1
|
Chen J, Aluisio AR, Tang OY, Nwakibu UA, Hunold KM, Wangara AA, Kiruja J, Maingi A, Mutiso V, Thompson P, Wachira B, Dunlop SJ, Martin IBK, Myers JG. Diagnostic Accuracy of the World Health Organization Pediatric Emergency Triage, Assessment and Treatment Tool Plus Among Patients Seeking Care in Nairobi, Kenya: A Cross-sectional Study. Pediatr Emerg Care 2024; 40:515-520. [PMID: 38048556 DOI: 10.1097/pec.0000000000003093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
INTRODUCTION The World Health Organization developed Emergency Triage Assessment and Treatment Plus (ETAT+) guidelines to facilitate pediatric care in resource-limited settings. ETAT+ triages patients as nonurgent, priority, or emergency cases, but there is limited research on the performance of ETAT+ regarding patient-oriented outcomes. This study assessed the diagnostic accuracy of ETAT+ in predicting the need for hospital admission in a pediatric emergency unit at Kenyatta National Hospital in Nairobi, Kenya. METHODS This was a secondary analysis of a cross-sectional study of pediatric emergency unit patients enrolled over a 4-week period using fixed random sampling. Diagnostic accuracy of ETAT+ was evaluated using receiver operating curves (ROCs) and respective 95% confidence intervals (CIs) with associated sensitivity and specificity (reference category: nonurgent). The ROC analysis was performed for the overall population and stratified by age group. RESULTS A total of 323 patients were studied. The most common reasons for presentation were upper respiratory tract disease (32.8%), gastrointestinal disease (15.5%), and lower respiratory tract disease (12.4%). Two hundred twelve participants were triaged as nonurgent (65.6%), 60 as priority (18.6%), and 51 as emergency (15.8%). In the overall study population, the area under the ROC curve was 0.97 (95% CI, 0.95-0.99). The ETAT+ sensitivity was 93.8% (95% CI, 87.0%-99.0%), and the specificity was 82.0% (95% CI, 77.0%-87.0%) for admission of priority group patients. The sensitivity and specificity for the emergency patients were 66.0% (95% CI, 55.0%-77.0%) and 98.0% (95% CI, 97.0%-100.0%), respectively. CONCLUSIONS ETAT+ demonstrated diagnostic accuracy for predicting patient need for hospital admission. This finding supports the utility of ETAT+ to inform emergency care practice. Further research on ETAT+ performance in larger populations and additional patient-oriented outcomes would enhance its generalizability and application in resource-limited settings.
Collapse
Affiliation(s)
- Josephine Chen
- From the Division of Biology and Medicine, Brown University
| | - Adam R Aluisio
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Oliver Y Tang
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Uzoma A Nwakibu
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Jason Kiruja
- Accident and Emergency Department, Kenyatta National Hospital
| | - Alice Maingi
- Department of Emergency Medicine, Ohio State University, Columbus, OH
| | - Vincent Mutiso
- University of Nairobi School of Medicine, Nairobi, Kenya
| | - Peyton Thompson
- Division of Infectious Disease, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | | | - Stephen J Dunlop
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Ian B K Martin
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Justin G Myers
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| |
Collapse
|
2
|
Zhao J, Zhao Y, Hu J, Huang Y, He L. Outcomes of Chengdu Pediatric Emergency Triage Criteria: A Retrospective Study of 198,628 Pediatric Patient Records. Med Sci Monit 2024; 30:e942814. [PMID: 38571286 PMCID: PMC11003308 DOI: 10.12659/msm.942814] [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: 02/26/2024] [Accepted: 01/27/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND The Chengdu pediatric emergency triage criteria were developed at our hospital and consist of 4 triage levels: immediate treatment (level 1), treatment within 10 min (level 2), treatment within 30 min (level 3), and treatment within 240 min (level 4). This study aimed to evaluate outcomes from the levels 1 to 4 of this triage criteria. MATERIAL AND METHODS A self-designed survey form was used to collect pediatric Emergency Department (ED) patients' general data, including age, sex, and chief concern, and clinical data, including triage level, whether the patient had died, and whether the patient was admitted to our hospital. A total of 198,628 patient records that were triaged during January to May 2022 using Chengdu pediatric emergency triage criteria were included in this retrospective study. The numbers of patients triaged to levels 1, 2, 3, and 4 were 128, 1164, 14,560, and 182,776, respectively. RESULTS Statistically significant differences were found in waiting time for treatment, hospital admission rates, admission conversion rates, and case mix index at admission under different triage levels. The higher the triage priority level, the shorter the waiting time for ED treatment, higher the hospital admission and admission conversion rates, and higher case mix index value. CONCLUSIONS The Chengdu pediatric emergency triage criteria developed and applied within our hospital appears to be characterized by good clinical validity. Equipped with this triage criteria, triage nurses are more capable of determining the severity and emergency of the pediatric ED patients' health conditions and effectively triaging the patients.
Collapse
Affiliation(s)
- Jing Zhao
- Department of Emergency Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, PR China
| | - Yingying Zhao
- Department of Emergency Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, PR China
| | - Juan Hu
- Department of Emergency Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, PR China
| | - Yan Huang
- Department of Emergency Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, PR China
| | - Liqing He
- Department of Emergency Nursing, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, PR China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, PR China
| |
Collapse
|
3
|
Mitchell R, White L, Elton L, Luke C, Bornstein S, Atua V. Triage implementation in resource-limited emergency departments: sharing tools and experience from the Pacific region. Int J Emerg Med 2024; 17:21. [PMID: 38355441 PMCID: PMC10865550 DOI: 10.1186/s12245-024-00583-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/12/2024] [Indexed: 02/16/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Rob Mitchell
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.
- Emergency & Trauma Centre, Alfred Hospital, Melbourne, Australia.
| | - Libby White
- Emergency & Trauma Centre, Alfred Hospital, Melbourne, Australia
| | - Leigh Elton
- National Critical Care & Trauma Response Centre, Darwin, Australia
| | - Cliff Luke
- Vila Central Hospital, Port Vila, Vanuatu
| | | | | |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Mitchell R, Fang W, Tee QW, O'Reilly G, Romero L, Mitchell R, Bornstein S, Cameron P. Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low- and middle-income country emergency departments? Acad Emerg Med 2024; 31:164-182. [PMID: 37803524 DOI: 10.1111/acem.14815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Rob Mitchell
- Alfred Health, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Wendy Fang
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Qiao Wen Tee
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Gerard O'Reilly
- Alfred Health, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | | | | | - Peter Cameron
- Alfred Health, Melbourne, Victoria, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
6
|
Chandna A, Mwandigha L, Koshiaris C, Limmathurotsakul D, Nosten F, Lubell Y, Perera-Salazar R, Turner C, Turner P. External validation of clinical severity scores to guide referral of paediatric acute respiratory infections in resource-limited primary care settings. Sci Rep 2023; 13:19026. [PMID: 37923813 PMCID: PMC10624658 DOI: 10.1038/s41598-023-45746-4] [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: 03/29/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
Accurate and reliable guidelines for referral of children from resource-limited primary care settings are lacking. We identified three practicable paediatric severity scores (the Liverpool quick Sequential Organ Failure Assessment (LqSOFA), the quick Pediatric Logistic Organ Dysfunction-2, and the modified Systemic Inflammatory Response Syndrome) and externally validated their performance in young children presenting with acute respiratory infections (ARIs) to a primary care clinic located within a refugee camp on the Thailand-Myanmar border. This secondary analysis of data from a longitudinal birth cohort study consisted of 3010 ARI presentations in children aged ≤ 24 months. The primary outcome was receipt of supplemental oxygen. We externally validated the discrimination, calibration, and net-benefit of the scores, and quantified gains in performance that might be expected if they were deployed as simple clinical prediction models, and updated to include nutritional status and respiratory distress. 104/3,010 (3.5%) presentations met the primary outcome. The LqSOFA score demonstrated the best discrimination (AUC 0.84; 95% CI 0.79-0.89) and achieved a sensitivity and specificity > 0.80. Converting the scores into clinical prediction models improved performance, resulting in ~ 20% fewer unnecessary referrals and ~ 30-50% fewer children incorrectly managed in the community. The LqSOFA score is a promising triage tool for young children presenting with ARIs in resource-limited primary care settings. Where feasible, deploying the score as a simple clinical prediction model might enable more accurate and nuanced risk stratification, increasing applicability across a wider range of contexts.
Collapse
Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia.
