Validation of the Interagency Integrated Triage Tool in a resource-limited, urban emergency department in Papua New Guinea: a pilot study

Epidemiology of prehospital emergency calls according to patient transport decision in a middle eastern emergency care environment: Retrospective cohort-based

Background and Aim

Though emergency medical services (EMS) respond to all types of emergency calls, they do not always result in the patient being transported to the hospital. This study aimed to explore the determinants influencing emergency call-response-based conveyance decisions in a Middle Eastern ambulance service.

Methods

This retrospective quantitative analysis of 93,712 emergency calls to the Hamad Medical Corporation Ambulance Service (HMCAS) between January 1 and May 31, 2023, obtained from the HMCAS electronic system, was analyzed to determine pertinent variables. Sociodemographic, emergency dispatch-related, clinical, and miscellaneous predictors were analyzed. Descriptive, bivariate, ridge logistic regression, and combination analyses were evaluated.

Results

23.95% (N = 21,194) and 76.05% (N = 67,285) resulted in patient nontransport and transportation, respectively. Sociodemographic analysis revealed that males predominantly activated EMS resources, and 60% of males (n = 12,687) were not transported, whilst 65% of females (n = 44,053) were transported. South Asians represented a significant proportion of the transported patients (36%, n = 24,007). "Home" emerged as the primary emergency location (56%, n = 37,725). Bivariate analysis revealed significant associations across several variables, though multicollinearity was identified as a challenge. Ridge regression analysis underscored the role of certain predictors, such as missing provisional diagnoses, in transportation decisions. The upset plot shows that hypertension and diabetes mellitus were the most common combinations in both groups.

Conclusions

This study highlights the nuanced complexities governing conveyance decisions. By unveiling patterns such as male predominance, which reflects Qatar's expatriate population, and specific temporal EMS activity peaks, this study accentuates the importance of holistic patient assessment that transcends medical histories.

Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region

According to the World Health Organization's (WHO) Emergency Care Systems Framework, triage is an essential function of emergency departments (EDs). This practice innovation article describes four strategies that have been used to support implementation of the WHO-endorsed Interagency Integrated Triage Tool (IITT) in the Pacific region, namely needs assessment, digital learning, public communications and electronic data management.Using a case study from Vila Central Hospital in Vanuatu, a Pacific Small Island Developing State, we reflect on lessons learned from IITT implementation in a resource-limited ED. In particular, we describe the value of a bespoke needs assessment tool for documenting triage and patient flow requirements; the challenges and opportunities presented by digital learning; the benefits of locally designed, public-facing communications materials; and the feasibility and impact of a low-cost electronic data registry system.Our experience of using these tools in Vanuatu and across the Pacific region will be of interest to other resource-limited EDs seeking to improve their triage practice and performance. Although the resources and strategies presented in this article are focussed on the IITT, the principles are equally relevant to other triage systems.

History of emergency medicine in Bhutan

Emergency medicine in Bhutan has made significant progress in the past few decades and continues to evolve. In this article, we provide valuable insights into the history of emergency medicine at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) and in Bhutan and highlight some of the future challenges we face as we move forward to meet the demands of increased patient volume and complexity.

Reliability of Risk Assessment for Intra-Hospital Venous Thromboembolism: An Exploratory Cross-Sectional Study

Objective

Hospital-associated venous thromboembolism (VTE) is a major cause of unintended death in hospitalized patients. Standardized and reasonable prevention measures may reduce its occurrence effectively. This study aims to analyze the consistency of VTE risk assessment by physicians and nurses and its potential causes.

Methods

A total of 897 patients admitted to Shanghai East Hospital from December 2021 to March 2022 were recruited. The VTE assessment scores of physicians and nurses and the activities of daily living (ADL) scores within the first 24 h of admission were collected for each patient. Cohen's Kappa values were calculated to assess the inter-rater consistency of these scores.

Results

VTE scores were fairly consistent between doctors and nurses in both surgical (Kappa = 0.30, 95% CI: 0.25-0.34) and non-surgical (Kappa = 0.35, 95% CI: 0.31-0.38) departments. There was moderate agreement in VTE risk assessment between doctors and nurses in surgical departments (Kappa = 0.50, 95% CI: 0.38-0.62) while fair agreement in VTE risk assessment between doctors and nurses in non-surgical departments (Kappa = 0.32, 95% CI: 0.26-0.40). The assessment of the mobility impairment component was fairly consistent between doctors and nurses in the non-surgical departments (Kappa = 0.31, 95% CI: 0.25-0.37).

