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Zimmerman A, Elahi C, Hernandes Rocha TA, Sakita F, Mmbaga BT, Staton CA, Vissoci JRN. Machine learning models to predict traumatic brain injury outcomes in Tanzania: Using delays to emergency care as predictors. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002156. [PMID: 37856444 PMCID: PMC10586611 DOI: 10.1371/journal.pgph.0002156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 09/13/2023] [Indexed: 10/21/2023]
Abstract
Constraints to emergency department resources may prevent the timely provision of care following a patient's arrival to the hospital. In-hospital delays may adversely affect health outcomes, particularly among trauma patients who require prompt management. Prognostic models can help optimize resource allocation thereby reducing in-hospital delays and improving trauma outcomes. The objective of this study was to investigate the predictive value of delays to emergency care in machine learning based traumatic brain injury (TBI) prognostic models. Our data source was a TBI registry from Kilimanjaro Christian Medical Centre Emergency Department in Moshi, Tanzania. We created twelve unique variables representing delays to emergency care and included them in eight different machine learning based TBI prognostic models that predict in-hospital outcome. Model performance was compared using the area under the receiver operating characteristic curve (AUC). Inclusion of our twelve time to care variables improved predictability in each of our eight prognostic models. Our Bayesian generalized linear model produced the largest AUC, with a value of 89.5 (95% CI: 88.8, 90.3). Time to care variables were among the most important predictors of in-hospital outcome in our best three performing models. In low-resource settings where delays to care are highly prevalent and contribute to high mortality rates, incorporation of care delays into prediction models that support clinical decision making may benefit both emergency medicine physicians and trauma patients by improving prognostication performance.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Cyrus Elahi
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Catherine A. Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States of America
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Anthony AA, Dutta R, Sarang B, David S, O'Reilly G, Raykar NP, Khajanchi M, Attergrim J, Soni KD, Sharma N, Mohan M, Gadgil A, Roy N, Gerdin Wärnberg M. Profile and triage validity of trauma patients triaged green: a prospective cohort study from a secondary care hospital in India. BMJ Open 2023; 13:e065036. [PMID: 37156594 PMCID: PMC10173999 DOI: 10.1136/bmjopen-2022-065036] [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: 05/10/2023] Open
Abstract
OBJECTIVES To evaluate the profile of non-urgent patients triaged 'green', as part of a triage trial in the emergency department (ED) of a secondary care hospital in India. The secondary aim was to validate the triage trial with the South African Triage Score (SATS). DESIGN Prospective cohort study. SETTING A secondary care hospital in Mumbai, India. PARTICIPANTS Patients aged 18 years and above with a history of trauma defined as having any of the external causes of morbidity and mortality listed in block V01-Y36, chapter XX of the International Classification of Disease version 10 codebook, triaged green between July 2016 and November 2019. PRIMARY AND SECONDARY OUTCOME MEASURES Outcome measures were mortality within 24 hours, 30 days and mistriage. RESULTS We included 4135 trauma patients triaged green. The mean age of patients was 32.8 (±13.1) years, and 77% were males. The median (IQR) length of stay of admitted patients was 3 (13) days. Half the patients had a mild Injury Severity Score (3-8), with the majority of injuries being blunt (98%). Of the patients triaged green by clinicians, three-quarters (74%) were undertriaged on validating with SATS. On telephonic follow-up, two patients were reported dead whereas one died while admitted in hospital. CONCLUSIONS Our study highlights the need for implementation and evaluation of training in trauma triage systems that use physiological parameters, including pulse, systolic blood pressure and Glasgow Coma Scale, for the in-hospital first responders in the EDs.
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Affiliation(s)
| | - Rohini Dutta
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Bhakti Sarang
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
- Department of Surgery, Terna Medical College & Hospital, New Mumbai, India
| | - Siddarth David
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - Gerard O'Reilly
- Department of Emergency Medicine, Monash University, Clayton, Victoria, Australia
| | - Nakul P Raykar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Monty Khajanchi
- Department of Surgery, Seth Gowardhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Jonatan Attergrim
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Kapil Dev Soni
- Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Naveen Sharma
- Department of Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Monali Mohan
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Anita Gadgil
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Nobhojit Roy
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Martin Gerdin Wärnberg
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
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Amato S, Culbreath K, Dunne E, Sarathy A, Siroonian O, Sartorelli K, Roy N, Malhotra A. Pediatric trauma mortality in India and the United States: A comparison and risk-adjusted analysis. J Pediatr Surg 2023; 58:99-105. [PMID: 36328820 DOI: 10.1016/j.jpedsurg.2022.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is a paucity of research comparing pediatric risk-adjusted trauma mortality between high-income and low- and middle-income countries. This limits identification of populations and injury patterns for targeted interventions. We aim to compare independent predictors of pediatric trauma mortality between India and the United States (US). METHODS A retrospective cohort study was conducted for pediatric patients (age <18 years) in India's Towards Improved Trauma Care Outcomes (TITCO) project database and the US National Trauma Data Bank (NTDB) from 2013 to 2015. Demographic, injury, physiologic, anatomic and outcome data were analyzed. Multivariable regressions were used to determine independent predictors of mortality. RESULTS 126,678 pediatric trauma patients were included (India 3,373; US 123,305). Pediatric patients in India were on average significantly younger, with a higher median injury severity score (ISS), had lower systolic blood pressure, and suffered a higher case fatality rate (13.0% vs. 1.0%). When controlling for demographic, mechanism, physiologic, and anatomic injury characteristics, sustaining an injury in India was the strongest predictor of mortality (OR 22.70, 95% CI 18.70-27.56). On subgroup analysis, the highest relative odds of mortality in India was seen in children with lower injury and physiologic severity. CONCLUSIONS Risk-adjusted pediatric trauma-related mortality is significantly higher in India compared to the US. The comparative odds of mortality are highest among children with lower injury and physiologic severity. This suggests that low-cost targeted interventions focused on standard timely trauma care, protocols, training and early imaging could improve pediatric injury mortality in India. TYPE OF STUDY Retrospective Prognosis Study LEVEL OF EVIDENCE: II.
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Affiliation(s)
- Stas Amato
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA.
| | - Katherine Culbreath
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA; Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Emma Dunne
- University of Vermont, Larner College of Medicine, 89 Beaumont Ave, Burlington, VT 05401, USA
| | - Ashwini Sarathy
- University of Vermont, Larner College of Medicine, 89 Beaumont Ave, Burlington, VT 05401, USA
| | - Olivia Siroonian
- Department of Pharmacology, University of Vermont, Larner College of Medicine, 89 Beaumont Ave, Burlington, VT 05401, USA
| | - Kennith Sartorelli
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA
| | - Nobhojit Roy
- The George Institute for Global Health, 308, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi 110025, India; WHO Collaborating Centre for Research in Surgical Care Delivery, Anushakti Nagar, Mumbai, MH 400094, India
| | - Ajai Malhotra
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA
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Providing Neurocritical Care in Resource-Limited Settings: Challenges and Opportunities. Neurocrit Care 2022; 37:583-592. [PMID: 35840824 DOI: 10.1007/s12028-022-01568-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/23/2022] [Indexed: 10/17/2022]
Abstract
Acute neurologic illnesses (ANI) contribute significantly to the global burden of disease and cause disproportionate death and disability in low-income and middle-income countries (LMICs) where neurocritical care resources and expertise are limited. Shifting epidemiologic trends in recent decades have increased the worldwide burden of noncommunicable diseases, including cerebrovascular disease and traumatic brain injury, which coexist in many LMICs with a persistently high burden of central nervous system infections such as tuberculosis, neurocysticercosis, and HIV-related opportunistic infections and complications. In the face of this heavy disease burden, many resource-limited countries lack the infrastructure to provide adequate care for patients with ANI. Major gaps exist between wealthy and poor countries in access to essential resources such as intensive care unit beds, neuroimaging, clinical laboratories, neurosurgical capacity, and medications for managing complex neurologic emergencies. Moreover, many resource-limited countries face critical shortages in health care workers trained to manage neurologic emergencies, with subspecialized neurocritical care expertise largely absent outside of high-income countries. Numerous opportunities exist to overcome these challenges through capacity-building efforts that improve outcomes for patients with ANI in resource-limited countries. These include research on needs and best practices for ANI management in LMICs, developing systems for effective triage, education and training to expand the neurology workforce, and supporting increased collaboration and data sharing among LMIC health care workers and systems. The success of these efforts in curbing the disproportionate and rising impact of ANI in LMICs will depend on the coordinated engagement of the global neurocritical care community.