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Lazaro Mwandigha
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Claudia Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| |
Collapse
|
7
|
Anand V, Dey CK, Shukla A, Tp M, T P, Rathia SK, Barman S, Goel AK, Srivastava NK, Meena H. Knowledge, Awareness, and Understanding of Pediatric Triage Among Nursing Officers in India: A Multicenter Study. Cureus 2023; 15:e46102. [PMID: 37900363 PMCID: PMC10611944 DOI: 10.7759/cureus.46102] [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] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
INTRODUCTION Triage is crucial in patient screening within emergency departments (EDs) worldwide. It is one of the essential and standard medical practices in many developed countries. However, in India, there is a need for improvement in triage utilization, as it is predominantly performed by resident doctors or medical officers, leading to an uneven distribution of clinical skills among healthcare providers (HCPs). A comprehensive analysis incorporating literature review and data collection revealed that while mandatory screening is conducted in most Indian EDs, the formal implementation of standardized triage protocols remains limited. Like in developed countries, registered nurses or nursing officers (NOs) can be effectively trained and directed to play the role of dedicated triage personnel in EDs of most of the healthcare facilities in India. METHOD AND MATERIALS This study aimed to examine the current state of triage utilization and its impact on the distribution of responsibilities among HCPs in Indian EDs. Through this online survey, the investigators assessed the knowledge and practical understanding of clinical triaging among NOs, working at various hospitals nationwide. RESULTS The participants included 5,029 NOs working in various parts of India, predominantly nursing graduates (82.52%), the majority being employed in government healthcare settings (84.01%) and most having over five years of cumulative working experience in the ED (70.77%). Nurses showed inadequate knowledge and awareness about the Pediatric Assessment Triangle (PAT) used for quick initial evaluation (62.18% among all participants). Concerning the complete triage process applicable, especially in pediatric ED settings, they had even less satisfactory knowledge and understanding, e.g., identifying primary (28.27%) and secondary (22.69%) survey components via focused history and examination, properly using temperature assessment (23.32%) and instant blood glucose level assessment (22.95%) in triage, and knowing various types of internationally accepted triage systems for ED-based health facilities such as the Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), and Australasian Triage Scale (ATS) (15.87%). ANOVA and post hoc analysis revealed that the intergroup performance of the study participants with maximum correct responses to the knowledge-determining specified subset of the questionnaire depicts the significantly higher role of graduate nursing degree over diploma such as General Nursing and Midwifery (GNM)/Auxiliary Nursing and Midwifery (ANM) qualification, working in government hospital versus private setup, and ED working experience of >5 years over that of <5 years. CONCLUSIONS Of the participants in the study, 50% were not evaluated for cognitive or psychomotor domains during their assessment examinations. The research illuminated a significant disparity in knowledge and proficiency levels among Indian nurses concerning pediatric triage, especially with the ability to effectively apply the PAT for initial patient evaluations, discern components of primary and secondary surveys, and comprehend various triage systems. This study underscores the importance of comprehensive reform in the Indian healthcare system and teaching curriculum by emphasizing clinical triage training and interprofessional collaboration, and establishing guidelines and regulations to ensure consistent and standardized triage practices across all EDs.
Collapse
Affiliation(s)
- Varun Anand
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Raipur, IND
| | - Chandan K Dey
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Raipur, IND
| | - Arvind Shukla
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Raipur, IND
| | - Murugan Tp
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, IND
| | - Pugazhenthan T
- Department of Pharmacology and Therapeutics, All India Institute of Medical Sciences, Raipur, IND
| | - Santosh K Rathia
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Raipur, IND
| | - Sandeep Barman
- Department of Pediatrics, Nagaon Medical College and Hospital, Nagaon, IND
| | - Anil Kumar Goel
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, IND
| | - Niraj K Srivastava
- Department of General Surgery, All India Institute of Medical Sciences, Raebareli, IND
| | - Harish Meena
- Department of Nursing, All India Institute of Medical Sciences, Raipur, IND
| |
Collapse
|
8
|
Li ECK, Tagoola A, Komugisha C, Nabweteme AM, Pillay Y, Ansermino JM, Khowaja AR. Cost-effectiveness analysis of Smart Triage, a data-driven pediatric sepsis triage platform in Eastern Uganda. BMC Health Serv Res 2023; 23:932. [PMID: 37653477 PMCID: PMC10468891 DOI: 10.1186/s12913-023-09977-5] [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: 03/31/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Sepsis, characterized by organ dysfunction due to presumed or proven infection, has a case-fatality over 20% in severe cases in low-and-middle income countries. Early diagnosis and treatment have proven benefits, prompting our implementation of Smart Triage at Jinja Regional Referral Hospital in Uganda, a program that expedites treatment through a data-driven triage platform. We conducted a cost-effectiveness analysis of Smart Triage to explore its impact on patients and inform multicenter scale up. METHODS The parent clinical trial for Smart Triage was pre-post in design, using the proportion of children receiving sepsis treatment within one hour as the primary outcome, a measure linked to mortality benefit in existing literature. We used a decision-analytic model with Monte Carlo simulation to calculate the cost per year-of-life-lost (YLL) averted of Smart Triage from societal, government, and patient perspectives. Healthcare utilization and lost work for seven days post-discharge were translated into costs and productivity losses via secondary linkage data. RESULTS In 2021 United States dollars, Smart Triage requires an annuitized program cost of only $0.05 per child, but results in $15.32 saved per YLL averted. At a willingness-to-pay threshold of only $3 per YLL averted, well below published cost-effectiveness threshold estimates for Uganda, Smart Triage approaches 100% probability of cost-effectiveness over the baseline manual triage system. This cost-effectiveness was observed from societal, government, and patient perspectives. The cost-effectiveness observed was driven by a reduction in admission that, while explainable by an improved triage mechanism, may also be partially attributable to changes in healthcare utilization influenced by the coronavirus pandemic. However, Smart Triage remains cost-effective in sensitivity analyses introducing a penalty factor of up to 50% in the reduction in admission. CONCLUSION Smart Triage's ability to both save costs and avert YLLs indicates that patients benefit both economically and clinically, while its high probability of cost-effectiveness strongly supports multicenter scale up. Areas for further research include the incorporation of years lived with disability when sepsis disability weights in low-resource settings become available and analyzing budget impact during multicenter scale up. TRIAL REGISTRATION NCT04304235 (registered on 11/03/2020, clinicaltrials.gov).
Collapse
Affiliation(s)
- Edmond C K Li
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.
- Department of Anesthesiology, Royal Columbian Hospital, Vancouver, BC, Canada.
| | | | - Clare Komugisha
- World Alliance for Lung and Intensive Care Medicine in Uganda, Kololo, Kampala, Uganda
| | | | - Yashodani Pillay
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - J Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
- Center for International Child Health, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Asif R Khowaja
- Faculty of Applied Health Sciences, Brock University, St. Catharines, ON, Canada
| |
Collapse
|
9
|
Chandna A, Lubell Y, Mwandigha L, Tanunchai P, Vinitsorn A, Richard-Greenblatt M, Koshiaris C, Limmathurotsakul D, Nosten F, Abdad MY, Perera-Salazar R, Turner C, Turner P. Defining the role of host biomarkers in the diagnosis and prognosis of the severity of childhood pneumonia: a prospective cohort study. Sci Rep 2023; 13:12024. [PMID: 37491541 PMCID: PMC10368669 DOI: 10.1038/s41598-023-38731-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/13/2023] [Indexed: 07/27/2023] Open
Abstract
Reliable tools to inform outpatient management of childhood pneumonia in resource-limited settings are needed. We investigated the value added by biomarkers of the host infection response to the performance of the Liverpool quick Sequential Organ Failure Assessment score (LqSOFA), for triage of children presenting with pneumonia to a primary care clinic in a refugee camp on the Thailand-Myanmar border. 900 consecutive presentations of children aged ≤ 24 months meeting WHO pneumonia criteria were included. The primary outcome was receipt of supplemental oxygen. We compared discrimination of a clinical risk score (LqSOFA) to markers of endothelial injury (Ang-1, Ang-2, sFlt-1), immune activation (CHI3L1, IP-10, IL-1ra, IL-6, IL-8, IL-10, sTNFR-1, sTREM-1), and inflammation (CRP, PCT), and quantified the net benefit of including biomarkers alongside LqSOFA. We evaluated the differential contribution of LqSOFA and host biomarkers to the diagnosis and prognosis of pneumonia severity. 49/900 (5.4%) presentations met the primary outcome. Discrimination of LqSOFA and Ang-2, the best performing biomarker, were comparable (AUC 0.82 [95% CI 0.76-0.88] and 0.81 [95% CI 0.74-0.87] respectively). Combining Ang-2 with LqSOFA improved discrimination (AUC 0.91; 95% CI 0.87-0.94; p < 0.001), and resulted in greater net benefit, with 10-30% fewer children who required oxygen supplementation incorrectly identified as safe for community-based management. Ang-2 had greater prognostic utility than LqSOFA to identify children requiring supplemental oxygen later in their illness course. Combining Ang-2 and LqSOFA could guide referrals of childhood pneumonia from resource-limited community settings. Further work on test development and integration into patient triage is required.
Collapse
Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia.