Conclusion

Due to the poor consistency of VTE risk assessment between doctors and nurses, it is necessary to provide systematic training and develop a standardized assessment process for healthcare professionals to construct a scientific and effective VTE prevention and treatment system.

Evaluation of emergency care education and triage implementation: an observational study at a hospital in rural Liberia

INTRODUCTION

In Liberia, emergency care is still in its early development. In 2019, two emergency care and triage education sessions were done at J. J. Dossen Hospital in Southeastern Liberia. The observational study objectives evaluated key process outcomes before and after the educational interventions.

METHODS

Emergency department paper records from 1 February 2019 to 31 December 2019 were retrospectively reviewed. Simple descriptive statistics were used to describe patient demographics and χ² analyses were used to test for significance. ORs were calculated for key predetermined process measures.

RESULTS

There were 8222 patient visits recorded that were included in our analysis. Patients in the post-intervention 1 group had higher odds of having a documented full set of vital signs compared with the baseline group (16% vs 3.5%, OR: 5.4 (95% CI: 4.3 to 6.7)). After triage implementation, patients who were triaged were 16 times more likely to have a full set of vitals compared with those who were not triaged. Similarly, compared with the baseline group, patients in the post-intervention 1 group had higher odds of having a glucose documented if they presented with altered mental status or a neurologic complaint (37% vs 30%, OR: 1.7 (95% CI: 1.3 to 2.2)), documented antibiotic administration if they had a presumed bacterial infection (87% vs 35%, OR: 12.8 (95% CI: 8.8 to 17.1)), documented malaria test if presenting with fever (76% vs 61%, OR: 2.05 (95% CI: 1.37 to 3.08)) or documented repeat set of vitals if presenting with shock (25% vs 6.6%, OR: 8.85 (95% CI: 1.67 to 14.06)). There was no significant difference in the above process outcomes between the education interventions.

CONCLUSION

This study showed improvement in most process measures between the baseline and post-intervention 1 groups, benefits that persisted post-intervention 2, thus supporting the importance of short-course education interventions to durably improve facility-based care.

Multimodal learning for emergency department triage implementation: experiences from Papua New Guinea during the COVID-19 pandemic

Background

Triage implementation in resource-limited emergency departments (EDs) has traditionally relied on intensive in-person training. This study sought to evaluate the impact of a novel digital-based learning strategy focused on the Interagency Integrated Triage Tool, a three-tier triage instrument recommended by the World Health Organization.

Methods

A mixed methods study utilising pre-post intervention methods was conducted in two EDs in Papua New Guinea. The primary outcome was the mean change in knowledge before and after completion of a voluntary, multimodal training program, primarily delivered through a digital learning platform accessible via smartphone. Secondary outcomes included the change in confidence to perform selected clinical tasks, and acceptability of the learning methods.

Findings

Among 136 eligible ED staff, 91 (66.9%) completed the digital learning program. The mean knowledge score on the post-training exam was 87.5% (SD 10.4), a mean increase of 12.9% (95% CI 10.7-15.1%, p < 0.0001) from the pre-training exam. There were statistically significant improvements in confidence for 13 of 15 clinical tasks, including undertaking a triage assessment and identifying an unwell patient.In an evaluation survey, 100% of 30 respondents agreed or strongly agreed the online learning platform was easy to access, use and navigate, and that the digital teaching methods were appropriate for their learning needs. In qualitative feedback, respondents reported that limited internet access and a lack of dedicated training time were barriers to participation.

Interpretation

The use of digital learning to support triage implementation in resource-limited EDs is feasible and effective when accompanied by in-person mentoring. Adequate internet access is an essential pre-requisite.

Funding

Development of the Kumul Helt Skul learning platform was undertaken as part of the Clinical Support Program (Phase II), facilitated by Johnstaff International Development on behalf of the Australian Government Department of Foreign Affairs and Trade through the PNG-Australia Partnership. RM is supported by a National Health and Medical Research Council Postgraduate Scholarship and a Monash Graduate Excellence Scholarship, while PC is supported by a Medical Research Future Fund Practitioner Fellowship. Funders had no role in study design, results analysis or manuscript preparation.