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Wireklint SC, Elmqvist C, Fridlund B, Göransson KE. A longitudinal, retrospective registry-based validation study of RETTS©, the Swedish adult ED context version. Scand J Trauma Resusc Emerg Med 2022; 30:27. [PMID: 35428351 PMCID: PMC9013139 DOI: 10.1186/s13049-022-01014-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/31/2022] [Indexed: 12/04/2022] Open
Abstract
Background Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. The Rapid Emergency Triage and Treatment System (RETTS©), with annual updates, is the most applied triage system. However, the national implementation has been performed despite low scientific foundation for triage as a method, mainly related to the absence of adjustment to age and gender. Furthermore, there is a lack of studies of RETTS© in Swedish ED context, especially of RETTS© validity. Hence, the aim the study was to determine the validity of RETTS©. Methods A longitudinal retrospective register study based on cohort data from a healthcare region comprising two EDs in southern Sweden. Two editions of RETTS© was selected; year 2013 and 2016, enabling comparison of crude data, and adjusted for age-combined Charlson comorbidity index (ACCI) and gender. All patients ≥ 18 years visiting either of the two EDs seeing a physician, was included. Primary outcome was ten-day mortality, secondary outcome was admission to Intensive Care Unit (ICU). The data was analysed with descriptive, and inferential statistics. Results Totally 74,845 patients were included. There was an increase in patients allocated red or orange triage levels (unstable) between the years, but a decrease of admission, both to general ward and ICU. Of all patients, 1031 (1.4%) died within ten-days. Both cohorts demonstrated a statistically significant difference between the triage levels, i.e. a higher risk for ten-day mortality and ICU admission for patients in all triage levels compared to those in green triage level. Furthermore, significant statistically differences were demonstrated for ICU admission, crude as well as adjusted, and for adjusted data ten-day mortality, indicating that ACCI explained ten-day mortality, but not ICU admission. However, no statistically significant difference was found for the two annual editions of RETTS© considering ten-day mortality, crude data. Conclusion The annual upgrade of RETTS© had no statistically significant impact on the validity of the triage system, considering the risk for ten-day mortality. However, the inclusion of ACCI, or at least age, can improve the validity of the triage system. Graphical Abstract ![]()
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Elbaih AH, Elhadary GK, Elbahrawy MR, Saleh SS. Assessment of the patients' outcomes after implementation of South African triage scale in emergency department, Egypt. Chin J Traumatol 2022; 25:95-101. [PMID: 34756667 PMCID: PMC9039833 DOI: 10.1016/j.cjtee.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 08/27/2021] [Accepted: 09/29/2021] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Overcrowding in emergency department (ED) is a concerning global problem and has been identified as a national crisis in some countries. Several emergency sorting systems designed successfully in the world. Launched in 2004, a group of branches in South African triage scale (SATS) developed. The effectiveness of the case sorting system of SATS was evaluated to reduce the patient's length of stay (LOS) and mortality rate within the ED at Suez Canal University Hospital. METHODS The study was designed as an intervention study that included a systematic random sample of patients who presented to the ED in Suez Canal University Hospital. This study was implemented in three phases: pre-intervention phase, 115 patients were assessed by the traditional protocols; intervention phase, a structured training program was provided to the ED staff, including a workshop and lectures; and post-intervention phase, 230 patients were assessed by SATS. All the patients were retriaged 2 h later, calculating the LOS per patient and the mortality. Data was collected and entered using Microsoft Excel software. Collected data from the triage sheet were analyzed using the SPSS software program version 22.0. RESULTS The LOS in the ED was about 183.78 min before the intervention; while after the training program and the application of SATS, it was reduced to 51.39 min. About 15.7% of the patients died before the intervention; however, after the intervention the ratio decreased to 10.7% deaths. CONCLUSION SATS is better at assessing patients without missing important data. Additionally, it resulted in a decrease in the LOS and reduction in the mortality rate compared to the traditional protocol.
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Affiliation(s)
- Adel Hamed Elbaih
- Emergency Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.
| | - Ghada Kamal Elhadary
- Emergency Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Magda Ramdan Elbahrawy
- Emergency Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Samar Sami Saleh
- Emergency Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Keeley AJ, Nsutebu E. Improving sepsis care in Africa: an opportunity for change? Pan Afr Med J 2022; 40:204. [PMID: 35136467 PMCID: PMC8783315 DOI: 10.11604/pamj.2021.40.204.30127] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/22/2021] [Indexed: 12/29/2022] Open
Abstract
Sepsis is common and represents a major public health burden with significant associated morbidity and mortality. However, despite substantial advances in sepsis recognition and management in well-resourced health systems, there remains a distinct lack of research into sepsis in Africa. The lack of evidence affects all levels of healthcare delivery from individual patient management to strategic planning at health-system level. This is particular pertinent as African countries experience some of the highest global burden of sepsis. The 2017 World Health Assembly resolution on sepsis and the creation of the Africa Sepsis Alliance provided an opportunity for change. However, progress so far has been frustratingly slow. The recurrent Ebola virus disease outbreaks and the COVID-19 pandemic on the African continent further reinforce the need for urgent healthcare system strengthening. We recommend that African countries develop national action plans for sepsis which should address the needs of all critically ill patients.
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Affiliation(s)
- Alexander James Keeley
- Florey Institute, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Emmanuel Nsutebu
- Infectious Disease Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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Laher AE, Paruk F, Venter WDF, Ayeni OA, Motara F, Moolla M, Richards GA. Development and internal validation of the HIV In-hospital Mortality Prediction (HIV-IMP) risk score. HIV Med 2022; 23:80-89. [PMID: 34486209 DOI: 10.1111/hiv.13159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/15/2021] [Accepted: 07/28/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Despite advances in availability and access to antiretroviral therapy (ART), HIV still ranks as a major cause of global mortality. Hence, the aim of this study was to develop and internally validate a risk score capable of accurately predicting in-hospital mortality in HIV-positive patients requiring hospital admission. METHODS Consecutive HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult emergency department between 7 July 2017 and 18 October 2018 were prospectively enrolled. Multivariate logistic regression was used to determine parameters for inclusion in the final risk score. Discrimination and calibration were assessed by means of the area under the receiver operating curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test, respectively. Internal validation was conducted using the regular bootstrap technique. RESULTS The overall in-hospital mortality rate was 13.6% (n = 166). Eight predictors were included in the final risk score: ART non-adherence or not yet on ART, Glasgow Coma Scale < 15, respiratory rate > 20 breaths/min, oxygen saturation < 90%, white cell count < 4 × 109 /L, creatinine > 120 μmol/L, lactate > 2 mmol/L and albumin < 35 g/L. After internal validation, the risk score maintained good discrimination [AUROC 0.83, 95% confidence interval (CI): 0.78-0.88] and calibration (Hosmer-Lemeshow χ2 = 2.26, p = 0.895). CONCLUSION The HIV In-hospital Mortality Prediction (HIV-IMP) risk score has overall good discrimination and calibration and is relatively easy to use. Further studies should be aimed at externally validating the score in varying clinical settings.
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Affiliation(s)
- Abdullah E Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fathima Paruk
- Department of Critical Care, University of Pretoria, Pretoria, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Oluwatosin A Ayeni
- SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Feroza Motara
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Muhammed Moolla
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Guy A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Amato S, Bonnell L, Mohan M, Roy N, Malhotra A. Comparing trauma mortality of injured patients in India and the USA: a risk-adjusted analysis. Trauma Surg Acute Care Open 2021; 6:e000719. [PMID: 34869908 PMCID: PMC8603298 DOI: 10.1136/tsaco-2021-000719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives Comparisons of risk-adjusted trauma mortality between high-income countries and low and middle-income countries (LMICs) can be used to identify specific patient populations and injury patterns for targeted interventions. Due to a paucity of granular patient and injury data from LMICs, there is a lack of such comparisons. This study aims to identify independent predictors of trauma mortality and significant differences between India and the USA. Methods A retrospective cohort study of two trauma databases was conducted. Demographic, injury, physiologic, anatomic and outcome data were analyzed from India’s Towards Improved Trauma Care Outcomes project database and the US National Trauma Data Bank from 2013 to 2015. Multivariate logistic regression analyses were performed to determine significant independent predictors of mortality. Results 687 407 adult trauma patients were included (India 11 796; USA 675 611). Patients from India were significantly younger with greater male preponderance, a higher proportion presented with physiologic abnormalities and suffered higher mortality rates (23.2% vs. 2.8%). When controlling for age, sex, physiologic abnormalities, and injury severity, sustaining an injury in India was the strongest predictor of mortality (OR 13.85, 95% CI 13.05 to 14.69). On subgroup analyses, the greatest mortality difference was seen in patients with lower Injury Severity Scores. Conclusion After adjusting for demographic, physiologic abnormalities, and injury severity, trauma-related mortality was found to be significantly higher in India. When compared with trauma patients in the USA, the odds of mortality are most notably different among patients with lower Injury Severity Scores. While troubling, this suggests that relatively simple, low-cost interventions focused on standard timely trauma care, early imaging, and protocolized treatment pathways could result in substantial improvements for injury mortality in India, and potentially other LMICs. Level of evidence Level 3, retrospective cohort study.
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Affiliation(s)
- Stas Amato
- Department of General Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Levi Bonnell
- Department of General Internal Medicine, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Monali Mohan
- Department of Health Systems Strengthening, Care India, Bihar, Patna, India
| | - Nobhojit Roy
- The George Institute for Global Health, New Delhi, India.,WHO Collaborating Centre for Research in Surgical Care Delivery, Mumbai, India
| | - Ajai Malhotra
- Department of General Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
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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: 1] [Impact Index Per Article: 0.3] [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.
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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
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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: 9] [Impact Index Per Article: 3.0] [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.
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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
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12
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Laher AE, Paruk F, Richards GA, Venter WDF. Predictors of prolonged hospital stay in HIV-positive patients presenting to the emergency department. PLoS One 2021; 16:e0249706. [PMID: 33882077 PMCID: PMC8059827 DOI: 10.1371/journal.pone.0249706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/23/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Prolonged hospitalization places a significant burden on healthcare resources. Compared to the general population, hospital length of stay (LOS) is generally longer in HIV-positive patients. We identified predictors of prolonged hospital length of stay (LOS) in HIV-positive patients presenting to an emergency department (ED). METHODS In this cross-sectional study, HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult ED were prospectively enrolled between 07 July 2017 and 18 October 2018. Data was subjected to univariate and multivariate logistic regression to determine parameters associated with a higher likelihood of prolonged hospital LOS, defined as ≥7 days. RESULTS Among the 1224 participants that were enrolled, the median (IQR) LOS was 4.6 (2.6-8.2) days, while the mean (SD) LOS was 6.9 (8.2) days. On multivariate analysis of the data, hemoglobin <11 g/dL (OR 1.37, p = 0.032), Glasgow coma scale (GCS) <15 (OR 1.80, p = 0.001), creatinine >120 μmol/L (OR 1.85, p = 0.000), cryptococcal meningitis (OR 2.45, p = 0.015) and bacterial meningitis (OR 4.83, p = 0.002) were significantly associated with a higher likelihood of LOS ≥7 days, while bacterial pneumonia (OR 0.35, p = 0.000) and acute gastroenteritis (OR 0.40, p = 0.025) were significantly associated with a lower likelihood of LOS ≥7 days. CONCLUSION Various clinical and laboratory parameters are useful in predicting prolonged hospitalization among HIV-positive patients presenting to the ED. These parameters may be useful in guiding clinical decision making and directing the allocation of resources.