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Lazaro Mwandigha
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Phattaranit Tanunchai
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Asama Vinitsorn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Melissa Richard-Greenblatt
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Public Health Ontario, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | | | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Mohammad Yazid Abdad
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Claudia Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| |
Collapse
|
10
|
Tan R, Cobuccio L, Beynon F, Levine GA, Vaezipour N, Luwanda LB, Mangu C, Vonlanthen A, De Santis O, Salim N, Manji K, Naburi H, Chirande L, Matata L, Bulongeleje M, Moshiro R, Miheso A, Arimi P, Ndiaye O, Faye M, Thiongane A, Awasthi S, Sharma K, Kumar G, Van De Maat J, Kulinkina A, Rwandarwacu V, Dusengumuremyi T, Nkuranga JB, Rusingiza E, Tuyisenge L, Hartley MA, Faivre V, Thabard J, Keitel K, D’Acremont V. ePOCT+ and the medAL-suite: Development of an electronic clinical decision support algorithm and digital platform for pediatric outpatients in low- and middle-income countries. PLOS DIGITAL HEALTH 2023; 2:e0000170. [PMID: 36812607 PMCID: PMC9931356 DOI: 10.1371/journal.pdig.0000170] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/23/2022] [Indexed: 01/20/2023]
Abstract
Electronic clinical decision support algorithms (CDSAs) have been developed to address high childhood mortality and inappropriate antibiotic prescription by helping clinicians adhere to guidelines. Previously identified challenges of CDSAs include their limited scope, usability, and outdated clinical content. To address these challenges we developed ePOCT+, a CDSA for the care of pediatric outpatients in low- and middle-income settings, and the medical algorithm suite (medAL-suite), a software for the creation and execution of CDSAs. Following the principles of digital development, we aim to describe the process and lessons learnt from the development of ePOCT+ and the medAL-suite. In particular, this work outlines the systematic integrative development process in the design and implementation of these tools required to meet the needs of clinicians to improve uptake and quality of care. We considered the feasibility, acceptability and reliability of clinical signs and symptoms, as well as the diagnostic and prognostic performance of predictors. To assure clinical validity, and appropriateness for the country of implementation the algorithm underwent numerous reviews by clinical experts and health authorities from the implementing countries. The digitalization process involved the creation of medAL-creator, a digital platform which allows clinicians without IT programming skills to easily create the algorithms, and medAL-reader the mobile health (mHealth) application used by clinicians during the consultation. Extensive feasibility tests were done with feedback from end-users of multiple countries to improve the clinical algorithm and medAL-reader software. We hope that the development framework used for developing ePOCT+ will help support the development of other CDSAs, and that the open-source medAL-suite will enable others to easily and independently implement them. Further clinical validation studies are underway in Tanzania, Rwanda, Kenya, Senegal, and India.
Collapse
Affiliation(s)
- Rainer Tan
- Digital and Global Health Unit, Unisanté, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- University of Basel, Basel, Switzerland
- * E-mail:
| | - Ludovico Cobuccio
- Digital and Global Health Unit, Unisanté, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fenella Beynon
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Gillian A. Levine
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Nina Vaezipour
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Chacha Mangu
- National Institute of Medical Research–Mbeya Medical Research Centre, Mbeya, United Republic of Tanzania
| | - Alan Vonlanthen
- Information Technology & Digital Transformation sector, Unisanté, Center for Primary Care and Public Health, University of Lausanne, Switzerland
| | - Olga De Santis
- Digital and Global Health Unit, Unisanté, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Nahya Salim
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | - Helga Naburi
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | - Lulu Chirande
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | - Lena Matata
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
- University of Basel, Basel, Switzerland
| | | | - Robert Moshiro
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences (MUHAS), Dar es Salaam, United Republic of Tanzania
| | | | - Peter Arimi
- College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Ousmane Ndiaye
- Department of Pediatrics, Cheikh Anta Diop University, Dakar, Senegal
| | - Moctar Faye
- Department of Pediatrics, Cheikh Anta Diop University, Dakar, Senegal
| | - Aliou Thiongane
- Department of Pediatrics, Cheikh Anta Diop University, Dakar, Senegal
| | - Shally Awasthi
- Department of Pediatrics, King George’s Medical University, Lucknow, India
| | | | - Gaurav Kumar
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Josephine Van De Maat
- Radboudumc, Department of Internal Medicine and Radboudumc Center for Infectious Diseases, Nijmegen, Netherlands
| | - Alexandra Kulinkina
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Victor Rwandarwacu
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Théophile Dusengumuremyi
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Emmanuel Rusingiza
- University Teaching Hospital of Kigali, Kigali, Rwanda
- School of Medicine and Pharmacy, University of Rwanda, Kigali, Rwanda
| | | | - Mary-Anne Hartley
- Intelligent Global Health, Machine Learning and Optimization Laboratory, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Vincent Faivre
- Information Technology & Digital Transformation sector, Unisanté, Center for Primary Care and Public Health, University of Lausanne, Switzerland
| | - Julien Thabard
- Information Technology & Digital Transformation sector, Unisanté, Center for Primary Care and Public Health, University of Lausanne, Switzerland
| | - Kristina Keitel
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Paediatric Emergency Department, Department of Pediatrics, University Hospital Berne, Berne, Switzerland
| | - Valérie D’Acremont
- Digital and Global Health Unit, Unisanté, Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| |
Collapse
|
11
|
Validity of the Brazilian pediatric triage system CLARIPED at a secondary level of emergency care. J Pediatr (Rio J) 2022; 99:247-253. [PMID: 36403739 DOI: 10.1016/j.jped.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 10/12/2022] [Accepted: 10/31/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To evaluate the validity of the triage system CLARIPED in a pediatric population in the city of São Paulo, Brazil. METHODS Prospective, observational study in a secondary-level pediatric emergency service from Sep-2018 to Ago-2019. A convenience sample of all patients aged 0-18 years triaged by the computerized CLARIPED system was selected. Associations between urgency levels and patient outcomes were analyzed to assess construct validity. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) to identify the most urgent patients were estimated, as well as under-triage and over-triage rates. RESULTS The distribution of 24,338 visits was: RED 0.02%, ORANGE 0.9%, YELLOW 23.5%, GREEN 47.9%, and BLUE 27.7% (highest to the lowest level of urgency). The frequency of the following outcomes increased with increasing urgency: hospital admission (0.0%, 0.02%, 0.1%, 7.1% and 20%); stay in ED observation room (1.9%, 2,4%, 4.8%, 24.1%, 60%); use of ≥ 2 diagnostic/therapeutic resources (2.3%, 3.0%, 5.9%, 28.8%, 40%); ED length of stay (12, 12, 15, 99.5, 362 min). The most urgent patients (RED, ORANGE, and YELLOW) exhibited higher chances of using ≥ 2 resources (OR 2.55; 95%CI: 2.23-2.92) or of being hospitalized (OR 23.9; 95%CI: 7.17-79.62), compared to the least urgent (GREEN and BLUE). The sensitivity to identify urgency was 0.88 (95%CI: 0.70-0.98); specificity, 0.76 (95%CI: 0.75-0.76); NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 23.0%, and undertriage, 11.5%. CONCLUSION This study corroborates the validity and safety of CLARIPED, demonstrating significant correlations with clinical outcomes, good sensitivity, and low undertriage rate in a secondary-level Brazilian pediatric emergency service.
Collapse
|
12
|
Validity of the computerized version of the pediatric triage system CLARIPED for emergency care. J Pediatr (Rio J) 2022; 98:369-375. [PMID: 34571017 PMCID: PMC9432060 DOI: 10.1016/j.jped.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 08/07/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the validity of the computerized version of the pediatric triage system CLARIPED. METHODS Prospective, observational study in a tertiary emergency department (ED) from Jan-2018 to Jan-2019. A convenience sample of patients aged 0-18 years who had computerized triage and outcome variables registered. Construct validity was assessed through the association between urgency levels and patient outcomes. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), undertriage, and overtriage rates were assessed. RESULTS 19,122 of 38,321 visits were analyzed. The urgency levels were: RED (emergency) 0.02%, ORANGE (high urgency) 3.21%, YELLOW (urgency) 35.69%, GREEN (low urgency) 58.46%, and BLUE (no urgency) 2.62%. The following outcomes increased according to the increase in the level of urgency: hospital admission (0.4%, 0.6%, 3.1%, 11.9% and 25%), stay in the ED observation room (2.8%, 4.7%, 15.9%, 40.4%, 50%), ≥ 2 diagnostic or therapeutic resources (7.8%, 16.5%, 33.7%, 60.6%, 75%), and ED length of stay in minutes (18, 24, 67, 120, 260). The odds of using ≥ 2 resources or being hospitalized were significantly greater in the most urgent patients (Red, Orange, and Yellow) compared to the least urgent (Green and Blue): OR 7.88 (95%CI: 5.35-11.6) and OR 2.85 (95%CI: 2.63-3.09), respectively. The sensitivity to identify urgency was 0.82 (95%CI: 0.77-0.85); specificity, 0.62 (95%CI: 0.61-0.6; NPV, 0.99 (95%CI: 0.99-1.00); overtriage rate, 4.28% and undertriage, 18.41%. CONCLUSION The computerized version of CLARIPED is a valid and safe pediatric triage system, with a significant correlation with clinical outcomes, good sensitivity, and low undertriage rate.
