mood. CONCLUSION This preliminary study suggests that, during the COVID-19 epidemic, urgent psychiatric consultations in ER were reduced, except for the most vulnerable people due to their clinical and/or social conditions.
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Affiliation(s)
- Rosaria Di Lorenzo
- Psychiatric Intensive Treatment Facility, Mental Health and Drug Abuse Department of AUSL-Modena, Modena, Italy
| | - Nicoletta Frattini
- Department of Biomedical, Metabolic and Neural Sciences, School of Nursing, University of Modena and Reggio Emilia, Modena, Italy
| | - Diego Dragone
- Department of Biomedical, Metabolic and Neural Sciences, School of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Farina
- Department of Biomedical, Metabolic and Neural Sciences, School of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Filippa Luisi
- Department of Biomedical, Metabolic and Neural Sciences, School of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Ferrari
- Department of Biomedical, Metabolic and Neural Sciences, School of Psychiatry, University of Modena and Reggio Emilia, Modena, Italy
| | - Geminiano Bandiera
- Emergency Room and Emergency Medicine Unit, General Hospital of Baggiovara, AOU of Modena, Modena, Italy
| | - Sergio Rovesti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Paola Ferri
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
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Orfali K. Getting to the Truth: Ethics, Trust, and Triage in the United States versus Europe during the Covid-19 Pandemic. Hastings Cent Rep 2021; 51:16-22. [PMID: 33486774 PMCID: PMC8014048 DOI: 10.1002/hast.1206] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Ethical issues around triage have been at the forefront of debates during the Covid-19 pandemic. This essay compares both discussion and guidelines around triage and the reality of what happened in the United States and in Europe, both in anticipation of and during the first wave of the pandemic. Why did the issue generate so many vivid debates in the United States and so few in most European countries, although the latter were also affected by the rationing of health care resources? Are countries with socialized health care systems better equipped to face the hard choices of triaging? Important lessons in transparency, trust, and accountability for policy-makers can be drawn from this comparison, demonstrating that fostering public involvement and ethical debate remains a critical element for the sustained acceptance of any triage plan.
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Harvey S, Zalud I. Obstetric hospital preparedness for a pandemic: an obstetric critical care perspective in response to COVID-19. J Perinat Med 2020; 48:874-882. [PMID: 32745072 DOI: 10.1515/jpm-2020-0281] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 01/10/2023]
Abstract
The Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pandemic has had a rapid and deadly onset, spreading quickly throughout the world. Pregnant patients have had high mortality rates, perinatal losses, and Intensive Care Unit (ICU) admissions from acute respiratory syndrome Coronavirus (SARS-CoV) and Middle East respiratory syndrome Coronavirus (MERS-CoV) in the past. Potentially, a surge of patients may require hospitalization and ICU care beyond the capacity of the health care system. This article is to provide institutional guidance on how to prepare an obstetric hospital service for a pandemic, mass casualty, or natural disaster by identifying a care model and resources for a large surge of critically ill pregnant patients over a short time. We recommend a series of protocols, education, and simulation training, with a structured and tiered approach to match the needs for the patients, for hospitals specialized in obstetrics.
