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

Triage systems in low-resource emergency care settings

Triage is widely regarded as a core emergency care function, as reflected in the World Health Organization (WHO) Emergency care systems framework and in recent World Health Assembly resolutions. In this article, we explore the evidence supporting triage in low-resource settings, with a focus on the Interagency Integrated Triage Tool. Following its release by WHO in the early stages of the coronavirus disease pandemic, the tool has been implemented across a range of low- and middle-income countries. We report evidence regarding its acceptability and performance from Papua New Guinea in the WHO Western Pacific Region. Data from four single-centre studies suggest that the tool can be reliably and efficiently applied by health workers, and its predictive validity is within the performance range of other triage instruments. The system is highly regarded by emergency care clinicians, and can be implemented with limited digital or in-person training. Although triage has intuitive and widely acknowledged value, recent research has identified a lack of high-quality evidence supporting an association between triage implementation and improved clinical outcomes. Evidence from several pre-post intervention studies suggests that the introduction of triage can reduce waiting times and mortality, but these data may have been subject to confounding and publication bias. Further research is required to establish the performance characteristics of the Interagency Integrated Triage Tool in other countries and contexts, and more rigorously examine the impact of triage implementation on quality of care.

Learning interventions and training methods in health emergencies: A scoping review

BACKGROUND

Keeping the health workforce and the public informed about the latest evolving health information during a health emergency is critical to preventing, detecting and responding to infectious disease outbreaks or other health emergencies. Having a well-informed, ready, willing, and skilled workforce and an informed public can help save lives, reduce diseases and suffering, and minimize socio-economic loss in affected communities and countries. Providing "just in time" support and opportunities for learning in health emergencies is much needed for capacity building. In this paper, 'learning intervention' refers to the provision of ad-hoc, focused, or personalized training sessions with the goal of preparing the health workers for emergencies or filling specific knowledge or skill gaps. We refer to 'training methods' as instructional design strategies used to teach someone the necessary knowledge and skills to perform a task.

METHODS

We conducted a scoping review to map and better understand what learning interventions and training methods have been used in different types of health emergencies and by whom. Studies were identified using six databases (Pubmed/Medline, Embase, Hinari, WorldCat, CABI and Web of Science) and by consulting with experts. Characteristics of studies were mapped and displayed and major topic areas were identified.

RESULTS

Of the 319 records that were included, contexts most frequently covered were COVID-19, disasters in general, Ebola and wars. Four prominent topic areas were identified: 1) Knowledge acquisition, 2) Emergency plans, 3) Impact of the learning intervention, and 4) Training methods. Much of the evidence was based on observational methods with few trials, which likely reflects the unique context of each health emergency. Evolution of methods was apparent, particularly in virtual learning. Learning during health emergencies appeared to improve knowledge, general management of the situation, quality of life of both trainers and affected population, satisfaction and clinical outcomes.

CONCLUSION

This is the first scoping review to map the evidence, which serves as a first step in developing urgently needed global guidance to further improve the quality and reach of learning interventions and training methods in this context.

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of an Online Training Program on COVID-19 for Health Workers in Papua New Guinea

BACKGROUND

Health worker training is an important component of a holistic outbreak response, and travel restrictions resulting from the COVID-19 pandemic have highlighted the potential of virtual training. Evaluation of training activities is essential for understanding the effectiveness of a training program on knowledge and clinical practice. We conducted an evaluation of the online COVID-19 Healthcare E-Learning Platform (CoHELP) in Papua New Guinea (PNG) to assess its effectiveness, measure engagement and completion rates, and determine barriers and enablers to implementation, in order to inform policy and practice for future training in resource-limited settings.

METHODS

The evaluation team conducted a mixed methods evaluation consisting of pre- and post-knowledge quizzes; quantification of engagement with the online platform; post-training surveys; qualitative interviews with training participants, non-participants, and key informants; and audits of six health facilities.

RESULTS

A total of 364 participants from PNG signed up to participate in the CoHELP online training platform, with 41% (147/360) completing at least one module. Of the 24 participants who completed the post-training survey, 92% (22/24) would recommend the program to others and 79% (19/24) had used the knowledge or skills gained through CoHELP in their clinical practice. Qualitative interviews found that a lack of time and infrastructural challenges were common barriers to accessing online training, and participants appreciated the flexibility of online, self-paced learning.

CONCLUSIONS

Initially high registration numbers did not translate to ongoing engagement with the CoHELP online platform, particularly for completion of evaluation activities. Overall, the CoHELP program received positive feedback from participants involved in the evaluation, highlighting the potential for further online training courses in PNG.