Collapse
|
13
|
Singh S, Awasthi S. Effect of In-Situation Versus Manchester Triage System-Based Initial Case Management on Hospital-Based Mortality: A Before and After Study. Indian J Pediatr 2022; 89:553-557. [PMID: 35275337 DOI: 10.1007/s12098-022-04092-5] [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: 04/11/2021] [Accepted: 10/25/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare mortality and treatment-initiation time pre- and post introduction of Manchester Triage System (MTS) in patients of age group 1 mo to 15 y admitted in a tertiary care hospital in India. METHODS Pre- and post intervention study conducted on a prospective cohort of patients hospitalized over a period of 6 mo, who were triaged using MTS and compared with a retrospective cohort, who were not formally triaged using any system and were admitted to the hospital during the past 6 mo, prior to commencement of the study. Intervention was training of resident doctors for five MTS urgencies using flowcharts and discriminators and displaying them in the emergency room. Data on clinical and outcome variables were abstracted from hospital case record sheets in both the cohorts. RESULTS The present study was conducted from May 2019 to April 2020 including 450 patients hospitalized from August 2019 to January 2020 in a prospective cohort and a retrospective cohort of 450 patients hospitalized from January 2019 to June 2019. Overall mortality in pre-MTS group was 26.2% (118/450) as compared to 20.9% (94/450) in post-MTS group (p value = 0.021). Average treatment time was reduced from 30 to 10 min after implementation of MTS (p value = 0.001). CONCLUSION Implementation of MTS in pediatric emergency leads to statistically significant reduction of mortality and average treatment-initiation time.
Collapse
Affiliation(s)
- Sweta Singh
- Department of Pediatrics, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Shally Awasthi
- Department of Pediatrics, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India.
| |
Collapse
|
14
|
Mawji A, Li E, Dunsmuir D, Komugisha C, Novakowski SK, Wiens MO, Vesuvius TA, Kissoon N, Ansermino JM. Smart triage: Development of a rapid pediatric triage algorithm for use in low-and-middle income countries. Front Pediatr 2022; 10:976870. [PMID: 36483471 PMCID: PMC9723221 DOI: 10.3389/fped.2022.976870] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/01/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Early and accurate recognition of children at risk of progressing to critical illness could contribute to improved patient outcomes and resource allocation. In resource limited settings digital triage tools can support decision making and improve healthcare delivery. We developed a model for rapid identification of critically ill children at triage. METHODS This was a prospective cohort study of acutely ill children presenting at Jinja Regional Referral Hospital in Eastern Uganda. Variables collected in the emergency department informed the development of a logistic model based on hospital admission using bootstrap stepwise regression. Low and high-risk thresholds for 90% minimum sensitivity and specificity, respectively generated three risk level categories. Performance was assessed using receiver operating characteristic curve analysis on a held-out test set generated by an 80:20 split with 10-fold cross validation. A risk stratification table informed clinical interpretation. RESULTS The model derivation cohort included 1,612 participants, with an admission rate of approximately 23%. The majority of admitted patients were under five years old and presenting with sepsis, malaria, or pneumonia. A 9-predictor triage model was derived: logit (p) = -32.888 + (0.252, square root of age) + (0.016, heart rate) + (0.819, temperature) + (-0.022, mid-upper arm circumference) + (0.048 transformed oxygen saturation) + (1.793, parent concern) + (1.012, difficulty breathing) + (1.814, oedema) + (1.506, pallor). The model afforded good discrimination, calibration, and risk stratification at the selected thresholds of 8% and 40%. CONCLUSION In a low income, pediatric population, we developed a nine variable triage model with high sensitivity and specificity to predict who should be admitted. The triage model can be integrated into any digital platform and used with minimal training to guide rapid identification of critically ill children at first contact. External validation and clinical implementation are in progress.
Collapse
Affiliation(s)
- Alishah Mawji
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Edmond Li
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Dustin Dunsmuir
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | | | - Stefanie K Novakowski
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Matthew O Wiens
- Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | | | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - J Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.,Centre for International Child Health, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| |
Collapse
|
15
|
Li ECK, Grays S, Tagoola A, Komugisha C, Nabweteme AM, Ansermino JM, Mitton C, Kissoon N, Khowaja AR. Cost-effectiveness analysis protocol of the Smart Triage program: A point-of-care digital triage platform for pediatric sepsis in Eastern Uganda. PLoS One 2021; 16:e0260044. [PMID: 34788338 PMCID: PMC8598020 DOI: 10.1371/journal.pone.0260044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Sepsis is a clinical syndrome characterized by organ dysfunction due to presumed or proven infection. Severe cases can have case fatality ratio 25% or higher in low-middle income countries, but early diagnosis and timely treatment have a proven benefit. The Smart Triage program in Jinja Regional Referral Hospital in Uganda will provide expedited sepsis treatment in children through a data-driven electronic patient triage system. To complement the ongoing Smart Triage interventional trial, we propose methods for a concurrent cost-effectiveness analysis of the Smart Triage platform. METHODS We will use a decision-analytic model taking a societal perspective, combining government and out-of-pocket costs, as patients bear a sizeable portion of healthcare costs in Uganda due to the lack of universal health coverage. Previously published secondary data will be used to link healthcare utilization with costs and intermediate outcomes with mortality. We will model uncertainty via probabilistic sensitivity analysis and present findings at various willingness-to-pay thresholds using a cost-effectiveness acceptability curve. DISCUSSION Our proposed analysis represents a first step in evaluating the cost-effectiveness of an innovative digital triage platform designed to improve clinical outcomes in pediatric sepsis through expediting care in low-resource settings. Our use of a decision analytic model to link secondary costing data, incorporate post-discharge healthcare utilization, and model clinical endpoints is also novel in the pediatric sepsis triage literature for low-middle income countries. Our analysis, together with subsequent analyses modelling budget impact and scale up, will inform future modifications to the Smart Triage platform, as well as motivate scale-up to the district and national levels. TRIAL REGISTRATION Trial registration of parent clinical trial: NCT04304235, https://clinicaltrials.gov/ct2/show/NCT04304235. Registered 11 March 2020.
Collapse
Affiliation(s)
- Edmond C. K. Li
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sela Grays
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - J. Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health, Vancouver, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Asif R. Khowaja
- Faculty of Applied Health Sciences, Brock University, St. Catharines, Canada
| |
Collapse
|
16
|
Mitchell R, McKup JJ, Banks C, Nason R, O'Reilly G, Kandelyo S, Bornstein S, Cole T, Reynolds T, Ripa P, Körver S, Cameron P. Validity and reliability of the Interagency Integrated Triage Tool in a regional emergency department in Papua New Guinea. Emerg Med Australas 2021; 34:99-107. [PMID: 34628718 DOI: 10.1111/1742-6723.13877] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/08/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The Interagency Integrated Triage Tool (IITT) is a novel, three-tier triage system recommended by the World Health Organization. The present study sought to assess the validity and reliability of a pilot version of the tool in a resource-limited ED in regional Papua New Guinea. METHODS This pragmatic prospective observational study, conducted at Mount Hagen Provincial Hospital, commenced 1 month after IITT implementation. The facility did not have a pre-existing triage system. All ED patients presenting within a 5-month period were included. The primary outcome was sensitivity for the detection of time-critical illness, defined by 10 pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced external triage officer. RESULTS There were 9437 presentations during the study period and 9175 (97.2%) had a triage category recorded. Overall, 138 (1.5%) were classified as category 1 (emergency), 1438 (15.7%) as category 2 (priority) and 7599 (82.8%) as category 3 (non-urgent). When applied by a mix of community health workers, nurses, health extension officers and doctors, the tool's sensitivity for the detection of time-critical illness was 77.8% (95% confidence interval 64.4-88.0). The admission rate was 14.5% (20/138) among emergency patients, 12.0% (173/1438) among priority patients and 0.4% (30/7599) among non-urgent patients (P = 0.00). Death in the ED occurred in 13 (9.4%) of 138 emergency patients, 34 (2.4%) of 1438 priority patients and four (0.1%) of 7599 non-urgent patients (P = 0.00). The negative predictive value for these outcomes was >99.5%. Among 170 observed triage assessments, weighted κ was 0.81 (excellent agreement). On average, it took clinicians 2 min 43 s (standard deviation 1:10) to complete a triage assessment. CONCLUSION There is limited published data regarding the predictive validity and inter-rater reliability of the IITT. In this pragmatic study, the pilot version of the tool demonstrated adequate performance. Evaluation in other emergency care settings is recommended.