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Affiliation(s)
- Scott Harvey
- University of Hawaii at Manoa, John A Burns School of Medicine, Department of Obstetrics, Gynecology and Women's Health, Honolulu, Hawaii, USA.,Kapiolani Medical Center for Women and Children, Department of Obstetrics/Gynecology and Womens Health1319 Punahou Street Suite 824, Honolulu, Hawaii 96816, USA
| | - Ivica Zalud
- University of Hawaii at Manoa, John A Burns School of Medicine, Department of Obstetrics, Gynecology and Women's Health, Honolulu, Hawaii, USA.,Kapiolani Medical Center for Women and Children, Department of Obstetrics/Gynecology and Womens Health1319 Punahou Street Suite 824, Honolulu, Hawaii 96816, USA
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Iacorossi L, Fauci AJ, Napoletano A, D'Angelo D, Salomone K, Latina R, Coclite D, Iannone P. Triage protocol for allocation of critical health resources during Covid-19 pandemic and public health emergencies. A narrative review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020162. [PMID: 33525236 PMCID: PMC7927504 DOI: 10.23750/abm.v91i4.10393] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/28/2020] [Indexed: 01/16/2023]
Abstract
Background and aim of the work. Triage during the Covid-19 pandemic can impose difficult allocation decisions when demand for mechanical ventilation or intensive care beds greatly exceeds available resources. Triage criteria should be objective, ethical, transparent, applied equitably and publically disclosed. The aim of this review is to describe the triage tools and process for critical care resources in a pandemic health emergency. Methods. A narrative review was conducted of the literature on five electronic databases, namely PubMed, CINHAL, Web of Science, Cochrane and Embase, searching for studies published from January 2006 to July 2020. Results. The results describe different triage tools. A gold standard of triage does not exist for the adult or paediatric population. Using probability of short-term survival as the sole allocation principle is problematic. In general, each triage protocol should be applied with a specific ethical justification, including transparency, duty to care, duty to steward resources, duty to plan, and distributive justice. Conclusions. Clinical triage decisions based on clinical judgment alone are prone to inconsistent application by triage officers in a pandemic. An ethical framework can inform decision-making and improve accountability. It remains difficult to connect clinical criteria and ethical criteria, because of the models on offer for health services. (www.actabiomedica.it)
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Affiliation(s)
- Laura Iacorossi
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Alice J Fauci
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Antonello Napoletano
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Daniela D'Angelo
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Katia Salomone
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | | | - Daniela Coclite
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
| | - Primiano Iannone
- National Center for Clinical Excellence, Quality and Safety of Care (CNEC), Istituto Superiore di Sanità, Via Giano della Bella, 34, 00162 Rome, Italy.
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Dos Santos MJ, Martins MS, Santana FLP, Furtado MCSPC, Miname FCBR, Pimentel RRDS, Brito ÁN, Schneider P, Dos Santos ES, da Silva LH. COVID-19: instruments for the allocation of mechanical ventilators-a narrative review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:582. [PMID: 32993736 PMCID: PMC7522926 DOI: 10.1186/s13054-020-03298-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/17/2020] [Indexed: 01/11/2023]
Abstract
After the World Health Organization declared COVID-19 to be a pandemic, the elaboration of comprehensive and preventive public policies became important in order to stop the spread of the disease. However, insufficient or ineffective measures may have placed health professionals and services in the position of having to allocate mechanical ventilators. This study aimed to identify instruments, analyze their structures, and present the main criteria used in the screening protocols, in order to help the development of guidelines and policies for the allocation of mechanical ventilators in the COVID-19 pandemic. The instruments have a low level of scientific evidence, and, in general, are structured by various clinical, non-clinical, and tiebreaker criteria that contain ethical aspects. Few instruments included public participation in their construction or validation. We believe that the elaboration of these guidelines cannot be restricted to specialists as this question involves ethical considerations which make the participation of the population necessary. Finally, we propose seventeen elements that can support the construction of screening protocols in the COVID-19 pandemic.
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Affiliation(s)
- Marcelo José Dos Santos
- Research Group "Bioethics and Administration: Teaching and Health Care", Nursing School of University of São Paulo, São Paulo, SP, Brazil. .,Departamento de Orientação Profissional, Escola de Enfermagem da Universidade de São Paulo, Rua Dr. Enéas de Carvalho Aguiar, 419, CEP - 05403-000 Cerqueira Cesar, São Paulo, SP, Brazil.