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Affiliation(s)
- Abdullah E. Laher
- Faculty of Health Sciences, Department of Emergency Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Fathima Paruk
- Department of Critical Care, University of Pretoria, Pretoria, South Africa
| | - Guy A. Richards
- Faculty of Health Sciences, Department of Critical Care, University of the Witwatersrand, Johannesburg, South Africa
| | - Willem D. F. Venter
- Faculty of Health Sciences, Ezintsha, University of the Witwatersrand, Johannesburg, South Africa
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13
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Laher AE, Paruk F, Venter W, Ayeni OA, Richards GA. Predictors of in-hospital mortality among HIV-positive patients presenting with an acute illness to the emergency department. HIV Med 2021; 22:557-566. [PMID: 33792151 DOI: 10.1111/hiv.13097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/04/2021] [Accepted: 02/22/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Despite better access to antiretroviral therapy (ART) over recent years, HIV remains a major global cause of mortality. The present study aimed to identify predictors of in-hospital mortality among HIV-positive patients presenting to an emergency department (ED). METHODS In this cross-sectional study, HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult ED between 07 July 2017 and 18 October 2018 were prospectively enrolled. Data were compared between participants who survived to hospital discharge and those who died. The data were further subjected to univariate and multivariate logistic regression analyses to determine variables that were associated with in-hospital mortality. RESULTS Of a total of 1224 participants, the in-hospital mortality was 13.6% (n = 166). On multivariate analysis, respiratory rate > 20 breaths/min [odds ratio (OR) = 1.90, P = 0.012], creatinine > 120 μmol/L (OR = 1.97, P = 0.006), oxygen saturation < 90% (OR = 2.09, P = 0.011), white cell count < 4.0 × 109 /L (OR = 2.09, P = 0.008), ART non-adherence or not yet on ART (OR = 2.39, P = 0.012), Glasgow Coma Scale < 15 (OR = 2.53, P = 0.000), albumin < 35 g/L (OR = 2.61, P = 0.002), lactate > 2 mmol/L (OR = 4.83, P = 0.000) and cryptococcal meningitis (OR = 6.78, P = 0.000) were significantly associated with in-hospital mortality. CONCLUSIONS Routine clinical and laboratory parameters are useful predictors of in-hospital mortality in HIV-positive patients presenting to the ED with an acute illness. These parameters may be of value in guiding clinical decision-making, directing the appropriate use of resources and influencing patient disposition, and may also be useful in developing an outcome prediction tool.
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Affiliation(s)
- A E Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - F Paruk
- Department of Critical Care, University of Pretoria, Pretoria, South Africa
| | - Wdf Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - O A Ayeni
- SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - G A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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14
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Laher AE, Venter WDF, Richards GA, Paruk F. Profile of presentation of HIV-positive patients to an emergency department in Johannesburg, South Africa. South Afr J HIV Med 2021; 22:1177. [PMID: 33604064 PMCID: PMC7876985 DOI: 10.4102/sajhivmed.v22i1.1177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 11/15/2020] [Indexed: 12/17/2022] Open
Abstract
Background Despite improved availability and better access to antiretroviral therapy (ART), approximately 36% of human immunodeficiency virus (HIV)-positive South Africans are still not virally suppressed. Objective The aim of this study was to describe the patterns of presentation of HIV-positive patients to a major central hospital emergency department (ED). Methods In this prospectively designed study, consecutive HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) adult ED were enrolled between 07 July 2017 and 18 October 2018. Results A total of 1224 participants were enrolled. Human immunodeficiency virus was newly diagnosed in 212 (17.3%) patients, 761 (75.2%) were on ART, 245 (32.2%) reported ART non-adherence, 276 (22.5%) had bacterial pneumonia, 244 (19.9%) had tuberculosis (TB), 86 (7.0%) had gastroenteritis, 205 (16.7%) required intensive care unit admission, 381 (31.1%) were admitted for ≥ 7 days and 166 (13.6%) died. With regard to laboratory parameters, CD4 cell count was < 100 cell/mm3 in 527 (47.6%) patients, the viral load (VL) was > 1000 copies/mL in 619 (59.0%), haemoglobin was < 11 g/dL in 636 (56.3%), creatinine was > 120 µmol/L in 294 (29.3%), lactate was > 2 mmol/L in 470 (42.0%) and albumin was < 35 g/L in 633 (60.8%). Conclusion Human immunodeficiency virus-positive patients presenting to the CMJAH ED demonstrated a high prevalence of opportunistic infections, required a prolonged hospital stay and had high mortality rates. There is a need to improve the quality of ART services and accessibility to care.
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Affiliation(s)
- Abdullah E Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Willem D F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Guy A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fathima Paruk
- Department of Critical Care, University of Pretoria, Pretoria, South Africa
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15
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Tang OY, Marqués CG, Ndebwanimana V, Uwamahoro C, Uwamahoro D, Lipsman ZW, Naganathan S, Karim N, Nkeshimana M, Levine AC, Stephen A, Aluisio AR. Performance of Prognostication Scores for Mortality in Injured Patients in Rwanda. West J Emerg Med 2021; 22:435-444. [PMID: 33856336 PMCID: PMC7972380 DOI: 10.5811/westjem.2020.10.48434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/12/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION While trauma prognostication and triage scores have been designed for use in lower-resourced healthcare settings specifically, the comparative clinical performance between trauma-specific and general triage scores for risk-stratifying injured patients in such settings is not well understood. This study evaluated the Kampala Trauma Score (KTS), Revised Trauma Score (RTS), and Triage Early Warning Score (TEWS) for accuracy in predicting mortality among injured patients seeking emergency department (ED) care at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda. METHODS A retrospective, randomly sampled cohort of ED patients presenting with injury was accrued from August 2015-July 2016. Primary outcome was 14-day mortality and secondary outcome was overall facility-based mortality. We evaluated summary statistics of the cohort. Bootstrap regression models were used to compare areas under receiver operating curves (AUC) with associated 95% confidence intervals (CI). RESULTS Among 617 cases, the median age was 32 years and 73.5% were male. The most frequent mechanism of injury was road traffic incident (56.2%). Predominant anatomical regions of injury were craniofacial (39.3%) and lower extremities (38.7%), and the most common injury types were fracture (46.0%) and contusion (12.0%). Fourteen-day mortality was 2.6% and overall facility-based mortality was 3.4%. For 14-day mortality, TEWS had the highest accuracy (AUC = 0.88, 95% CI, 0.76-1.00), followed by RTS (AUC = 0.73, 95% CI, 0.55-0.92), and then KTS (AUC = 0.65, 95% CI, 0.47-0.84). Similarly, for facility-based mortality, TEWS (AUC = 0.89, 95% CI, 0.79-0.98) had greater accuracy than RTS (AUC = 0.76, 95% CI, 0.61-0.91) and KTS (AUC = 0.68, 95% CI, 0.53-0.83). On pairwise comparisons, RTS had greater prognostic accuracy than KTS for 14-day mortality (P = 0.011) and TEWS had greater accuracy than KTS for overall (P = 0.007) mortality. However, TEWS and RTS accuracy were not significantly different for 14-day mortality (P = 0.864) or facility-based mortality (P = 0.101). CONCLUSION In this cohort of emergently injured patients in Rwanda, the TEWS demonstrated the greatest accuracy for predicting mortality outcomes, with no significant discriminatory benefit found in the use of the trauma-specific RTS or KTS instruments, suggesting that the TEWS is the most clinically useful approach in the setting studied and likely in other similar ED environments.
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Affiliation(s)
- Oliver Y Tang
- Brown University Warren Alpert Medical School, Department, Providence, Rhode Island
| | - Catalina González Marqués
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Vincent Ndebwanimana
- University of Rwanda, Department of Anesthesia, Emergency Medicine, and Critical Care, Kigali, Rwanda.,Centre Hospitalier Universitaire de Kigali, Department of Accident & Emergency, Kigali, Rwanda
| | - Chantal Uwamahoro
- University of Rwanda, Department of Anesthesia, Emergency Medicine, and Critical Care, Kigali, Rwanda.,Centre Hospitalier Universitaire de Kigali, Department of Accident & Emergency, Kigali, Rwanda
| | - Doris Uwamahoro
- University of Rwanda, Department of Anesthesia, Emergency Medicine, and Critical Care, Kigali, Rwanda.,Centre Hospitalier Universitaire de Kigali, Department of Accident & Emergency, Kigali, Rwanda
| | - Zachary W Lipsman
- Kaiser Permanente, GSAA, San Leandro & Fremont Medical Centers, San Leandro, California
| | - Sonya Naganathan
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Naz Karim
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Menelas Nkeshimana
- University of Rwanda, Department of Anesthesia, Emergency Medicine, and Critical Care, Kigali, Rwanda.,Centre Hospitalier Universitaire de Kigali, Department of Accident & Emergency, Kigali, Rwanda
| | - Adam C Levine
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Andrew Stephen
- Brown University Warren Alpert Medical School, Department of Surgery, Providence, Rhode Island
| | - Adam R Aluisio
- Brown University Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
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16
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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: 5] [Impact Index Per Article: 1.3] [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.