Collapse
Affiliation(s)
- Rob Mitchell
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - John J McKup
- Emergency Department, Mount Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Colin Banks
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Regina Nason
- Emergency Department, Mount Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Gerard O'Reilly
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Scotty Kandelyo
- Emergency Department, Port Moresby General Hospital, Port Moresby, Papua New Guinea.,National Department of Health, Port Moresby, Papua New Guinea
| | - Sarah Bornstein
- Global Emergency Care Desk, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia
| | - Travis Cole
- Emergency Department, Townsville University Hospital, Townsville, Queensland, Australia
| | - Teri Reynolds
- Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Paulus Ripa
- Mount Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Sarah Körver
- Global Emergency Care Desk, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia
| | - Peter Cameron
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
17
|
Mitchell R, Bue O, Nou G, Taumomoa J, Vagoli W, Jack S, Banks C, O'Reilly G, Bornstein S, Ham T, Cole T, Reynolds T, Körver S, Cameron P. Validation of the Interagency Integrated Triage Tool in a resource-limited, urban emergency department in Papua New Guinea: a pilot study. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2021; 13:100194. [PMID: 34527985 PMCID: PMC8358156 DOI: 10.1016/j.lanwpc.2021.100194] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/30/2021] [Accepted: 06/03/2021] [Indexed: 01/03/2023]
Abstract
Background The Interagency Integrated Triage Tool (IITT) is a three-tier triage system designed for resource-limited emergency care (EC) settings. This study sought to assess the validity and reliability of a pilot version of the tool in an urban emergency department (ED) in Papua New Guinea. Methods A pragmatic observational study was conducted at Gerehu General Hospital in Port Moresby, commencing eight weeks after IITT implementation. All ED patients presenting within the subsequent two-month period were included. Triage assessments were performed by a variety of ED clinicians, including community health workers, nurses and doctors. The primary outcome was sensitivity for the detection of time-critical illness, defined by ten pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced, external triage officer. Findings Among 4512 presentations during the study period, 58 (1.3%) were classified as category one (emergency), 967 (21.6%) as category two (priority) and 3478 (77.1%) as category three (non-urgent). The tool's sensitivity for detecting the pre-specified set of time-sensitive conditions was 70.8% (95%CI 58.2-81.4%), with negative predictive values of 97.3% (95%CI 96.7 - 97.8%) for admission/transfer and 99.9% (95%CI 99.7 - 100.0%) for death. The admission/transfer rate was 44.8% (26/58) among emergency patients, 22.9% (223/976) among priority patients and 2.7% (94/3478) among non-urgent patients (Cramer's V=0.351, p=0.00). Four of 58 (6.9%) emergency patients, 19/976 (2.0%) priority patients and 3/3478 (0.1%) non-urgent patients died in the ED (Cramer's V=0.14, p=0.00). The under-triage rate was 2.7% (94/3477) and the over-triage rate 48.2% (28/58), both within pre-specified limits of acceptability. On average, it took staff 3 minutes 34 seconds (SD 1:06) to determine and document a triage category. Among 70 observed assessments, weighted κ was 0.84 (excellent agreement). Interpretation The pilot version of the IITT demonstrated acceptable performance characteristics, and validation in other EC settings is warranted. Funding This project was funded through a Friendship Grant from the Australian Government Department of Foreign Affairs and Trade and an International Development Fund Grant from the Australasian College for Emergency Medicine Foundation.
Collapse
Affiliation(s)
- Rob Mitchell
- Emergency Physician, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia PhD Candidate, Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
- Corresponding author. Emergency Physician, Emergency & Trauma Centre, Alfred Health, Commercial Rd, Melbourne, VIC, Australia 3004
| | - Ovia Bue
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Gary Nou
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Jude Taumomoa
- Clinical Nurse, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Ware Vagoli
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Steven Jack
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Colin Banks
- Emergency Physician, Emergency Department, Townsville University Hospital, Townsville, Australia
| | - Gerard O'Reilly
- Emergency Physician and Head of Global Programs, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia, Associate Professor, Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
- Head, Epidemiology and Biostatistics, National Trauma Research Institute, Alfred Health, Melbourne, Australia
| | - Sarah Bornstein
- Project lead, Papua New Guinea Emergency Care Capacity Development Remote Training and Support Model Project, Australasian College for Emergency Medicine, Melbourne, Australia
| | - Tracie Ham
- Associate Nurse Unit Manager, Emergency Department, St Vincent's Hospital, Melbourne, Australia
| | - Travis Cole
- Emergency Clinical Nurse Specialist, Emergency Department, Townsville University Hospital, Townsville, Australia
| | - Teri Reynolds
- Unit Head, Clinical Services and Systems, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Sarah Körver
- Global Emergency Care Manager, Australasian College for Emergency Medicine, Melbourne, Australia
| | - Peter Cameron
- Director of Academic Programs, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia,Professor, Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
18
|
Chandna A, Osborn J, Bassat Q, Bell D, Burza S, D'Acremont V, Fernandez-Carballo BL, Kain KC, Mayxay M, Wiens M, Dittrich S. Anticipating the future: prognostic tools as a complementary strategy to improve care for patients with febrile illnesses in resource-limited settings. BMJ Glob Health 2021; 6:bmjgh-2021-006057. [PMID: 34330761 PMCID: PMC8327814 DOI: 10.1136/bmjgh-2021-006057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/25/2021] [Indexed: 12/17/2022] Open
Abstract
In low-income and middle-income countries, most patients with febrile illnesses present to peripheral levels of the health system where diagnostic capacity is very limited. In these contexts, accurate risk stratification can be particularly impactful, helping to guide allocation of scarce resources to ensure timely and tailored care. However, reporting of prognostic research is often imprecise and few prognostic tests or algorithms are translated into clinical practice. Here, we review the often-conflated concepts of prognosis and diagnosis, with a focus on patients with febrile illnesses. Drawing on a recent global stakeholder consultation, we apply these concepts to propose three use-cases for prognostic tools in the management of febrile illnesses in resource-limited settings: (1) guiding referrals from the community to higher-level care; (2) informing resource allocation for patients admitted to hospital and (3) identifying patients who may benefit from closer follow-up post-hospital discharge. We explore the practical implications for new technologies and reflect on the challenges and knowledge gaps that must be addressed before this approach could be incorporated into routine care settings. Our intention is that these use-cases, alongside other recent initiatives, will help to promote a harmonised yet contextualised approach for prognostic research in febrile illness. We argue that this is especially important given the heterogeneous settings in which care is often provided for patients with febrile illnesses living in low-income and middle-income countries.
Collapse
Affiliation(s)
- Arjun Chandna
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia .,Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
| | - Jennifer Osborn
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Quique Bassat
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ICREA, Pg. Lluís Companys 23, Barcelona, Spain.,Pediatrics Department, Hospital Sant Joan de Dé, Universitat de Barcelona, Esplugues, Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - David Bell
- Independent Consultant, Issaquah, Washington, USA
| | | | - Valérie D'Acremont
- Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Kevin C Kain
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Mayfong Mayxay
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK.,Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao People's Democratic Republic.,Institute of Research and Education Development (IRED), University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Matthew Wiens
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada.,Mbarara University of Science and Technology, Mbarara, Uganda.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.,Walimu, Kampala, Uganda
| | - Sabine Dittrich
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK.,Foundation for Innovative New Diagnostics, Geneva, Switzerland
| |
Collapse
|
19
|
Chandna A, Aderie EM, Ahmad R, Arguni E, Ashley EA, Cope T, Dat VQ, Day NPJ, Dondorp AM, Illanes V, De Jesus J, Jimenez C, Kain K, Suy K, Koshiaris C, Lasry E, Mayxay M, Mondal D, Perera R, Pongvongsa T, Rattanavong S, Rekart M, Richard-Greenblatt M, Shomik M, Souvannasing P, Tallo V, Turner C, Turner P, Waithira N, Watson JA, Yosia M, Burza S, Lubell Y. Prediction of disease severity in young children presenting with acute febrile illness in resource-limited settings: a protocol for a prospective observational study. BMJ Open 2021; 11:e045826. [PMID: 33495264 PMCID: PMC7839891 DOI: 10.1136/bmjopen-2020-045826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/03/2020] [Accepted: 01/11/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION In rural and difficult-to-access settings, early and accurate recognition of febrile children at risk of progressing to serious illness could contribute to improved patient outcomes and better resource allocation. This study aims to develop a prognostic clinical prediction tool to assist community healthcare providers identify febrile children who might benefit from referral or admission for facility-based medical care. METHODS AND ANALYSIS This prospective observational study will recruit at least 4900 paediatric inpatients and outpatients under the age of 5 years presenting with an acute febrile illness to seven hospitals in six countries across Asia. A venous blood sample and nasopharyngeal swab is collected from each participant and detailed clinical data recorded at presentation, and each day for the first 48 hours of admission for inpatients. Multianalyte assays are performed at reference laboratories to measure a panel of host biomarkers, as well as targeted aetiological investigations for common bacterial and viral pathogens. Clinical outcome is ascertained on day 2 and day 28.Presenting syndromes, clinical outcomes and aetiology of acute febrile illness will be described and compared across sites. Following the latest guidance in prediction model building, a prognostic clinical prediction model, combining simple clinical features and measurements of host biomarkers, will be derived and geographically externally validated. The performance of the model will be evaluated in specific presenting clinical syndromes and fever aetiologies. ETHICS AND DISSEMINATION The study has received approval from all relevant international, national and institutional ethics committees. Written informed consent is provided by the caretaker of all participants. Results will be shared with local and national stakeholders, and disseminated via peer-reviewed open-access journals and scientific meetings. TRIAL REGISTRATION NUMBER NCT04285021.
