Validity and reliability of the Interagency Integrated Triage Tool in a regional emergency department in Papua New Guinea

Performance of the Interagency Integrated Triage Tool in a resource-constrained emergency department during the COVID-19 pandemic

BACKGROUND

The Interagency Integrated Triage Tool (IITT) is a three-tier triage instrument recommended by the World Health Organization, but only the pilot version of the tool has been comprehensively assessed for its validity and reliability. This study sought to evaluate the performance of the IITT in a resource-constrained emergency department (ED) during the COVID-19 pandemic.

METHODS

This prospective observational study was conducted at ANGAU Memorial Provincial Hospital in Lae, Papua New Guinea. The study period commenced approximately six weeks after introduction of the IITT, coinciding with a major COVID-19 wave. The primary outcome was sensitivity for the detection of time-critical illness, defined by eight pre-specified conditions. Secondary outcomes included the relationship between triage category and disposition. Inter-rater reliability was assessed using Cohen's Kappa.

RESULTS

There were 759 eligible presentations during the study period. Thirty patients (4.0%) were diagnosed with one of the eight pre-specified time-critical conditions and 21 were categorised as red or yellow, equating to a sensitivity of 70.0% (95%CI 50.6-85.3). There was a clear association between triage category and disposition, with 22 of 53 red patients (41.5%), 72 of 260 yellow patients (27.7%) and 22 of 452 green patients (4.9%) admitted (p = <0.01). Negative predictive values for admission and death were 95.1% (95%CI 92.7-96.9) and 99.3% (95%CI 98.1-99.9) respectively. Among a sample of 106 patients, inter-rater reliability was excellent (κ = 0.83) and the median triage assessment time was 94 seconds [IQR 57-160].

CONCLUSION

In this single-centre study, the IITT's sensitivity for the detection of time-critical illness was comparable to previous evaluations of the tool and within the performance range reported for other triage instruments. There was a clear relationship between triage category and disposition, suggesting the tool can predict ED outcomes. Health service pressures related to COVID-19 may have influenced the findings.

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.

Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low- and middle-income country emergency departments?

INTRODUCTION

Triage is widely regarded as an essential function of emergency care (EC) systems, especially in resource-limited settings. Through a systematic search and review of the literature, we investigated the effect of triage implementation on clinical outcomes and process measures in low- and middle-income country (LMIC) emergency departments (EDs).

METHODS

Structured searches were conducted using MEDLINE, CENTRAL, EMBASE, CINAHL, and Global Health. Eligible articles identified through screening and full-text review underwent risk-of-bias assessment using the Newcastle-Ottawa Scale. The quality of evidence for each effect measure was summarized using GRADE.

RESULTS

Among 10,394 articles identified through the search strategy, 58 underwent full-text review and 16 were included in the final synthesis. All utilized pre-/postintervention methods and a majority were single center. Effect measures included mortality, waiting time, length of stay, admission rate, and patient satisfaction. Of these, ED mortality and time to clinician assessment were evaluated most frequently. The majority of studies using these outcomes identified a positive effect, namely a reduction in deaths and waiting time among patients presenting for EC. The quality of the evidence was moderate for these measures but low or very low for all other outcomes and process indicators.

CONCLUSIONS

There is moderate quality of evidence supporting an association between the introduction of triage and a reduction in deaths and waiting time. Although the available data support the value of triage in LMIC EDs, the risk of confounding and publication bias is significant. Future studies will benefit from more rigorous research methods.

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.

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.

Emergency department triage and COVID-19: Performance of the Interagency Integrated Triage Tool during a pandemic surge in Papua New Guinea

OBJECTIVE

To determine the sensitivity of the Interagency Integrated Triage Tool to identify severe and critical illness among adult patients with COVID-19.

METHODS

A retrospective observational study conducted at Port Moresby General Hospital ED during a three-month Delta surge.

RESULTS

Among 387 eligible patients with COVID-19, 63 were diagnosed with severe or critical illness. Forty-seven were allocated a high acuity triage category, equating to a sensitivity of 74.6% (95% CI 62.1-84.7) and a negative predictive value of 92.7% (95% CI 88.4-95.8).

CONCLUSION

In a resource-constrained context, the tool demonstrated reasonable sensitivity to detect severe and critical COVID-19, comparable with its reported performance for other urgent conditions.