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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
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Zimmerman A, Fox S, Griffin R, Nelp T, Thomaz EBAF, Mvungi M, Mmbaga BT, Sakita F, Gerardo CJ, Vissoci JRN, Staton CA. An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country. PLoS One 2020; 15:e0240528. [PMID: 33045030 PMCID: PMC7549769 DOI: 10.1371/journal.pone.0240528] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022] Open
Abstract
Background Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting. Methods We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes. Results Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery. Conclusions Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Samara Fox
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Randi Griffin
- Department of Evolutionary Anthropology, Duke University, Durham, North Carolina, United States of America
| | - Taylor Nelp
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Mark Mvungi
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Charles J Gerardo
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Catherine A Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
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Aspelund AL, Patel MQ, Kurland L, McCaul M, van Hoving DJ. Evaluating trauma scoring systems for patients presenting with gunshot injuries to a district-level urban public hospital in Cape Town, South Africa. Afr J Emerg Med 2019; 9:193-196. [PMID: 31890483 PMCID: PMC6933194 DOI: 10.1016/j.afjem.2019.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/24/2019] [Indexed: 11/21/2022] Open
Abstract
Introduction Trauma scoring systems are widely used in emergency settings to guide clinical decisions and to predict mortality. It remains unclear which system is most suitable to use for patients with gunshot injuries at district-level hospitals. This study compares the Triage Early Warning Score (TEWS), Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Kampala Trauma Score (KTS) and Revised Trauma Score (RTS) as predictors of mortality among patients with gunshot injuries at a district-level urban public hospital in Cape Town, South Africa. Methods Gunshot-related patients admitted to the resuscitation area of Khayelitsha Hospital between 1 January 2016 and 31 December 2017 were retrospectively analysed. Receiver Operating Characteristic (ROC) analysis were used to determine the accuracy of each score to predict all-cause in-hospital mortality. The odds ratio (with 95% confidence intervals) was used as a measure of association. Results In total, 331 patients were included in analysing the different scores (abstracted from database n = 431, excluded: missing files n = 16, non gunshot injury n = 10, <14 years n = 1, information incomplete to calculate scores n = 73). The mortality rate was 6% (n = 20). The TRISS and KTS had the highest area under the ROC curve (AUC), 0.90 (95% CI 0.83-0.96) and 0.86 (95% CI 0.79–0.94), respectively. The KTS had the highest sensitivity (90%, 95% CI 68-99%), while the TEWS and RTS had the highest specificity (91%, 95% CI 87–94% each). Conclusions None of the different scoring systems performed better in predicting mortality in this high-trauma burden area. The results are limited by the low number of recorded deaths and further studies are needed. Gunshot injuries most often occurs in young males. Trauma scores can be used to prognosticate patients in order to allocate appropriate resources. Accuracy-related data of trauma scores in entry-level hospitals is limited.
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Affiliation(s)
| | | | - Lisa Kurland
- Department of Research and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Sciences, Department of Emergency Medicine, Örebro, Sweden
| | - Michael McCaul
- Biostatistics Unit, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, South Africa
| | - Daniël Jacobus van Hoving
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
- Corresponding author at: PO Box 241, Cape Town 8000, South Africa.
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19
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Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti. BMC Emerg Med 2019; 19:56. [PMID: 31627715 PMCID: PMC6798378 DOI: 10.1186/s12873-019-0266-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/12/2019] [Indexed: 12/04/2022] Open
Abstract
Background Bleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA. Methods Patients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18–65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit. Results One-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group “before” (adjusted odds ratio 0.3, 95%confidence interval 0.1–0.8). They also had a significantly shorter hospital length of stay (p = 0.02). Conclusions Implementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.
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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: 13] [Impact Index Per Article: 2.6] [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.
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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
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Validity of the South African Triage Scale in a rural district hospital. Afr J Emerg Med 2018; 8:145-149. [PMID: 30534518 PMCID: PMC6277536 DOI: 10.1016/j.afjem.2018.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 05/20/2018] [Accepted: 07/08/2018] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The implementation of a triage system is a vital step in improving the functioning and patient flow of the emergency centre in a rural district hospital. The South African Triage Scale (SATS) is a well validated and reliable tool used widely in South Africa and other low- and middle-income countries. This study aims to assess the validity of the SATS in a rural district hospital context. METHODS This is a cross-sectional study. All patients presenting to the Zithulele Hospital emergency centre from 1 October 2015 to 31 December 2015 were triaged using the SATS system, routinely collected data was used to determine the correlation between assigned acuity and outcome to determine rates of under- and over-triage. Patient demographics were collected and waiting times were compared to existing standards of the SATS tool. RESULTS Of the 4002 patients presenting to the emergency centre during the study period, 2% were triaged as emergency patients, 15% as very urgent, 38% as urgent and 45% as routine. The assigned acuities correlate well with outcome (f = 0.37; p < 0.0001) and an acceptable rate of over-triage (49%) and under-triage (9%) was found. Waiting time targets were poorly achieved with only 49% of emergency, 23% very urgent, 46% urgent and 69% routine patients seen within ideal target times. DISCUSSION The SATS is a valid tool to implement in a rural district emergency centre. Strict waiting time goals may not be achievable in this setting without structural and resource allocation changes to allow for improvements in the surge capacity of staff to manage urgent and emergency patients.
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Mwandri MB, Hardcastle TC. Burden, Characteristics and Process of Care Among the Pediatric and Adult Trauma Patients in Botswana's Main Hospitals. World J Surg 2018; 42:2321-2328. [PMID: 29450701 DOI: 10.1007/s00268-018-4528-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Botswana is notable among countries with high rates of Road Traffic Collisions (RTC); like many other lower-middle-income countries (LMICs), it lacks trauma systems. The World Health Organization recommends 'Essential Trauma Care' in countries with no formal trauma systems. The proportion of injuries in Emergency Departments and the care process were investigated to gain an overview for enabling the design of a relevant LMICs trauma system. METHOD Blunt and penetrating trauma patients were included from three major hospitals, examining the proportion of injuries, patient characteristics, the care process and comparing these between pediatrics and adults. Data are presented using descriptive statistics. RESULTS The proportion of trauma ranged between 6 and 10% of Emergency Department cases. Pediatrics constituted 19%, and 59% of all patients were male. The median age was 28 years [IQR 17-39] and 8 years [IQR 4-11] for adults and pediatrics, respectively. The leading causes of injuries were: falls in pediatrics (55%) and interpersonal violence in the adults (34%), followed by RTC in both children (20%) and adults (30%). The public inter-hospital vehicles transported 77% of pediatrics and 69% of adults, while formal ambulance transported only 9% of pediatrics and 22% of adults. The median Emergency Department waiting time for pediatrics was 187 min [IQR 102-397] and for adults was 208 min [IQR 100-378]: Most were triaged as non-urgent (70% pediatrics and 72% adults), and the majority were discharged (84% pediatrics and 76% adults). CONCLUSION The Emergency Department workload of injuries is notably high, with differing mechanisms of injury and transport modes between pediatrics and adults: Waiting time is severely prolonged for urgent and critical patients. Diagnoses, triage categories and patients disposition were similar.
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Affiliation(s)
- Michael B Mwandri
- Department Surgery, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa. .,Department of Surgery, Kilimanjaro Christian Medical University College, P.O. Box 3010, Moshi, Tanzania.
| | - Timothy C Hardcastle
- Department Surgery, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa.,Trauma Service and Trauma ICU, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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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.
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Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review. Eur J Emerg Med 2018; 25:154-160. [PMID: 28263204 DOI: 10.1097/mej.0000000000000445] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite the universal acknowledgment that triage is necessary to prioritize emergency care, there is no review that provides an overview of triage tools evaluated and utilized in resource-poor settings, such as low- and middle-income countries (LMICs). We seek to quantify and evaluate studies evaluating triage tools in LMICs. METHODS We performed a systematic review of the literature between 2000 and 2015 to identify studies that evaluated the reliability and validity of triage tools for adult emergency care in LMICs. Studies were then evaluated for the overall quality of evidence using the GRADE criteria. RESULTS Eighteen studies were included in the review, evaluating six triage tools. Three of the 18 studies were in low-income countries and none were in rural hospitals. Two of the six tools had evaluations of reliability. Each tool positively predicted clinical outcomes, although the variety in resource environments limited ability to compare the predictive nature of any one tool. The South African Triage Scale had the highest quality of evidence. In comparison with high-income countries, the review showed fewer studies evaluating reliability and presented a higher number of studies with small sample sizes that decreased the overall quality of evidence. CONCLUSION The quality of evidence supporting any single triage tool's validity and reliability in LMICs is moderate at best. Research on triage tool applicability in low-resource environments must be targeted to the actual clinical environment where the tool will be utilized, and must include low-income countries and rural, primary care settings.