Collapse
Affiliation(s)
- Arjun Chandna
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Endashaw M Aderie
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Riris Ahmad
- Centre for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Daerah Istimewa Yogyakart, Indonesia
| | - Eggi Arguni
- Centre for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Daerah Istimewa Yogyakart, Indonesia
| | - Elizabeth A Ashley
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
| | - Tanya Cope
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Nicholas P J Day
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Arjen M Dondorp
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Victor Illanes
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Joanne De Jesus
- Clinical Trials, Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Carolina Jimenez
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Kevin Kain
- Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Keang Suy
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Angkor Hospital for Children, Siem Reap, Siem Reap, Cambodia
| | | | - Estrella Lasry
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Mayfong Mayxay
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
- Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Lao People's Democratic Republic
| | - Dinesh Mondal
- Centre for Nutrition and Food Security (CNFS), icddr,b, Dhaka, Dhaka, Bangladesh
| | - Rafael Perera
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tiengkham Pongvongsa
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
- Savannakhet Provincial Health Department, Savannakhet, Lao People's Democratic Republic
| | - Sayaphet Rattanavong
- Microbiology Department, Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Vientiane, Lao People's Democratic Republic
| | - Michael Rekart
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | | | - Mohammad Shomik
- Centre for Nutrition and Food Security (CNFS), icddr,b, Dhaka, Dhaka, Bangladesh
| | | | - Veronica Tallo
- Clinical Trials, Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Claudia Turner
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Angkor Hospital for Children, Siem Reap, Siem Reap, Cambodia
| | - Paul Turner
- Angkor Hospital for Children, Cambodia Oxford Medical Research Unit, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Naomi Waithira
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - James A Watson
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Mikhael Yosia
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Sakib Burza
- Médecins Sans Frontières Operational Centre Barcelona, Barcelona, Spain
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Faculty of Tropical Medicine, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| |
Collapse
|
20
|
Chandna A, Tan R, Carter M, Van Den Bruel A, Verbakel J, Koshiaris C, Salim N, Lubell Y, Turner P, Keitel K. Predictors of disease severity in children presenting from the community with febrile illnesses: a systematic review of prognostic studies. BMJ Glob Health 2021; 6:e003451. [PMID: 33472837 PMCID: PMC7818824 DOI: 10.1136/bmjgh-2020-003451] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 11/26/2020] [Accepted: 12/19/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Early identification of children at risk of severe febrile illness can optimise referral, admission and treatment decisions, particularly in resource-limited settings. We aimed to identify prognostic clinical and laboratory factors that predict progression to severe disease in febrile children presenting from the community. METHODS We systematically reviewed publications retrieved from MEDLINE, Web of Science and Embase between 31 May 1999 and 30 April 2020, supplemented by hand search of reference lists and consultation with an expert Technical Advisory Panel. Studies evaluating prognostic factors or clinical prediction models in children presenting from the community with febrile illnesses were eligible. The primary outcome was any objective measure of disease severity ascertained within 30 days of enrolment. We calculated unadjusted likelihood ratios (LRs) for comparison of prognostic factors, and compared clinical prediction models using the area under the receiver operating characteristic curves (AUROCs). Risk of bias and applicability of studies were assessed using the Prediction Model Risk of Bias Assessment Tool and the Quality In Prognosis Studies tool. RESULTS Of 5949 articles identified, 18 studies evaluating 200 prognostic factors and 25 clinical prediction models in 24 530 children were included. Heterogeneity between studies precluded formal meta-analysis. Malnutrition (positive LR range 1.56-11.13), hypoxia (2.10-8.11), altered consciousness (1.24-14.02), and markers of acidosis (1.36-7.71) and poor peripheral perfusion (1.78-17.38) were the most common predictors of severe disease. Clinical prediction model performance varied widely (AUROC range 0.49-0.97). Concerns regarding applicability were identified and most studies were at high risk of bias. CONCLUSIONS Few studies address this important public health question. We identified prognostic factors from a wide range of geographic contexts that can help clinicians assess febrile children at risk of progressing to severe disease. Multicentre studies that include outpatients are required to explore generalisability and develop data-driven tools to support patient prioritisation and triage at the community level. PROSPERO REGISTRATION NUMBER CRD42019140542.
Collapse
Affiliation(s)
- Arjun Chandna
- Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Rainer Tan
- Unisanté Centre for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Basel-Stadt, Switzerland
| | - Michael Carter
- Department of Women and Children's Health, King's College London, London, UK
| | - Ann Van Den Bruel
- Academic Centre of General Practice, University of Leuven, Leuven, Flanders, Belgium
| | - Jan Verbakel
- Academic Centre of General Practice, University of Leuven, Leuven, Flanders, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Nahya Salim
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
- Department of Pediatrics and Child Health, Muhimbili University Health and Allied Sciences, Dar-es-Salaam, Tanzania
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Paul Turner
- Cambodia-Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Kristina Keitel
- Swiss Tropical and Public Health Institute, Basel, Basel-Stadt, Switzerland
- Division of Emergency Medicine, Department of Pediatrics, University Children's Hospital, Inselpital, University of Bern, Bern, Switzerland
| |
Collapse
|
21
|
Mitchell R, McKup JJ, Bue O, Nou G, Taumomoa J, Banks C, O'Reilly G, Kandelyo S, Bornstein S, Cole T, Ham T, Miller JP, Reynolds T, Körver S, Cameron P. Implementation of a novel three-tier triage tool in Papua New Guinea: A model for resource-limited emergency departments. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2020; 5:100051. [PMID: 34327395 PMCID: PMC8315437 DOI: 10.1016/j.lanwpc.2020.100051] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/18/2020] [Accepted: 10/23/2020] [Indexed: 01/31/2023]
Abstract
In emergency departments (EDs), demand for care often exceeds the available resources. Triage addresses this problem by sorting patients into categories of urgency. The Interagency Integrated Triage Tool (IITT) is a novel triage system designed for resource-limited emergency care (EC) settings. The system was piloted by two EDs in Papua New Guinea as part of an EC capacity development program. Implementation involved a five-hour teaching program for all ED staff, complemented by training resources including flowcharts and reference guides. Clinical redesign helped optimise flow and infrastructure, and development of simple electronic registries enabled data collection. Local champions were identified, and experienced EC clinicians from Australia acted as mentors during system roll-out. Evaluation data suggests the IITT, and the associated change management process, have high levels of acceptance amongst staff. Subject to validation, the IITT may be relevant to other resource-limited EC settings.
