Primary Triage Research Articles

Pre-operative sera interleukin-6 in the diagnosis of high-grade serous ovarian cancer

Pre-operative discrimination of malignant masses is crucial for accurate diagnosis and prompt referral to a gynae oncology centre for optimal surgical intervention. HGSOC progression is correlated with local and systemic inflammation. We hypothesised that inclusion of inflammatory biomarkers in sera may improve diagnostic tests. In the training cohort, we tested four existing clinical tests (RMI score and ROMA, CA125 and HE4) and a panel of 28 immune soluble biomarkers in sera from 66 patients undergoing surgery for suspected ovarian cancer. Six promising immune biomarkers alone, or in combination with conventional tests, were subsequently analysed in an independent validation cohort (n = 69). IL-6 was identified as the main driver of variability followed closely by conventional diagnostic tests. Median sera IL-6 was higher in HGSOC patients compared to those with a benign mass or controls with normal ovaries (28.3 vs 7.3 vs 1.2 pg/ml, p < 0.0001). The combination of IL-6 further improved the overall predictive probability of the conventional tests. Modelling a two-step triage of women with a suspicious ovarian mass, with IL-6 > 3.75 pg/ml as primary triage followed by conventional tests (CA125 or RMI score) identified ovarian cancer in patients with a misclassification rate of 4.54–3.03%, superior to the use of CA125 or RMI alone (9.09 to 10.60). The validation cohort demonstrated a similar improvement in the diagnostic sensitivity following addition of IL-6. IL-6 in combination with conventional tests may be a useful clinical biomarker for triage of patients with a suspected malignant ovarian mass.

Performance of First Aid Trained Staff using a Modified START Triage Tool at Achieving Appropriate Triage Compared to a Physiology-Based Triage Strategy at Australian Mass Gatherings.

Triage at mass gatherings in Australia is commonly performed by staff members with first aid training. There have been no evaluations of the performance of first aid staff with respect to diagnostic accuracy or identification of presentations requiring ambulance transport to hospital. It was hypothesized that triage decisions by first aid staff would be considered correct in at least 61% of presentations. A retrospective audit of 1,048 presentations to a single supplier of event health care services in Australia was conducted. The presentations were assessed based on the first measured set of physiological parameters, and the primary triage decision was classified as "expected" if the primary and secondary triage classifications were the same or "not expected" if they differed. The performance of the two triage systems was compared using area under the receiver operating characteristic curve (AUROC) analysis. The expected decision was made by first aid staff in 674 (71%) of presentations. Under-triage occurred in 131 (14%) presentations and over-triage in 142 (15%) presentations. The primary triage strategy had an AUROC of 0.7644, while the secondary triage strategy had an AUROC of 0.6280, which was significantly different (P = .0199). The results support the continued use of first aid trained staff members in triage roles at Australian mass gatherings. Triage tools should be simple, and the addition of physiological variables to improve the sensitivity of triage tools is not recommended because such an approach does not improve the discriminatory capacity of the tools.

Automatic classification and triage of diabetic retinopathy from retinal images based on a convolutional neural networks (CNN) method

AbstractPurposeDiabetic retinopathy (DR) is one of the leading causes of adult vision loss in the developed countries. Epidemiological and demographic factors, including the rising rates of diabetes related to obesity and an aging population, are driving the incidence of diabetic eye complication inexorably higher.MethodDeep learning emerges as a powerful tool for analyzing and classifying retinal images in an automatic way, but the classification results depend greatly on the availability of large datasets. As the number of categories and the imbalance ratio increase, the performance of deep learning models diminishes. In the context of DR grading, minority classes (mild and severe DR) are critical to diagnose. Experiments were performed on a real dataset developed at local hospital and at different hospitals around the world. Overall, 42 179 retinal images were obtained from Diagnos database. All images were graded by 3 retinal experts using the early treatment diabetic retinopathy study severity scale (ETDRS). The dataset was built by expanding on 4 categories: R0 or normal, R1 or mild DR, R2 or moderate DR, and R3&amp;R4 or severe and proliferative DR. The data was split 90/10 for training and testing respectively, and an ensemble of Convolutional Neural Networks was trained to perform DR grading.ResultsThe proposed method achieves high accuracy in predicting DR grades, with the R1 class showing lower performance, in line with recently proposed methods. An area under the ROC curve of 0.96 (0.95–0.96) for R0, 0.70 (0.65–0.75) for R1, 0.95 (0.94–0.95) for R2 and 0.92 (0.89–0.96) for R34.ConclusionComparable to the score of human experts, the deep learning techniques in this study were effective to be applied in clinical use as primary care setting and could be a valuable tool to help primary care triage. Improvement in detection of R1 subjects is needed for further progressing in this area.