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Abebe Y, Dida T, Yisma E, Silvestri DM. Ambulance use is not associated with patient acuity after road traffic collisions: a cross-sectional study from Addis Ababa, Ethiopia. BMC Emerg Med 2018; 18:7. [PMID: 29433441 PMCID: PMC5810000 DOI: 10.1186/s12873-018-0158-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 02/06/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Africa accounts for one sixth of global road traffic deaths-most in the pre-hospital setting. Ambulance transport is expensive relative to other modes of pre-hospital transport, but has advantages in time-sensitive, high-acuity scenarios. Many countries, including Ethiopia, are expanding ambulance fleets, but clinical characteristics of patients using ambulances remain ill-defined. METHODS This is a cross-sectional study of 662 road traffic collisions (RTC) patients arriving to a single trauma referral center in Addis Ababa, Ethiopia, over 7 months. Emergency Department triage records were used to abstract clinical and arrival characteristics, including acuity. The outcome of interest was ambulance arrival. Secondary outcomes of interest were inter-facility referral and referral communication. Descriptive and multivariable statistics were computed to identify factors independently associated with outcomes. RESULTS Over half of patients arrived with either high (13.1%) or moderate (42.2%) acuity. Over half (59.0%) arrived by ambulance, and nearly two thirds (65.9%) were referred. Among referred patients, inter-facility communication was poor (57.7%). Patients with high acuity were most likely to be referred (aOR 2.20, 95%CI 1.16-4.17), but were not more likely to receive ambulance transport (aOR 1.56, 95%CI 0.86-2.84) or inter-facility referral communication (aOR 0.98, 95%CI 0.49-1.94) than those with low acuity. Nearly half (40.2%) of all patients were referred by ambulance despite having low acuity. CONCLUSIONS Despite ambulance expansion in Addis Ababa, ambulance use among RTC patients remains heavily concentrated among those with low-acuity. Inter-facility referral appears a primary contributor to low-acuity ambulance use. In other contexts, similar routine ambulance monitoring may help identify low-value utilization. Regional guidelines may help direct ambulance use where most valuable, and warrant further evaluation.
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Affiliation(s)
- Yonas Abebe
- Department of Emergency and Critical Care Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Tolesa Dida
- Department of Emergency and Critical Care Nursing, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Engida Yisma
- School of Allied Health Sciences, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Robinson Research Institute, School of Medicine, The University of Adelaide, Adelaide, Australia
| | - David M. Silvestri
- National Clinician Scholars Program and Department of Emergency Medicine, Yale School of Medicine, New Haven, USA
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Abdelwahab R, Yang H, Teka HG. A quality improvement study of the emergency centre triage in a tertiary teaching hospital in northern Ethiopia. Afr J Emerg Med 2017; 7:160-166. [PMID: 30456132 PMCID: PMC6234140 DOI: 10.1016/j.afjem.2017.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 04/08/2017] [Accepted: 05/29/2017] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION An effective emergency triage system should prioritize both trauma and non-trauma patients according to level of acuity, while also addressing local disease burden and resource availability. In March 2012, an adapted version of the South African Triage Scale was introduced in the emergency centre (EC) of Ayder Comprehensive Specialized Hospital in northern Ethiopia. METHODS This quality improvement study was conducted to evaluate the implementation of nurse-led emergency triage in a large Ethiopian teaching hospital using the Donabedian model. A 45% random sample was selected from all adult emergency patients during the study period, May 10th to May 25th 2015. Patient charts were collected and retrospectively reviewed. Presence and proper completion of the triage form were appraised. Triage level was abstracted and compared with patient outcome (dichotomized as "admitted to hospital or died" and "discharged alive from emergency centre") to quantify over- and under-triage triage. RESULTS From 251 randomly selected patients, 107 (42.6%) charts were retrieved. From these, only 45/107 (42.1%) contained the triage form filled within the chart. None of the triage forms were filled out completely. From 13 (28.9%) admitted or deceased patients, the under-triage rate was 30.7% and from 32 (71.1%) patients discharged alive from the EC the over-triage rate was 21.9%. DISCUSSION The under-triage rate observed in this study exceeds the recommended threshold of 5% and is a serious patient safety concern. However, under-triage may have been magnified by irregularities in the hospital admission process. Haphazard medical record handling, poor documentation, erroneous triage decisions, and poor rapport between nurses and physicians were the main process-related challenges that must be addressed through intensive training and improved human resource management approaches to enhance the quality of triage in the emergency centre.
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Affiliation(s)
| | - Hannah Yang
- Mekelle University College of Health Sciences, PO Box 1871, Mekelle, Tigray, Ethiopia
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD 21205, USA
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de Magalhães-Barbosa MC, Robaina JR, Prata-Barbosa A, Lopes CDS. Validity of triage systems for paediatric emergency care: a systematic review. Emerg Med J 2017; 34:711-719. [PMID: 28978650 DOI: 10.1136/emermed-2016-206058] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/04/2022]
Abstract
AIM To present a systematic review on the validity of triage systems for paediatric emergency care. METHODS Search in MEDLINE, Cochrane Library, Latin American and Caribbean Health Sciences Literature (LILACS), Scientific Electronic Library Online (SciELO), Nursing Database Index (BDENF) and Spanish Health Sciences Bibliographic Index (IBECS) for articles in English, French, Portuguese or Spanish with no time limit. Validity studies of five-level triage systems for patients 0-18 years old were included. Two reviewers performed data extraction and quality assessment as recommended by PRISMA statement. RESULTS We found 25 studies on seven triage systems: Manchester Triage System (MTS); paediatric version of Canadian Triage and Acuity Scale (PedCTAS) and its adaptation for Taiwan (paediatric version of the Taiwan Triage and Acuity System); Emergency Severity Index version 4 (ESI v.4); Soterion Rapid Triage System and South African Triage Scale and its adaptation for Bostwana (Princess Marina Triage Scale). Only studies on the MTS used a reference standard for urgency, while all systems were evaluated using a proxy outcome for urgency such as admission. Over half of all studies were low quality. The MTS, PedCTAS and ESI v.4 presented the largest number of moderate and high quality studies. The three tools performed better in their countries or near them, showing a consistent association with hospitalisation and resource utilisation. Studies of all three tools found that patients at the lowest urgency levels were hospitalised, reflecting undertriage. CONCLUSIONS There is some evidence to corroborate the validity of the MTS, PedCTAS and ESI v.4 for paediatric emergency care in their own countries or near them. Efforts to improve the sensitivity and to minimise the undertriage rates should continue. Cross-cultural adaptation is necessary when adopting these triage systems in other countries.
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Affiliation(s)
| | | | - Arnaldo Prata-Barbosa
- Department of Paediatrics, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, RJ, Brazil.,Department of Paediatrics, School of Medicine, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Claudia de Souza Lopes
- Department of Epidemiology, Instituto de Medicina Social (IMS), Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
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Bruijns SR, Wallis LA. The Kampala Trauma Score has poor diagnostic accuracy for most emergency presentations. Injury 2017; 48:2366-2367. [PMID: 28855083 DOI: 10.1016/j.injury.2017.07.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/28/2017] [Indexed: 02/02/2023]
Affiliation(s)
- Stevan R Bruijns
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa.
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Massaut J, Valles P, Ghismonde A, Jacques CJ, Louis LP, Zakir A, Van den Bergh R, Santiague L, Massenat RB, Edema N. The modified south African triage scale system for mortality prediction in resource-constrained emergency surgical centers: a retrospective cohort study. BMC Health Serv Res 2017; 17:594. [PMID: 28835247 PMCID: PMC5569494 DOI: 10.1186/s12913-017-2541-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 08/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The South African Triage Scale (SATS) was developed to facilitate patient triage in emergency departments (EDs) and is used by Médecins Sans Frontières (MSF) in low-resource environments. The aim was to determine if SATS data, reason for admission, and patient age can be used to develop and validate a model predicting the in-hospital risk of death in emergency surgical centers and to compare the model's discriminative power with that of the four SATS categories alone. METHODS We used data from a cohort hospitalized at the Nap Kenbe Surgical Hospital in Haiti from January 2013 to June 2015. We based our analysis on a multivariate logistic regression of the probability of death. Age cutoff, reason for admission categorized into nine groups according to MSF classifications, and SATS triage category (red, orange, yellow, and green) were used as candidate parameters for the analysis of factors associated with mortality. Stepwise backward elimination was performed for the selection of risk factors with retention of predictors with P < 0.05, and bootstrapping was used for internal validation. The likelihood ratio test was used to compare the combined and restricted models. These models were also applied to data from a cohort of patients from the Kunduz Trauma Center, Afghanistan, to validate mortality prediction in an external trauma patients population. RESULTS A total of 7618 consecutive hospitalized patients from the Nap Kenbe Hospital were analyzed. Variables independently associated with in-hospital mortality were age > 45 and < = 65 years (odds ratio, 2.04), age > 65 years (odds ratio, 5.15) and the red (odds ratio, 65.08), orange (odds ratio, 3.5), and non-trauma (odds ratio, 3.15) categories. The combined model had an area under the receiver operating characteristic curve (AUROC) of 0.8723 and an AUROC corrected for optimism of 0.8601. The AUROC of the model run on the external data-set was 0.8340. The likelihood ratio test was highly significant in favor of the combined model for both the original and external data-sets. CONCLUSIONS SATS category, patient age, and reason for admission can be used to predict in-hospital mortality. This predictive model had good discriminative ability to identify ED patients at a high risk of death and performed better than the SATS alone.