Collapse
Affiliation(s)
- Rob Mitchell
- Emergency Physician, Emergency & Trauma Centre, Alfred Health, Commercial Rd, Melbourne 3004, Australia.,PhD Candidate, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - John Junior McKup
- Emergency Physician, Emergency Department, Mount Hagen Provincial Hospital, Mount Hagen, Papua New Guinea
| | - Ovia Bue
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Gary Nou
- Emergency Physician, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Jude Taumomoa
- Clinical Nurse, Emergency Department, Gerehu General Hospital, Port Moresby, Papua New Guinea
| | - Colin Banks
- Emergency Physician, Emergency Department, Townsville University Hospital, Townsville, Australia
| | - Gerard O'Reilly
- Emergency Physician and Head of Global Programs, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia.,Associate Professor, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Scotty Kandelyo
- Emergency Physician Emergency Department, Port Moresby General Hospital, Port Moresby, Papua New Guinea.,Regional Chief of Emergency Medicine, Highlands Region, National Department of Health, Port Moresby, Papua New Guinea
| | - Sarah Bornstein
- Critical Care Nurse, Emergency Department, St Vincent's Hospital, Sydney, Australia
| | - Travis Cole
- Emergency Clinical Nurse Specialist, Emergency Department, Townsville Hospital, Townsville, Australia
| | - Tracie Ham
- Associate Nurse Unit Manager, Emergency Department, St Vincent's Hospital, Melbourne, Australia
| | - Jean-Philippe Miller
- Critical Care Nurse, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia
| | - Teri Reynolds
- Unit Head, Clinical Services and Systems, Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | - Sarah Körver
- Global Emergency Care Manager, Australasian College for Emergency Medicine, Melbourne, Australia
| | - Peter Cameron
- Emergency Physician, Emergency & Trauma Centre, Alfred Health, Commercial Rd, Melbourne 3004, Australia.,Director of Academic Programs, Emergency & Trauma Centre, Alfred Health, Melbourne, Australia.,Professor, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
22
|
Moon TD, Maússe FE, Gebretsadik T, Kenga DB, Charles P, Agy M, Simbine S, Sacarlal J. Altered Mental Status Among Febrile Hospitalized HIV-Infected Children Aged 0-59 Months in Mozambique. J Trop Pediatr 2020; 67:5890704. [PMID: 32778888 PMCID: PMC8319629 DOI: 10.1093/tropej/fmaa052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Altered mental status (AMS) is a priority presenting sign that must be assessed in HIV-infected, febrile children, yet diagnosis is difficult in areas with limited diagnostic capacity. Malaria and bacterial meningitis have been reported as the most common causes of AMS in febrile children presenting to the hospital in sub-Saharan Africa. However, in an HIV-infected child, central nervous system manifestations are diverse. METHODS We conducted a clinical observational study of HIV-infected febrile children, aged 0-59 months, hospitalized in Mozambique and prospectively followed. Within this cohort, a nested study was designed to characterize children admitted with AMS and to assess factors associated with mortality. Univariate and multivariable analysis were performed comparing characteristics of the cohort by AMS status and evaluated demographic and clinical factors by in-hospital mortality outcome. RESULTS In total, 727 children were enrolled between April 2016 and February 2019, 16% had AMS at admission. HIV-infected, febrile children, who presented with AMS and who had a diagnosis of bacteremia, had a 4-fold increased relative odds of in-hospital mortality, and children who presented with neurologic symptoms on admission had a roughly 8-fold higher odds of in-hospital mortality relative to children without presenting neurologic findings. CONCLUSIONS Mozambique has a pressing need to expand local diagnostic capacity. Our results highlight the critical need for clinicians to incorporate a broader differential into their potential causes of AMS, and to develop a Ministry of Health approved diagnostic and management algorithm, which is standardly used, to manage patients for whom reliable and relevant diagnostic services are not available.
Collapse
Affiliation(s)
- Troy D Moon
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37203, USA,Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN 37203, USA,Correspondence: Troy D. Moon, MD, MPH. Department of Pediatrics, Division of Pediatric Infectious Diseases, Vanderbilt Institute for Global Health; 2525 West End Avenue, Suite 750, Nashville, TN 37203, USA. Tel: +615-343-8264. E-mail <>
| | - Fabião E Maússe
- Department of Microbiology, Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | - Tebeb Gebretsadik
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37203, USA
| | - Darlenne B Kenga
- Department of Microbiology, Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | | | - Mustuafá Agy
- General Hospital José Macamo, Maputo, Mozambique
| | - Samuel Simbine
- Department of Microbiology, Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | - Jahit Sacarlal
- Department of Microbiology, Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| |
Collapse
|
23
|
Reñosa MD, Dalglish S, Bärnighausen K, McMahon S. Key challenges of health care workers in implementing the integrated management of childhood illnesses (IMCI) program: a scoping review. Glob Health Action 2020; 13:1732669. [PMID: 32114968 PMCID: PMC7067189 DOI: 10.1080/16549716.2020.1732669] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/14/2020] [Indexed: 11/03/2022] Open
Abstract
Background: Several evaluative studies demonstrate that a well-coordinated Integrated Management of Childhood Illnesses (IMCI) program can reduce child mortality. However, there is dearth of information on how frontline providers perceive IMCI and how, in their view, the program is implemented and how it could be refined and revitalized.Purpose: To determine the key challenges affecting IMCI implementation from the perspective of health care workers (HCWs) in primary health care facilities.Methods: A scoping review based on the five-step framework of Arskey and O'Malley was utilized to identify key challenges faced by HCWs implementing the IMCI program in primary health care facilities. A comprehensive search of peer-reviewed literature through PubMed, ScienceDirect, EBSCOhost and Google Scholar was conducted. A total of 1,475 publications were screened for eligibility and 41 publications identified for full-text evaluation. Twenty-four (24) published articles met our inclusion criteria, and were investigated to tease out common themes related to challenges of HCWs in terms of implementing the IMCI program.Results: Four key challenges emerged from our analysis: 1) Insufficient financial resources to fund program activities, 2) Lack of training, mentoring and supervision from the tertiary level, 3) Length of time required for effective and meaningful IMCI consultations conflicts with competing demands and 4) Lack of planning and coordination between policy makers and implementers resulting in ambiguity of roles and accountability. Although the IMCI program can provide substantial benefits, more information is still needed regarding implementation processes and acceptability in primary health care settings.Conclusion: Recognizing and understanding insights of those enacting health programs such as IMCI can spark meaningful strategic recommendations to improve IMCI program effectiveness. This review suggests four domains that merit consideration in the context of efforts to scale and expand IMCI programs.
Collapse
Affiliation(s)
- Mark Donald Reñosa
- Heidelberg Institute of Global Health, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
- Department of Epidemiology and Biostatistics, Research Institute for Tropical Medicine - Department of Health, Manila, Philippines
| | - Sarah Dalglish
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kate Bärnighausen
- Department of Epidemiology and Biostatistics, Research Institute for Tropical Medicine - Department of Health, Manila, Philippines
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Shannon McMahon
- Heidelberg Institute of Global Health, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Germany
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
24
|
Utilization of age-adjusted shock index in a resource-strained setting. J Pediatr Surg 2019; 54:2621-2626. [PMID: 31521372 DOI: 10.1016/j.jpedsurg.2019.08.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 08/24/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Identification of injury severity and appropriate triage are critical to effective surgical care, especially where medical and surgical resources are strained. We hypothesized that pediatric age-adjusted shock index (SIPA) would outperform traditional shock index (SI) in a middle-income country (MIC) setting. METHODS Injured children hospitalized in two trauma centers (South Africa and the United States) from 2012 to 2017 were reviewed. Maximum heart rate and minimum systolic blood pressure defined SI. SI > 0.9 defined elevation. SIPA elevation was based on SI stratified by age: 1-6 years (SI > 1.22), 7-12 years (SI > 1.0), and 13-17 years (SI > 0.9). SI and SIPA were compared using univariate analyses and area under the receiver operating characteristic curves (AUROC). RESULTS 1648 patients (741 MIC and 907 high-income country (HIC)) were evaluated with a median [IQR] age of 11 [6-15] years. SI was elevated in 377 (51%) MIC children, whereas SIPA was elevated in 248 (34%). In both the HIC and MIC, elevated SIPA was more associated with ISS ≥ 25, ICU admission, and mortality. In MIC patients specifically, elevated SIPA improved discrimination for in-hospital mortality (AUROC 0.66 vs AUROC 0.57, p < 0.01). CONCLUSION In a multinational cohort including MIC patients, SIPA facilitated identification of injured children with altered physiology, reflecting greater injury severity and poorer outcomes. Use of SIPA has the potential for more effective resource utilization in MICs. LEVEL OF EVIDENCE Level III.
Collapse
|
25
|
Dekker-Boersema J, Hector J, Jefferys LF, Binamo C, Camilo D, Muganga G, Aly MM, Langa EBR, Vounatsou P, Hobbins MA. Triage conducted by lay-staff and emergency training reduces paediatric mortality in the emergency department of a rural hospital in Northern Mozambique. Afr J Emerg Med 2019; 9:172-176. [PMID: 31890479 PMCID: PMC6933270 DOI: 10.1016/j.afjem.2019.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/16/2019] [Accepted: 05/20/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION The majority of emergency paediatric death in African countries occur within the first 24 h of admission. A coloured triage system is widely implemented in high-income countries and the emergency triage and assessment treatment (ETAT) is recommended by the World Health Organization, but not put into practice in Mozambique. We implemented a three-colour triage system in a rural district hospital with lay-staff workers conducting the first triage. METHODS A retrospective, before and after, mortality analysis was performed using routine patient files from the district hospital between 2014 and 2017. The triage system was implemented in August 2016. Inclusion criteria were children under 15 years of age that entered the emergency centre. Primary outcome was child mortality rate. Secondary outcomes included the percentage agreement between the clinical and non-clinical staff and the duration from triage to first treatment. We used a negative binomial model in STATA 15 to compare mortality rates, and Kappa statistics to estimate the agreement between clinical and non-clinical staff. RESULTS 4176 admissions were included. The mortality rate ratio (MMR) was 45% lower after the start of the intervention (2016; MRR = 0.55; 0.38, 0.81; p = 0.002), compared to before. To estimate the agreement between non-clinical and clinical staff, 548 (of the 671) patient files were included. The agreement was estimated at 88.7% (Kappa = 0.644; p < 0.001). The median waiting time decreased with urgency of the triage: 2 h33 for 'green'/least serious (IQR 1 h58-3 h30), 21 min for yellow/serious (IQR 0 h10-0 h58) and nine minutes for 'red'/urgent (IQR 2-40 min). CONCLUSION In a rural setting with nurse-led clinical care and non-clinician staff working at the triage reception, implementation of a three-coloured triage system was feasible. Triage and ETAT training was associated with a decrease of 45% of paediatric deaths. The impact on mortality, low cost, and ease of the implementation supports scaling this intervention in similar settings.