| | - Maristela Santini Martins
- Research Group "Bioethics and Administration: Teaching and Health Care", Nursing School of University of São Paulo, São Paulo, SP, Brazil
| | - Fabiana Lopes Pereira Santana
- Research Group "Bioethics and Administration: Teaching and Health Care", Nursing School of University of São Paulo, São Paulo, SP, Brazil
| | | | | | - Rafael Rodrigo da Silva Pimentel
- Research Group "Bioethics and Administration: Teaching and Health Care", Nursing School of University of São Paulo, São Paulo, SP, Brazil
| | - Ágata Nunes Brito
- Research Group "Bioethics and Administration: Teaching and Health Care", Nursing School of University of São Paulo, São Paulo, SP, Brazil
| | - Patrick Schneider
- Research Group "Bioethics and Administration: Teaching and Health Care", Nursing School of University of São Paulo, São Paulo, SP, Brazil
| | - Edson Silva Dos Santos
- Research Group "Bioethics and Administration: Teaching and Health Care", Nursing School of University of São Paulo, São Paulo, SP, Brazil
| | - Luciane Hupalo da Silva
- Research Group "Bioethics and Administration: Teaching and Health Care", Nursing School of University of São Paulo, São Paulo, SP, Brazil
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Ehmann MR, Zink EK, Levin AB, Suarez JI, Belcher HME, Daugherty Biddison EL, Doberman DJ, D'Souza K, Fine DM, Garibaldi BT, Gehrie EA, Golden SH, Gurses AP, Hill PM, Hughes MT, Kahn JP, Koch CG, Marx JJ, Meisenberg BR, Natterman J, Rushton CH, Sapirstein A, Selinger SR, Stephens RS, Toner ES, Unguru Y, van Stone M, Kachalia A. Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis. Chest 2020; 159:1076-1083. [PMID: 32991873 PMCID: PMC7521357 DOI: 10.1016/j.chest.2020.09.246] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/06/2020] [Indexed: 12/25/2022] Open
Abstract
The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium—with diverse expertise and representation—representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens’ values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource’s varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.
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Affiliation(s)
- Michael R Ehmann
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD
| | - Elizabeth K Zink
- Department of Neurology, Johns Hopkins University, Baltimore, MD; Department of Neuroscience Nursing, The Johns Hopkins Hospital, Baltimore, MD
| | - Amanda B Levin
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jose I Suarez
- Department of Neurology, Johns Hopkins University, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD; Department of Neurosurgery, Johns Hopkins University, Baltimore, MD
| | - Harolyn M E Belcher
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD; Center for Diversity in Public Health Leadership Training, Kennedy Krieger Institute, Baltimore, MD
| | | | | | - Karen D'Souza
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
| | - Derek M Fine
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Brian T Garibaldi
- Department of Medicine, Johns Hopkins University, Baltimore, MD; Department of Physiology, Johns Hopkins University, Baltimore, MD
| | - Eric A Gehrie
- Department of Pathology, Johns Hopkins University, Baltimore, MD; Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Sherita H Golden
- Department of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins University, Baltimore, MD; Office of Diversity, Inclusion, and Health Equity, Johns Hopkins Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
| | - Ayse P Gurses
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
| | - Peter M Hill
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD
| | - Mark T Hughes
- Department of Medicine, Johns Hopkins University, Baltimore, MD; Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
| | - Jeffrey P Kahn
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD
| | - Colleen G Koch
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jason J Marx
- Department of Medicine, University of Maryland St Joseph Medical Center, University of Maryland Medical System, Towson, MD
| | | | - Jeffrey Natterman
- Department of Risk Management, The Johns Hopkins Hospital, Baltimore, MD
| | - Cynda H Rushton
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD; School of Nursing, Johns Hopkins University, Baltimore, MD
| | - Adam Sapirstein
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Stephen R Selinger
- Department of Medicine, MedStar Franklin Square Medical Center, MedStar Harbor Hospital, Baltimore, MD
| | | | - Eric S Toner
- Johns Hopkins Center for Health Security, Johns Hopkins University, Baltimore, MD
| | - Yoram Unguru
- Division of Pediatric Hematology/Oncology, Sinai Hospital, Baltimore, MD
| | - Maureen van Stone
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Maryland Center for Developmental Disabilities, Kennedy Krieger Institute, Baltimore, MD
| | - Allen Kachalia
- Department of Medicine, Johns Hopkins University, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD.