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Affiliation(s)
- Jacques Massaut
- Nap Kenbe Hospital Haiti, Médecins Sans Frontières OCB, Université Libre de Bruxelles, Rue Antoine Bréart 90, 1060, Brussels, Belgium.
| | - Pola Valles
- Medical Department, Médecins Sans Frontières OCB, Rue de l'Arbre Bénit 46, 1050, Brussels, Belgium
| | - Arnold Ghismonde
- Nap Kenbe Hospital Haiti, Médecins Sans Frontières OCB, Tabarre, Rue La Fleur, Tabarre, Port-au-Prince, Haiti
| | - Claudinette Jn Jacques
- Nap Kenbe Hospital Haiti, Médecins Sans Frontières OCB, Tabarre, Rue La Fleur, Tabarre, Port-au-Prince, Haiti
| | - Liseberth Pierre Louis
- Nap Kenbe Hospital Haiti, Médecins Sans Frontières OCB, Tabarre, Rue La Fleur, Tabarre, Port-au-Prince, Haiti
| | - Abdulmutalib Zakir
- Médecins Sans Frontières OCB, Quala-e-Fatullah, Street #3, House #4, Kunduz, Kabul District 10, Afghanistan
| | - Rafael Van den Bergh
- Operational Research Unit, Médecins Sans Frontières OCB, Rue de l'Arbre Bénit 46, 1050, Brussels, Belgium
| | - Lunick Santiague
- Nap Kenbe Hospital Haiti, Médecins Sans Frontières OCB, Tabarre, Rue La Fleur, Tabarre, Port-au-Prince, Haiti
| | - Rose Berly Massenat
- Nap Kenbe Hospital Haiti, Médecins Sans Frontières OCB, Tabarre, Rue La Fleur, Tabarre, Port-au-Prince, Haiti
| | - Nathalie Edema
- Nap Kenbe Hospital Haiti, Médecins Sans Frontières OCB, Tabarre, Rue La Fleur, Tabarre, Port-au-Prince, Haiti
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Soogun S, Naidoo M, Naidoo K. An evaluation of the use of the South African Triage Scale in an urban district hospital in Durban, South Africa. S Afr Fam Pract (2004) 2017. [DOI: 10.1080/20786190.2017.1307908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
| | - M Naidoo
- Discipline of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - K Naidoo
- Discipline of Family Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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Reynolds TA, Stewart B, Drewett I, Salerno S, Sawe HR, Toroyan T, Mock C. The Impact of Trauma Care Systems in Low- and Middle-Income Countries. Annu Rev Public Health 2017; 38:507-532. [DOI: 10.1146/annurev-publhealth-032315-021412] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Injury is a leading cause of death globally, and organized trauma care systems have been shown to save lives. However, even though most injuries occur in low- and middle-income countries (LMICs), most trauma care research comes from high-income countries where systems have been implemented with few resource constraints. Little context-relevant guidance exists to help policy makers set priorities in LMICs, where resources are limited and where trauma care may be implemented in distinct ways. We have aimed to review the evidence on the impact of trauma care systems in LMICs through a systematic search of 11 databases. Reports were categorized by intervention and outcome type and summarized. Of 4,284 records retrieved, 71 reports from 32 countries met inclusion criteria. Training, prehospital systems, and overall system organization were the most commonly reported interventions. Quality-improvement, costing, rehabilitation, and legislation and governance were relatively neglected areas. Included reports may inform trauma care system planning in LMICs, and noted gaps may guide research and funding agendas.
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Affiliation(s)
- Teri A. Reynolds
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva CH-1211, Switzerland;, ,
| | - Barclay Stewart
- Department of Surgery, University of Washington, Seattle, Washington 98105
| | - Isobel Drewett
- School of Medicine, Monash University, Melbourne 3800, Australia
| | - Stacy Salerno
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva CH-1211, Switzerland;, ,
| | - Hendry R. Sawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam 11103, Tanzania
| | - Tamitza Toroyan
- Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, Geneva CH-1211, Switzerland;, ,
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, Washington 98105
- Department Global Health, University of Washington, Seattle, Washington 98105
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Rouhani SA, Aaronson E, Jacques A, Brice S, Marsh RH. Evaluation of the implementation of the South African Triage System at an academic hospital in central Haiti. Int Emerg Nurs 2017; 33:26-31. [PMID: 28228342 DOI: 10.1016/j.ienj.2016.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/18/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Effective triage is an important part of high quality emergency care, yet is frequently lacking in resource-limited settings. The South African Triage Scale (SATS) is designed for these settings and consists of a numeric score (triage early warning score, TEWS) and a list of clinical signs (known as discriminators). Our objective was to evaluate the implementation of SATS at a new teaching hospital in Haiti. METHODS A random sample of emergency department charts from October 2013 were retrospectively reviewed for the completeness and accuracy of the triage form, correct calculation of the triage score, and final patient disposition. Over and under triage were calculated. Comparisons were evaluated with chi-squared analysis. RESULTS Of 390 charts were reviewed, 385 contained a triage form and were included in subsequent analysis. The final triage color was recorded for 68.4% of patients, clinical discriminators for 48.6%, and numeric score for 96.1%. The numeric score was calculated correctly 78.3% of the time; in 13.2% of patients a calculation error was made that would have changed triage priority. In 23% of cases, chart review identified clinical discriminators should have been circled but were not recorded. Overtriage and undertriage were 75.6% and 7.4% respectively. CONCLUSION This study demonstrates that with limited structured training, SATS was widely adopted, but the clinical discriminators were used less commonly than the numeric score. This should be considered in future implementations of SATS.
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Affiliation(s)
- Shada A Rouhani
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States; University Teaching Hospital at Mirebalais, Mirebalais, Haiti; Partners In Health, Boston, MA, United States.
| | - Emily Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States
| | - Angella Jacques
- University Teaching Hospital at Mirebalais, Mirebalais, Haiti
| | - Sandy Brice
- University Teaching Hospital at Mirebalais, Mirebalais, Haiti
| | - Regan H Marsh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States; Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States; University Teaching Hospital at Mirebalais, Mirebalais, Haiti; Partners In Health, Boston, MA, United States
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Hansoti B, Jenson A, Keefe D, De Ramirez SS, Anest T, Twomey M, Lobner K, Kelen G, Wallis L. Reliability and validity of pediatric triage tools evaluated in Low resource settings: a systematic review. BMC Pediatr 2017; 17:37. [PMID: 28122537 PMCID: PMC5267450 DOI: 10.1186/s12887-017-0796-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 01/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the high burden of pediatric mortality from preventable conditions in low and middle income countries and the existence of multiple tools to prioritize critically ill children in low-resource settings, no analysis exists of the reliability and validity of these tools in identifying critically ill children in these scenarios. METHODS The authors performed a systematic search of the peer-reviewed literature published, for studies pertaining to for triage and IMCI in low and middle-income countries in English language, from January 01, 2000 to October 22, 2013. An updated literature search was performed on on July 1, 2015. The databases searched included the Cochrane Library, EMBASE, Medline, PubMed and Web of Science. Only studies that presented data on the reliability and validity evaluations of triage tool were included in this review. Two independent reviewers utilized a data abstraction tool to collect data on demographics, triage tool components and the reliability and validity data and summary findings for each triage tool assessed. RESULTS Of the 4,717 studies searched, seven studies evaluating triage tools and 10 studies evaluating IMCI were included. There were wide varieties in method for assessing reliability and validity, with different settings, outcome metrics and statistical methods. CONCLUSIONS Studies evaluating triage tools for pediatric patients in low and middle income countries are scarce. Furthermore the methodology utilized in the conduct of these studies varies greatly and does not allow for the comparison of tools across study sites.
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Affiliation(s)
- Bhakti Hansoti
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Alexander Jenson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Devin Keefe
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Sarah Stewart De Ramirez
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Trisha Anest
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Michelle Twomey
- University of Cape Town Division of Emergency Medicine, Private Bag X24, Bellville, 7535 South Africa
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins School of Medicine, Baltimore, USA
| | - Gabor Kelen
- Department of Emergency Medicine, Johns Hopkins School of Medicine, 1830 Monument St Suite 6-100, Baltimore, MD 21287 USA
| | - Lee Wallis
- University of Cape Town Division of Emergency Medicine, Private Bag X24, Bellville, 7535 South Africa
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Hasselbalch RB, Plesner LL, Pries-Heje M, Ravn L, Lind M, Greibe R, Jensen BN, Rasmussen LS, Iversen K. The Copenhagen Triage Algorithm: a randomized controlled trial. Scand J Trauma Resusc Emerg Med 2016; 24:123. [PMID: 27724978 PMCID: PMC5057417 DOI: 10.1186/s13049-016-0312-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/30/2016] [Indexed: 11/12/2022] Open
Abstract
Background Crowding in the emergency department (ED) is a well-known problem resulting in an increased risk of adverse outcomes. Effective triage might counteract this problem by identifying the sickest patients and ensuring early treatment. In the last two decades, systematic triage has become the standard in ED’s worldwide. However, triage models are also time consuming, supported by limited evidence and could potentially be of more harm than benefit. The aim of this study is to develop a quicker triage model using data from a large cohort of unselected ED patients and evaluate if this new model is non-inferior to an existing triage model in a prospective randomized trial. Methods The Copenhagen Triage Algorithm (CTA) study is a prospective two-center, cluster-randomized, cross-over, non-inferiority trial comparing CTA to the Danish Emergency Process Triage (DEPT). We include patients ≥16 years (n = 50.000) admitted to the ED in two large acute hospitals. Centers are randomly assigned to perform either CTA or DEPT triage first and then use the other triage model in the last time period. The CTA stratifies patients into 5 acuity levels in two steps. First, a scoring chart based on vital values is used to classify patients in an immediate category. Second, a clinical assessment by the ED nurse can alter the result suggested by the score up to two categories up or one down. The primary end-point is 30-day mortality and secondary end-points are length of stay, time to treatment, admission to intensive care unit, and readmission within 30 days. Discussion If proven non-inferior to standard DEPT triage, CTA will be a faster and simpler triage model that is still able to detect the critically ill. Simplifying triage will lessen the burden for the ED staff and possibly allow faster treatment. Trial registration Clinicaltrials.gov: NCT02698319, registered 24. of February 2016, retrospectively registered
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Affiliation(s)
| | | | - Mia Pries-Heje
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Rasmus Greibe
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Lars S Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark.,Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
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Oteng RA, Whiteside LK, Rominski SD, Amuasi JH, Carter PM, Donkor P, Cunningham R. Individual and Medical Characteristics of Adults Presenting to an Urban Emergency Department in Ghana. Ghana Med J 2016; 49:136-41. [PMID: 26693187 DOI: 10.4314/gmj.v49i3.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The aims of this study were to characterize the patients seeking acute care for injury and non-injury complaints in an urban Emergency Department in Ghana in order to 1) inform the curriculum of the newly developed Emergency Medicine resident training program 2) improve treatment processes, and 3) direct future community-wide injury prevention policies. STUDY DESIGN A prospective cross-sectional survey of patients 18 years or older seeking care in an urban Accident and Emergency Center (AEC) was conducted between 7/13/2009 and 7/30/2009. Questionnaires were administered by trained research staff and each survey took 10-15 minutes to complete. Patients were asked questions regarding demographics, overall health and chief complaint. RESULTS 254 patients were included in the sample. Participants' chief complaints were classified as either medical or injury-related. Approximately one third (38%) of patients presented with injuries and 62% presented for medical complaints. The most common injury at presentation was due to a road traffic injury, followed by falls and assault/fight. The most common medical presentation was abdominal pain followed by difficulty breathing and fainting/ blackout. Only 13% arrived to AEC by ambulance and 51% were unable to ambulate at the time of presentation. CONCLUSION Approximately one-third of non-fatal adult visits were for acute injury. Future research should focus on developing surveillance systems for both medical and trauma patients. Physicians that are specifically trained to manage both the acutely injured patient and the medical patient will serve this population well given the variety of patients that seek care at the AEC.