Patient, hospital and regional characteristics associated with undertriage of injured children in California (2005–2015): a retrospective cohort study

Background/objectiveTrauma centers save lives, but they are scarce and concentrated in urban settings. The population of severely injured children in California who do not receive trauma center care (undertriage) is...

A Pediatric Primary Care Nurse Triage Telehealth Model of Care

A Pediatric Primary Care Nurse Triage Telehealth Model of Care

Investigating the effects of under-triage by existing major incident triage tools.

Triage is a key principle in the effective management of a major incident. Its effectiveness is a balance between identifying those in need of life-saving intervention, and those triaged incorrectly as either needing/not needing a life-saving intervention. The primary aim of this study was to report mortality in those under-triaged by existing major incident triage tools. Secondary aims were to report the ability of triage tools at identifying serious injury by body region (defined as an Abbreviated Injury Scale severity score≥3). Retrospective database analysis of the UK Trauma Audit Research Network for all adult patients (≥18 years) between 2006 and 2014. Patients were defined as priority one using a previously published list. Using the first recorded hospital physiology, patients were categorized by the Modified Physiological Triage Tool (MPTT), National Ambulance Resilience Unit (NARU) Sieve and the Major Incident Medical Management and Support (MIMMS) Triage Sieve. Categorical and continuous data were analyzed using a χ-test and Mann-Whitney U-test respectively. During the study period, 218 985 adult patients met the Trauma Audit Research Network inclusion criteria, with 24 791 (19.5%) priority one patients, of which 70% were male with a median age of 51 (33-71) years and injury severity score of 16 (9-25). The MPTT showed the lowest rate of under-triage (42.4%, P<0.001). Compared with existing methods, the MPTT under-triage population had significantly lower mortality (5.7%, P<0.001) with significantly fewer serious thorax and head injuries under-triaged than both the NARU Sieve and MIMMS Triage Sieve (P<0.001). This study has defined the implications of under-triage in the context of a major trauma population. The MPTT misses fewer severely injured patients, with a significant reduction in mortality. We suggest the MPTT to be considered as an alternative to existing primary major incident triage tools.

Thoracic trauma in military settings: a review of current practices and recommendations.

To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population. Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters. The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.

Major incident triage and the evaluation of the Triage Sort as a secondary triage method

IntroductionA key principle in the effective management of major incidents is triage, the process of prioritising patients on the basis of their clinical acuity. In many countries including the UK,...

Nestabilní nemocný při prvním kontaktu s lékařem v nemocnici: jak rozpoznat riziko?

The primary triage of patients on first contact with a physician is crucial for its further direction and it essentially influences the prognosis. In addition to the physicians experience and given the proper stratification, an important role is played by medical history, basic clinical examinations and laboratory tests. The level of established risk affects the indication for hospital admission or possibly admission to a monitored bed. For each new patient, it is advisable to monitor the development of the overall condition and response to the initiated therapy within the first hours of hospitalization. Team cooperation often helps to get a complete picture of the disease. This article mainly focuses on a situation where a patient comes to a health facility with basic medical equipment.

Intra- and inter-laboratory agreement of the FAM19A4/mir124-2 methylation test: Results from an international study.

BackgroundHPV‐based cervical screening detects women at an increased risk of cervical cancer and precancer. To differentiate among HPV‐positive women those with (pre)cancer, triage testing is necessary. The detection of cancer‐associated host‐cell DNA methylation (FAM19A4 and hsa‐mir124‐2) in cervical samples has shown valuable as triage test. This multicenter study from 6 collaborating European laboratories and one reference laboratory was set out to determine the intra‐ and inter‐laboratory agreement of FAM19A4/mir124‐2 DNA methylation analysis utilizing the QIAsure Methylation Test.MethodsAgreement analysis for the QIAsure Methylation Test was assessed on high‐risk HPV‐positive cervical specimens (n = 1680) both at the level of the assay and at the full workflow, including bisulfite conversion.ResultsIntra‐ and inter‐laboratory assay agreement were 91.4% (534/584; 95% CI 88.9‐93.5; κ = 0.82) and 92.5% (369/399; 95% CI 90.0‐94.7; κ = 0.83), respectively. The inter‐laboratory workflow (bisulfite conversion and assay combined) agreement was 90.0% (627/697; 95% CI 87.5%‐92.0%; κ = 0.76).ConclusionThese data show that the QIAsure Methylation Test performs robust and reproducible in different laboratory contexts. These results support the use of the QIAsure Methylation Test for full molecular screening for cervical cancer, including primary HPV testing and triage testing by methylation analysis.

Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach.

BACKGROUND:Injuries caused by emergencies and accidents are increasing in the world. To prioritise patients to provide them with proper services and to optimally use the resources and facilities of the medical centres during accidents, the use of triage systems, which are one of the key principles of accident management, seems essential.AIM:This study is an attempt to identify available triage systems and compare the differences and similarities of the standards of these systems during emergencies and disasters through a review study.METHODS:This study was conducted through a review of the triage systems used in emergencies and disasters throughout the world. Accordingly, all articles published between 1990 and 2018 in both English and Persian journals were searched based on several keywords including Triage, Disaster, Mass Casualty Incidents, in the Medlib, Scopus, Web of Science, PubMed, Cochrane Library, Science Direct, Google scholar, Irandoc, Magiran, Iranmedex, and SID databases in isolation and in combination using both and/ or conjunctions.RESULTS:Based on the search done in these databases, twenty different systems were identified in the primary adult triage field including START, Homebush triage Standard, Sieve, CareFlight, STM, Military, CESIRA Protocol, MASS, Revers, CBRN Triage, Burn Triage, META Triage, Mass Gathering Triage, SwiFT Triage, MPTT, TEWS Triage, Medical Triage, SALT, mSTART and ASAV. There were two primary triage systems including Jump START and PTT for children, and also two secondary triage systems encompassing SAVE and Sort identified in this respect. ESI and CRAMS were two other cases distinguished for hospital triage systems.CONCLUSION:There are divergent triage systems in the world, but there is no general and universal agreement on how patients and injured people should be triaged. Accordingly, these systems may be designed based on such criteria as vital signs, patient’s major problems, or the resources and facilities needed to respond to patients’ needs. To date, no triage system has been known as superior, specifically about the patients’ clinical outcomes, improvement of the scene management or allocation of the resources compared to other systems. Thus, it is recommended that different countries such as Iran design their triage model for emergencies and disasters by their native conditions, resources and relief forces.

PP62 Cost-Effectiveness Of Cervical Cancer Screening In Estonia

IntroductionIn Estonia, organized cervical cancer screening program is targeted at women aged 30–55(59) years and Pap-tests are taken every five years. Since cervical cancer is associated with human papillomavirus (HPV), a number of countries have introduced the HPV-test as the primary method of screening. The objective of this study was to evaluate the cost-effectiveness of organized cervical cancer screening program in Estonia by comparing HPV- and Pap-test based strategies.MethodsFor the cost-effectiveness analysis, a Markov cohort model was developed. The model was used to estimate costs and quality-adjusted life-years (QALYs) of eight screening strategies, varying the primary screening test and triage scenarios, upper age limit of screening, and testing interval. Incremental cost-effectiveness ratios (ICERs) were calculated in comparison to current screening practice as well as to the next best option. Sensitivity analysis was performed by varying one or more similar parameter(s) at a time, while holding others at their base case value. The analysis was performed from the healthcare payer perspective adopting a five percent annual discount rate for both costs and utilities.ResultsIn the base-case scenario, ICER for HPV-test based strategies in comparison to the current screening practice was estimated at EUR 8,596–9,786 per QALY. For alternative Pap-test based strategies ICER was estimated at EUR 2,332–2,425 per QALY. In comparison to the next best option, HPV-test based strategies were dominated by Pap-test based strategies. At the cost-effectiveness threshold of EUR 10,000 per QALY Pap-testing every three years would be the cost-effective strategy for women participating in the screening program from age 30 to 63 (ICER being EUR 3,112 per QALY).ConclusionsDecreasing Pap-test based screening interval or changing to HPV-test based screening can both improve the effectiveness of cervical cancer screening program in Estonia, but based on the current cost-effectiveness study Pap-test based screening every three years should be preferred.