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Optimizing Scarce Resource Allocation During COVID-19: Rapid Creation of a Regional Health-Care Coalition and Triage Teams in San Diego County, California. Disaster Med Public Health Prep 2020; 16:321-327. [PMID: 32907684 PMCID: PMC7684024 DOI: 10.1017/dmp.2020.344] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Successful management of an event where health-care needs exceed regional health-care capacity requires coordinated strategies for scarce resource allocation. Publications for rapid development, training, and coordination of regional hospital triage teams to manage the allocation of scarce resources during coronavirus disease 2019 (COVID-19) are lacking. Over a period of 3 weeks, over 100 clinicians, ethicists, leaders, and public health authorities convened virtually to achieve consensus on how best to save the most lives possible and share resources. This is referred to as population-based crisis management. The rapid regionalization of 22 acute care hospitals across 4500 square miles in the midst of a pandemic with a shifting regulatory landscape was challenging, but overcome by mutual trust, transparency, and confidence in the public health authority. Because many cities are facing COVID-19 surges, we share a process for successful rapid formation of health-care care coalitions, Crisis Standard of Care, and training of Triage Teams. Incorporation of continuous process improvement and methods for communication is essential for successful implementation. Use of our regional health-care coalition communications, incident command system, and the crisis care committee helped mitigate crisis care in the San Diego and Imperial County region as COVID-19 cases surged and scarce resource collaborative decisions were required.
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Practice Recommendations for Lung Cancer Radiotherapy During the COVID-19 Pandemic: An ESTRO-ASTRO Consensus Statement. Int J Radiat Oncol Biol Phys 2020; 107:631-640. [PMID: 32589990 PMCID: PMC7836268 DOI: 10.1016/j.ijrobp.2020.05.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 01/08/2023]
Abstract
Background The COVID-19 pandemic has caused radiotherapy resource pressures and led to increased risks for lung cancer patients and healthcare staff. An international group of experts in lung cancer radiotherapy established this practice recommendation pertaining to whether and how to adapt radiotherapy for lung cancer in the COVID-19 pandemic. Methods For this ESTRO & ASTRO endorsed project, 32 experts in lung cancer radiotherapy contributed to a modified Delphi consensus process. We assessed potential adaptations of radiotherapy in two pandemic scenarios. The first, an early pandemic scenario of risk mitigation, is characterized by an altered risk–benefit ratio of radiotherapy for lung cancer patients due to their increased susceptibility for severe COVID-19 infection, and minimization of patient travelling and exposure of radiotherapy staff. The second, a later pandemic scenario, is characterized by reduced radiotherapy resources requiring patient triage. Six common lung cancer cases were assessed for both scenarios: peripherally located stage I NSCLC, locally advanced NSCLC, postoperative radiotherapy after resection of pN2 NSCLC, thoracic radiotherapy and prophylactic cranial irradiation for limited stage SCLC and palliative thoracic radiotherapy for stage IV NSCLC. Results In a risk-mitigation pandemic scenario, efforts should be made not to compromise the prognosis of lung cancer patients by departing from guideline-recommended radiotherapy practice. In that same scenario, postponement or interruption of radiotherapy treatment of COVID-19 positive patients is generally recommended to avoid exposure of cancer patients and staff to an increased risk of COVID-19 infection. In a severe pandemic scenario characterized by reduced resources, if patients must be triaged, important factors for triage include potential for cure, relative benefit of radiation, life expectancy, and performance status. Case-specific consensus recommendations regarding multimodality treatment strategies and fractionation of radiotherapy are provided. Conclusion This joint ESTRO-ASTRO practice recommendation established pragmatic and balanced consensus recommendations in common clinical scenarios of radiotherapy for lung cancer in order to address the challenges of the COVID-19 pandemic.
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Maves RC, Downar J, Dichter JR, Hick JL, Devereaux A, Geiling JA, Kissoon N, Hupert N, Niven AS, King MA, Rubinson LL, Hanfling D, Hodge JG, Marshall MF, Fischkoff K, Evans LE, Tonelli MR, Wax RS, Seda G, Parrish JS, Truog RD, Sprung CL, Christian MD. Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians. Chest 2020; 158:212-225. [PMID: 32289312 PMCID: PMC7151463 DOI: 10.1016/j.chest.2020.03.063] [Citation(s) in RCA: 185] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 02/01/2023] Open
Abstract
Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.
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Affiliation(s)
| | | | | | - John L Hick
- Hennepin County Medical Center, Minneapolis, MN
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michael D Christian
- London's Air Ambulance, Royal London Hospital, Barts NHS Health Trust, London, England
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