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Affiliation(s)
- R A Oteng
- University of Michigan, Department of Emergency Medicine, Ann Arbor, MI, USA ; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - L K Whiteside
- University of Washington, Division of Emergency Medicine, Seattle, WA, USA
| | - S D Rominski
- Global REACH, University of Michigan Medical School, Ann Arbor, MI, USA
| | - J H Amuasi
- Komfo Anokye Teaching Hospital, Kumasi, Ghana ; Kumasi Center for Collaborative Research in Tropical Medicine, Kumasi, Ghana
| | - P M Carter
- University of Michigan, Department of Emergency Medicine, Ann Arbor, MI, USA ; University of Michigan, Injury Center, Ann Arbor, MI, USA
| | - P Donkor
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - R Cunningham
- University of Michigan, Department of Emergency Medicine, Ann Arbor, MI, USA ; University of Michigan, Injury Center, Ann Arbor, MI, USA
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Tshitenge ST, Ogunbanjo GA, Mbuka DO. The effectiveness of the South African Triage Toll use in Mahalapye District Hospital - Emergency Department, Botswana. Afr J Prim Health Care Fam Med 2016; 8:e1-5. [PMID: 27543284 PMCID: PMC4992184 DOI: 10.4102/phcfm.v8i1.1030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 01/22/2016] [Accepted: 01/29/2016] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The study aimed to determine the proportion of each priority level of patients, time of performance in each priority level, and the reliability of the South African Triage Scale (SATS) tool at the Mahalapye District Hospital - Emergency Department (MDH-ED), a setting where the majority of the nurses were not formally trained on the use of the SATS. METHODS This was a cross-sectional study using case records in MDH-ED from 1 January 2014 to 31 December 2014. A panel of experts from the Mahalapye site of the Family Medicine Department, University of Botswana, reviewed and scored each selected case record that was compared with the scores previously attributed to the nurse triage. RESULTS From the 315 case records, both the nurse triage and the panel of expert triage assigned the majority of cases in the routine category (green), 146 (46%) and 125 (40%), respectively, or in the urgent category (yellow), they assigned 140 (44%) and 111 (35%) cases, respectively.Overall, there was an adequate agreement between the nurse triage and the panel of expert triage (k = 0.4, 95% confidence interval: 0.3-0.5), although the level of agreement was satisfactory. CONCLUSION Findings of the study reported that the profile of the priority-level categories in MDH-ED was made in the majority of routine and urgent patients, only the routine and the emergency patients were seen within the targeted time and they had a satisfactory level of reliability (between 0.4 and 0.6).
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Mulindwa F, Blitz J. Perceptions of doctors and nurses at a Ugandan hospital regarding the introduction and use of the South African Triage Scale. Afr J Prim Health Care Fam Med 2016; 8:e1-7. [PMID: 27247152 PMCID: PMC4820643 DOI: 10.4102/phcfm.v8i1.1056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 02/29/2016] [Accepted: 01/14/2016] [Indexed: 11/13/2022] Open
Abstract
Background International Hospital Kampala (IHK) experienced a challenge with how to standardise the triaging and sorting of patients. There was no triage tool to help to prioritise which patients to attend to first, with very sick patient often being missed. Aim and setting To explore whether the introduction of the South African Triage Scale (SATS) was seen as valuable and sustainable by the IHK’s outpatient department and emergency unit (OPD and EU) staff. Methods The study used qualitative methods to introduce SATS in the OPD and EU at IHK and to obtain the perceptions of doctors and nurses who had used it for 3–6 months on its applicability and sustainability. Specific questions about challenges faced prior to its introduction, strengths and weaknesses of the triage tool, the impact it had on staff practices, and their recommendations on the continued use of the tool were asked. In-depth interviews were conducted with 4 doctors and 12 nurses. Results SATS was found to be necessary, applicable and recommended for use in the IHK setting. It improved the sorting of patients, as well as nurse-patient and nurse-doctor communication. The IHK OPD & EU staff attained new skills, with nurses becoming more involved in-patient care. It is possibly also useful in telephone triaging and planning of hospital staffing. Conclusion Adequate nurse staffing, a computer application for automated coding of patients, and regular training would encourage consistent use and sustainability of SATS. Setting up a hospital committee to review signs and symptoms would increase acceptability and sustainability. SATS is valuable in the IHK setting because it improved overall efficiency of triaging and care, with significantly more strengths than weaknesses.
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Affiliation(s)
- Francis Mulindwa
- Faculty of Medicine and Health Sciences, Division of Family Medicine and Primary Care, Stellenbosch University.
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Turner EL, Nielsen KR, Jamal SM, von Saint André-von Arnim A, Musa NL. A Review of Pediatric Critical Care in Resource-Limited Settings: A Look at Past, Present, and Future Directions. Front Pediatr 2016; 4:5. [PMID: 26925393 PMCID: PMC4757646 DOI: 10.3389/fped.2016.00005] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/22/2016] [Indexed: 01/09/2023] Open
Abstract
Fifteen years ago, United Nations world leaders defined millenium development goal 4 (MDG 4): to reduce under-5-year mortality rates by two-thirds by the year 2015. Unfortunately, only 27 of 138 developing countries are expected to achieve MDG 4. The majority of childhood deaths in these settings result from reversible causes, and developing effective pediatric emergency and critical care services could substantially reduce this mortality. The Ebola outbreak highlighted the fragility of health care systems in resource-limited settings and emphasized the urgent need for a paradigm shift in the global approach to healthcare delivery related to critical illness. This review provides an overview of pediatric critical care in resource-limited settings and outlines strategies to address challenges specific to these areas. Implementation of these tools has the potential to move us toward delivery of an adequate standard of critical care for all children globally, and ultimately decrease global child mortality in resource-limited settings.
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Affiliation(s)
- Erin L Turner
- Asante Rogue Regional Medical Center, Pediatric Hospital Medicine , Medford, OR , USA
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Dalwai MK, Tayler-Smith K, Trelles M, Jemmy JP, Maikéré J, Twomey M, Wakeel M, Iqbal M, Zachariah R. Implementation of a triage score system in an emergency room in Timergara, Pakistan. Public Health Action 2015; 3:43-5. [PMID: 26392995 DOI: 10.5588/pha.12.0083] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 12/10/2012] [Indexed: 11/10/2022] Open
Abstract
Following implementation of the South African Triage Scale (SATS) system in the emergency department (ED) at the District Headquarter Hospital in Timergara, Pakistan, we 1) describe the implementation process, and 2) report on how accurately emergency staff used the system. Of the 370 triage forms evaluated, 320 (86%) were completed without errors, resulting in the correct triage priority being assigned. Fifty completed forms displayed errors, but only 16 (4%) resulted in an incorrect triage priority being assigned. This experience shows that the SATS can be implemented successfully and used accurately by nurses in an ED in Pakistan.
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Affiliation(s)
- M K Dalwai
- Médecins Sans Frontières (MSF), Islamabad, Pakistan ; Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - K Tayler-Smith
- Medical Department, Operational Research, Operational Centre Brussels, MSF-Luxembourg, Luxembourg
| | - M Trelles
- MSF, Brussels Operational Centre, Brussels, Belgium
| | - J-P Jemmy
- MSF, Brussels Operational Centre, Brussels, Belgium
| | - J Maikéré
- Médecins Sans Frontières (MSF), Islamabad, Pakistan
| | - M Twomey
- Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - M Wakeel
- Ministry of Health, Timergara, Lower Dir, Pakistan
| | - M Iqbal
- Médecins Sans Frontières (MSF), Islamabad, Pakistan
| | - R Zachariah
- Medical Department, Operational Research, Operational Centre Brussels, MSF-Luxembourg, Luxembourg
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Gordon SAN, Brits H, Raubenheimer JE. The effectiveness of the implementation of the Cape Triage Score at the emergency department of the National District Hospital, Bloemfontein. S Afr Fam Pract (2004) 2015. [DOI: 10.1080/20786190.2014.977056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Geiling J, Burkle FM, Amundson D, Dominguez-Cherit G, Gomersall CD, Lim ML, Luyckx V, Sarani B, Uyeki TM, West TE, Christian MD, Devereaux AV, Dichter JR, Kissoon N. Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2015; 146:e156S-67S. [PMID: 25144337 DOI: 10.1378/chest.14-0744] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Planning for mass critical care (MCC) in resource-poor or constrained settings has been largely ignored, despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing MCC in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas. METHODS The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. RESULTS The five key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part 1, Infrastructure/Capacity in this article, and part 2, Response/Recovery/Research in the accompanying article. CONCLUSIONS Lack of, or presence of, rudimentary ICU resources and limited capacity to enhance services further challenge resource-poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.