Collapse
Affiliation(s)
| | | | | | | | - Deavis Camilo
- District Health Directorate, Chiure, Cabo Delgado, Mozambique
| | - Gerard Muganga
- District Health Directorate, Chiure, Cabo Delgado, Mozambique
| | - Mussa Manuel Aly
- Operational Research Unit Pemba, Pemba, Cabo Delgado, Mozambique
| | | | | | | |
Collapse
|
26
|
Zachariasse JM, van der Hagen V, Seiger N, Mackway-Jones K, van Veen M, Moll HA. Performance of triage systems in emergency care: a systematic review and meta-analysis. BMJ Open 2019; 9:e026471. [PMID: 31142524 PMCID: PMC6549628 DOI: 10.1136/bmjopen-2018-026471] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/23/2019] [Accepted: 03/28/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED). DESIGN Systematic review and meta-analysis. DATA SOURCES EMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018. ELIGIBILITY CRITERIA Studies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded. REVIEW METHODS Reviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems' performance. RESULTS Sixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems' performance. CONCLUSIONS Established triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems' performance and how the performance of existing triage systems can be improved.
Collapse
Affiliation(s)
- Joany M Zachariasse
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Vera van der Hagen
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nienke Seiger
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Mirjam van Veen
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Pediatrics, Groene Hart Ziekenhuis, Gouda, The Netherlands
| | - Henriette A Moll
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
27
|
Wangara AA, Hunold KM, Leeper S, Ndiawo F, Mweu J, Harty S, Fuchs R, Martin IBK, Ekernas K, Dunlop SJ, Twomey M, Maingi AW, Myers JG. Implementation and performance of the South African Triage Scale at Kenyatta National Hospital in Nairobi, Kenya. Int J Emerg Med 2019; 12:5. [PMID: 31179944 PMCID: PMC6371470 DOI: 10.1186/s12245-019-0221-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/21/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Triage protocols standardize and improve patient care in accident and emergency departments (A&Es). Kenyatta National Hospital (KNH), the largest public tertiary hospital in East Africa, is resource-limited and was without A&E-specific triage protocols. OBJECTIVES We sought to standardize patient triage through implementation of the South African Triage Scale (SATS). We aimed to (1) assess the reliability of triage decisions among A&E healthcare workers following an educational intervention and (2) analyze the validity of the SATS in KNH's A&E. METHODS Part 1 was a prospective, before and after trial utilizing an educational intervention and assessing triage reliability using previously validated vignettes administered to 166 healthcare workers. Part 2 was a triage chart review wherein we assessed the validity of the SATS in predicting patient disposition outcomes by inclusion of 2420 charts through retrospective, systematic sampling. RESULTS Healthcare workers agreed with an expert defined triage standard for 64% of triage scenarios following an educational intervention, and had a 97% agreement allowing for a one-level discrepancy in the SATS score. There was "good" inter-rater agreement based on an intraclass correlation coefficient and quadratic weighted kappa. We analyzed 1209 pre-SATS and 1211 post-SATS patient charts and found a non-significant difference in undertriage and statistically significant decrease in overtriage rates between the pre- and post-SATS cohorts (undertriage 3.8 and 7.8%, respectively, p = 0.2; overtriage 70.9 and 62.3%, respectively, p < 0.05). The SATS had a sensitivity of 92.2% and specificity of 37.7% for predicting admission, death, or discharge in the A&E. CONCLUSION Healthcare worker triage decisions using the SATS were more consistent with expert opinion following an educational intervention. The SATS also performed well in predicting outcomes with high sensitivity and satisfactory levels of both undertriage and overtriage, confirming the SATS as a contextually appropriate triage system at a major East African A&E.
Collapse
Affiliation(s)
- Ali A. Wangara
- Accident and Emergency Department, Kenyatta National Hospital, PO Box 3956-00200, Nairobi, Kenya
| | - Katherine M. Hunold
- Department of Emergency Medicine, The Ohio State University, Columbus, OH USA
| | - Sarah Leeper
- Department of Emergency Medicine, University of Maryland Prince George’s Hospital Center, Maryland, MD USA
| | - Frederick Ndiawo
- Accident and Emergency Department, Kenyatta National Hospital, PO Box 3956-00200, Nairobi, Kenya
| | - Judith Mweu
- Critical Care Unit, Kenyatta National Hospital, Nairobi, Kenya
| | - Shaun Harty
- Department of Emergency Medicine, The University of Cincinnati, Cincinnati, OH USA
| | - Rachael Fuchs
- Department of Biostatistics, FHI 360 & UNC Gillings School of Global Public Health, Chapel Hill, NC USA
| | - Ian B. K. Martin
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI USA
| | - Karen Ekernas
- Department of Emergency Medicine, St. Joseph Hospital, Denver, CO USA
| | - Stephen J. Dunlop
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN USA
| | | | - Alice W. Maingi
- Accident and Emergency Department, Kenyatta National Hospital, PO Box 3956-00200, Nairobi, Kenya
| | - Justin Guy Myers
- Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, 170 Manning Drive, CB 7594, Chapel Hill, NC 27599 USA
| |
Collapse
|
28
|
Gage AD, Kruk ME, Girma T, Lemango ET. The know-do gap in sick child care in Ethiopia. PLoS One 2018; 13:e0208898. [PMID: 30540855 PMCID: PMC6291134 DOI: 10.1371/journal.pone.0208898] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 11/26/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND While health care provider knowledge is a commonly used measure for process quality of care, evidence demonstrates that providers don't always perform as much as they know. We describe this know-do gap for malaria care for sick children among providers in Ethiopia and examine what may predict this gap. METHODS We use a 2014 nationally-representative survey of Ethiopian providers that includes clinical knowledge vignettes of malaria care and observations of care provided to children in facilities. We compare knowledge and performance of assessment, treatment and counseling items and overall. We subtract performance scores from knowledge and use regression analysis to examine what facility and provider characteristics predict the gap. 512 providers that completed the malaria vignette and were observed providing care to sick children were included in the analysis. RESULTS Vignette and observed performance were both low, with providers on average scoring 39% and 34% respectively. The know-do gap for assessment was only 1%, while the gap for treatment and counseling items was 39%. Doctors had the largest gap between knowledge and performance. Only provider type and availability of key equipment significantly predicted the know-do gap. CONCLUSIONS While both provider knowledge and performance in sick child care are poor, there is a gap between knowledge and performance particularly with regard to treatment and counseling. Interventions to improve quality of care must address not only deficiencies in provider knowledge, but also the gap between knowledge and action.
Collapse
Affiliation(s)
- Anna D. Gage
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston MA, United States of America
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston MA, United States of America
| | - Tsinuel Girma
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Ephrem T. Lemango
- International Institue for Primary Health Care- Ethiopia, Addis Ababa, Ethiopia
| |
Collapse
|
29
|
Validation of a Modified Triage Scale in a Norwegian Pediatric Emergency Department. Int J Pediatr 2018; 2018:4676758. [PMID: 30410545 PMCID: PMC6205310 DOI: 10.1155/2018/4676758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/03/2018] [Indexed: 11/18/2022] Open
Abstract
Objective Triage is a tool developed to identify patients who need immediate care and those who can safely wait. The aim of this study was to assess the validity and interrater reliability of a modified version of the pediatric South African triage scale (pSATS) in a single-center tertiary pediatric emergency department in Norway. Methods This prospective, observational study included all patients with medical conditions, referred to the pediatric emergency department of a tertiary hospital in Norway from September 1, 2015, to November 17, 2015. Their assigned triage priority was compared with rate of hospitalization and resource utilization. Validity parameters were sensitivity, specificity, positive and negative predictive value, and percentage of over- and undertriage. Interrater agreement and accuracy of the triage ratings were calculated from triage performed by nurses on written case scenarios. Results During the study period, 1171 patients arrived at the hospital for emergency assessment. A total of 790 patients (67 %) were triaged and included in the study. The percentage of hospital admission increased with increasing level of urgency, from 30 % of the patients triaged to priority green to 81 % of those triaged to priority red. The sensitivity was 74 %, the specificity was 48 %, the positive predictive value was 52 %, and the negative predictive value was 70 % for predicting hospitalization. The level of over- and undertriage was 52 % and 26 %, respectively. Resource utilization correlated with higher triage priority. The interrater agreement had an intraclass correlation coefficient of 0.99 by Cronbach's alpha, and the accuracy was 92 %. Conclusions The modified pSATS had a moderate sensitivity and specificity but showed good correlation with resource utilization. The nurses demonstrated excellent interrater agreement and accuracy when triaging written case scenarios.
Collapse
|