A prospective, internal validation of an emergency patient triage tool for use in a low resource setting

Aim

Assess the performance of a simple triage disposition score based on mental status, mobility and either oxygen saturation or respiratory rate by three principal metrics: 24 h mortality, the need for hospital admission and the urgency ranking of patient presentations.

Method

Prospective observational non-interventional study of consecutive patients presenting to the emergency and outpatient departments of a low-resource sub-Saharan hospital

Results

Out of 14,585 consecutive patients arriving to hospital 1,804 (12.4%) were admitted and 39 died (0.3%) within 24 hours. No patients with normal mental status or a stable independent gait died within 24 h, and 95% of those who did had an oxygen saturation <94%. The c statistic of the score for death within 24 hours was >0.95 and not significantly changed if respiratory rate replaced oxygen saturation as a score component, or mental status was assessed subjectively or objectively. However, an objective measure of mental status significantly reduced the c statistic for hospital admission from 0.970 SE 0.003 to 0.956 SE 0.004, p 0.002. The score attributed a higher acuity rating than the South African Triage System urgency ranking of presentations to 11.1% of patients and a lower acuity rating to 1.3%. However, 53% of the patients given a higher acuity rating were subsequently admitted to hospital and 6.1% of them died.

Conclusion

The score identified patients who subsequently required hospital admission and who were likely to die within 24 hours.

Reliability and Validity of a New Computer-Based Triage Decision Support Tool: ANKUTRIAGE

OBJECTIVE

Triage is a tool used to determine patients' severity of illness or injury within minutes of arrival. This study aims to assess the reliability and validity of a new computer-based triage decision support tool, ANKUTRIAGE, prospectively.

METHODS

ANKUTRIAGE, a 5-level triage tool was established considering 2 major factors, patient's vital signs and characteristics of the admission complaint. Adult patients admitted to the ED between July and October, 2019 were consecutively and independently double triaged by 2 assessors using ANKUTRIAGE system. To measure inter-rater reliability, quadratic-weighted kappa coefficients (Kw) were calculated. For the validity, associations among urgency levels, resource use, and clinical outcomes were evaluated.

RESULTS

The inter-rater reliability between users of ANKUTRIAGE was excellent with an agreement coefficient (Kw) greater than 0.8 in all compared groups. In the validity phase, hospitalization rate, intensive care unit admission and mortality rate decreased from level 1 to 5. Likewise, according to the urgency levels, resource use decreased significantly as the triage level decreased (P < 0.05).

CONCLUSIONS

ANKUTRIAGE proved to be a valid and reliable tool in the emergency department. The results showed that displaying the key discriminator for each complaint to assist decision leads to a high inter-rater agreement with good correlation between urgency levels and clinical outcomes, as well as between urgency levels and resource consumptions.

Sudanese emergency departments: a study to identify the barriers to a well-functioning triage

BACKGROUND

Triage system is a sorting system that categorizes patients on the basis of the severity of their condition and the availability of the resources in the emergency department. There has been little attention in the public literature to triage systems in Sudan. The aim of this study was to explore the triage system and identify the barriers in its application in hospitals in Sudan.

METHODS

A cross-sectional hospital based study was conducted at eight hospitals in Khartoum during December 2020. A multi-stage cluster sampling was applied. Data were obtained by interviewing emergency department staff using a structured questionnaire. The data were analyzed using statistical package for social sciences to find the association between various variables by chi-square test.

RESULTS

Most of the respondents stated that the triage system was deficient. Most of the participants of this study agreed that the role played by the administration in taking legislative decisions is crucial in improving the triage system. Among the factors found to be significant to a well-functioning triage system were, the need for substantial capital expenditure, p-value: 0.026, prudent legislative decisions, p-value: 0.026, adequate training of staff on means of performing efficient triaging, p-value: 0.007 and raising the awareness of the staff on the correct application of triage guidelines, p-value: 0.017.

CONCLUSION

Currently there is no formal triage system in the State of Khartoum and has yet to be established. Policy making by administrators will play an important role in its implementation. It is suggested that prompt executive orders on improving the current triage system in Khartoum, should be carried out sooner than later, as the ripple effects of a well-functioning triage will decrease the average length of stay, mortality and morbidity rates and will eventually increase the patient's satisfaction.