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Sunyoto T, Van den Bergh R, Valles P, Gutierrez R, Ayada L, Zachariah R, Yassin A, Hinderaker SG, Harries AD. Providing emergency care and assessing a patient triage system in a referral hospital in Somaliland: a cross-sectional study. BMC Health Serv Res 2014; 14:531. [PMID: 25373769 PMCID: PMC4229595 DOI: 10.1186/s12913-014-0531-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 10/14/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In resource-poor settings, where health systems are frequently stretched to their capacity, access to emergency care is often limited. Triage systems have been proposed as a tool to ensure efficiency and optimal use of emergency resources in such contexts. However, evidence on the practice of emergency care and the implementation of triage systems in such settings, is scarce. This study aimed to assess emergency care provision in the Burao district hospital in Somaliland, including the application of the South African Triage Scale (SATS) tool. METHODS A cross-sectional descriptive study was undertaken. Routine programme data of all patients presenting at the Emergency Department (ED) of Burao Hospital during its first year of service (January to December 2012) were analysed. The American College of Surgeons Committee on Trauma (ACSCOT) indicators were used as SATS targets for high priority emergency cases ("high acuity" proportion), overtriage and undertriage (with thresholds of >25%, <50% and <10%, respectively). RESULTS In 2012, among 7212 patients presented to the ED, 41% were female, and 18% were aged less than five. Only 21% of these patients sought care at the ED within 24 hours of developing symptoms. The high acuity proportion was 22.3%, while the overtriage (40%) and undertriage (9%) rates were below the pre-set thresholds. The overall mortality rate was 1.3% and the abandon rate 2.0%. The outcomes of patients corresponds well with the color code assigned using SATS. CONCLUSION This is the first study assessing the implementation of SATS in a post-conflict and resource-limited African setting showing that most indicators met the expected standards. In particular, specific attention is needed to improve the relatively low rate of true emergency cases, delays in patient presentation and in timely provision of care within the ED. This study also highlights the need for development of emergency care thresholds that are more adapted to resource-poor contexts. These issues are discussed.
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Affiliation(s)
- Temmy Sunyoto
- />Médecins Sans Frontières – Operational Centre Brussels, Somaliland Mission, Hargeisa, Somaliland
- />Médecins Sans Frontières, Operational Centre Barcelona, Delhi, India
| | - Rafael Van den Bergh
- />Médecins Sans Frontières – Operational Centre Brussels, Operational Research Unit (LuxOR), Luxembourg, Grand Duchy of Luxembourg
| | - Pola Valles
- />Médecins Sans Frontières – Operational Centre Brussels, Brussels, Belgium
| | - Reinaldo Gutierrez
- />Médecins Sans Frontières – Operational Centre Brussels, Somaliland Mission, Hargeisa, Somaliland
| | - Latifa Ayada
- />Médecins Sans Frontières – Operational Centre Brussels, Brussels, Belgium
| | - Rony Zachariah
- />Médecins Sans Frontières – Operational Centre Brussels, Operational Research Unit (LuxOR), Luxembourg, Grand Duchy of Luxembourg
| | - Abdi Yassin
- />Ministry of Health, Togdheer Region, Somaliland
| | | | - Anthony D Harries
- />International Union Against Tuberculosis and Lung Disease (The Union), Winchester, UK
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Naidoo DK, Rangiah S, Naidoo SS. An evaluation of the Triage Early Warning Score in an urban accident and emergency department in KwaZulu-Natal. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2014.10844586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- DK Naidoo
- Addington Hospital Department of Family Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - S Rangiah
- Department of Family Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
| | - SS Naidoo
- College of Family Physicians of South Africa Department of Family Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal
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Aloyce R, Leshabari S, Brysiewicz P. Assessment of knowledge and skills of triage amongst nurses working in the emergency centres in Dar es Salaam, Tanzania. Afr J Emerg Med 2014. [DOI: 10.1016/j.afjem.2013.04.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Nee-Kofi Mould-Millman C, Rominski S, Oteng R. Ambulance or taxi? High acuity prehospital transports in the Ashanti region of Ghana. Afr J Emerg Med 2014. [DOI: 10.1016/j.afjem.2013.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Twomey M, Wallis LA, Myers JE. Evaluating the construct of triage acuity against a set of reference vignettes developed via modified Delphi method. Emerg Med J 2013; 31:562-566. [DOI: 10.1136/emermed-2013-202352] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 02/26/2013] [Accepted: 03/31/2013] [Indexed: 11/03/2022]
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Mullan PC, Torrey SB, Chandra A, Caruso N, Kestler A. Reduced overtriage and undertriage with a new triage system in an urban accident and emergency department in Botswana: a cohort study. Emerg Med J 2013; 31:356-60. [PMID: 23407375 DOI: 10.1136/emermed-2012-201900] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Improvements in triage have demonstrated improved clinical outcomes in resource-limited settings. In 2009, the Accident and Emergency (A&E) Department at the Princess Marina Hospital (PMH) in Botswana identified the need for a more objective triage system and adapted the South African Triage Scale to create the PMH A&E Triage Scale (PATS). AIM The primary purpose was to compare the undertriage and overtriage rates in the PATS and pre-PATS study periods. METHODS Data were collected from 5 April 2010 to 1 May 2011 for the PATS and compared with a database of patients triaged from 1 October 2009 to 24 March 2010 for the pre-PATS. Data included patient disposition outcomes, demographics and triage level assignments. RESULTS 14 706 (pre-PATS) and 25 243 (PATS) patient visits were reviewed. Overall, overtriage rates improved from 53% (pre-PATS) to 38% (PATS) (p<0.001); likewise, undertriage rates improved from 47% (pre-PATS) to 16% (PATS) (p<0.001). Statistically significant decreases in both rates were found when paediatric and adult cases were analysed separately. PATS was more predictive of inpatient admission, Intensive Care Unit (ICU) admission and death rates in the A&E than was the pre-PATS. The lowest acuity category of each system had a 0.6% (pre-PATS) and 0% (PATS) chance of death in the A&E or ICU admission (p<0.001). No change in death rate was seen between the pre-PATS and PATS, but ICU admission rates decreased from 0.35% to 0.06% (p<0.001). CONCLUSIONS PATS is a more predictive triage system than pre-PATS as evidenced by improved overtriage, undertriage and patient severity predictability across triage levels.
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Affiliation(s)
- Paul C Mullan
- Division of Emergency Medicine, Children's National Medical Center, George Washington University, Washington, DC, USA
| | - Susan B Torrey
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York University School of Medicine, New York, New York, USA
| | - Amit Chandra
- Department of Emergency Medicine, University of Botswana School of Medicine, Gaborone, Botswana
| | - Ngaire Caruso
- Department of Emergency Medicine, University of Botswana School of Medicine, Gaborone, Botswana
| | - Andrew Kestler
- Department of Emergency Medicine, University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
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Whiteside LK, Oteng R, Carter P, Amuasi J, Abban E, Rominski S, Nypaver M, Cunningham RM. Non-fatal injuries among pediatric patients seeking care in an urban Ghanaian emergency department. Int J Emerg Med 2012; 5:36. [PMID: 23014102 PMCID: PMC3517513 DOI: 10.1186/1865-1380-5-36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 08/31/2012] [Indexed: 11/16/2022] Open
Abstract
Background According to the World Health Organization (WHO), injuries represent the largest cause of death among people ages 140 –and contribute to a large burden of disease worldwide. The aims of this study were to characterize the prevalence and relative mechanism of injury among children seeking emergency care and describe the demographics at time of presentation among these children to inform further research in Ghana and sub-Saharan Africa. Methods A prospective cross-sectional survey of pediatric patients (n = 176) was conducted between 13 July 2009 and 30 July 2009 in the Accident and Emergency Center at Komfo Anoche Teaching Hospital (KATH) in Kumasi, Ghana. Participants were asked questions regarding demographics, insurance status, overall health, and chief complaint. Results Of the 176 patients surveyed, 66% (n = 116) presented for injuries. The mean age was 4.7 years (range 1.5 months to 17 years), and 68% (n = 120) were male. Of those presenting with injury, 43% (n = 50) had road traffic injuries (RTI). Of the RTIs, 58% (n = 29) were due to being an occupant in a car crash, 26% (n = 13) were pedestrian injuries, and 14% (n = 7) were from motorcycles. There was no significant difference in demographics, health status or indicators of socioeconomic status between injured and non-injured patients. Conclusions Among pediatric patients presenting for acute care at KATH during the study time frame, the majority (n = 116, 66%) presented for injuries. To date, there are no studies that characterize pediatric patients that present for acute care in Ghana. Identifying injury patterns and collecting epidemiologic data are important to guide future research and educational initiatives for Emergency Medicine.
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Affiliation(s)
- Lauren K Whiteside
- Department of Emergency Medicine, University of Michigan, UM Injury Center 24 Frank Lloyd Wright Drive Suite H3200, Ann Arbor, MI, 48105, United States of America.
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Gottschalk SB, Warner C, Burch VC, Wallis LA. Warning scores in triage – Is there any point? Afr J Emerg Med 2012. [DOI: 10.1016/j.afjem.2012.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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