Flow Cytometry With Inflorescence-An Accessible Method in the Study of Qualitative and Quantitative Modifications of Blood Platelets in Immune Thrombocytopenic Purpura

The immune thrombocytopenic purpura (ITP) is a polymorphic and hematologic pathology, in terms of both clinical manifestations and etiopathogenic mechanisms, which bring on this disease. Establishing the type of thrombocytopenia, which can either be primary or secondary, peripheral or central, is essential for a further proper therapeutic conduct. The current means of diagnosis include a large variety of hematologic, immunologic and biochemical explorations, from the traditional ones to the latest methods, either genetical or molecular. The purpose of this paper is to emphasize the importance of a classical method of diagnosis, used in the primary triage of patients suffering from thrombocytopenia, highly valuable in the diagnosis process: the analysis of the mean platelet volume (MPV) and of the platelet distribution width (PDW), parameters revealed by the CBC (complete blood count). Evaluating the size of the platelets is a useful tool in the differential diagnosis between immune thrombocytopenic purpura and hereditary macrothrombocytopenia. The platelet distribution width and the mean platelet volume are read simultaneously, in order to differentiate the immune peripheral thrombocytopenia from the central one. The classical, viable and accessible method facilitates the measurement of MPV and PDW with the automatic analyzer, which functions according to the principle of flow cytometry with inflorescence, by using a LASER semiconductor and hydrodynamic focusing.

Five-Year Risk of Cervical Precancer Following p16/Ki-67 Dual-Stain Triage of HPV-Positive Women

As cervical cancer screening transitions to primary human papillomavirus (HPV) testing, effective triage and management of HPV-positive women is critical to avoid unnecessary colposcopy referral and associated harms while maintaining high sensitivity for cervical precancer. Triage with p16/Ki-67 dual-stain (DS) testing has shown high sensitivity and specificity for detection of cervical precancers; however, longitudinal studies are needed to determine the long-term risk of precancer following a negative DS result. To evaluate the longitudinal performance of p16/Ki-67 DS triage for detection of cervical precancer in HPV-positive women over 5 years of follow-up in the context of clinical management thresholds. Prospective cohort study of HPV-positive women 30 years or older undergoing routine cervical cancer screening in 2012 with HPV and Papanicolaou (hereinafter "cytology") co-testing within the Kaiser Permanente Northern California health care system. Follow-up of medical records was conducted through 2017. All p16/Ki-67 DS testing was performed on residual SurePath material, and slides were evaluated for p16/Ki-67 positivity. Histological end points were ascertained from the clinical database through 2017. We estimated 5-year cumulative risks of cervical intraepithelial neoplasia grades of 2 or worse (≥CIN2) or grades 3 or worse (≥CIN3) by baseline DS and cytology at yearly intervals using Logistic Weibull models. Risks were compared with clinical management thresholds for colposcopy referral and a 1-year return interval. Among the 1549 HPV-positive women in this study, the mean age at enrollment was 42.2 years, and the median follow-up time was 3.7 years (range, 0.2-5.4 years). Positive DS results were associated with significantly higher cumulative 5-year risks of ≥CIN2 compared with abnormal cytology (31.0%; 95% CI, 27.2%-35.3% vs 25.0%; 95% CI, 21.7%-28.7%; P = .03). Women with DS-negative findings had significantly lower 5-year risks of ≥CIN2 compared with women with normal cytology (8.5%; 95% CI, 6.5%-11.1% vs 12.3%; 95% CI, 9.8%-15.4%; P = .04). In DS-negative women, the risks of both ≥CIN2 and ≥CIN3 remained below the colposcopy referral threshold for all 5 years, crossing the 1-year return threshold at 3 years. Triage with p16/Ki-67 DS provides better long-term risk stratification than cytology over 5 years. The low risk of cervical precancer in p16/Ki-67 DS-negative women permits safe extension of follow-up intervals for 3 years.

Aligning ambulance dispatch priority to patient acuity: A methodology

In Victoria, Australia, Emergency Medical Service (EMS) demand has increased almost 5% per annum over the past 5 years. This may adversely affect response times to time-critical patients. Additionally, >55% of cases have received Code 1 (lights/sirens) responses. Primary telephone triage occurs using the Medical Priority Dispatch System (MPDS); however, MPDS is reported to be highly sensitive, with common over-triage. The present study describes the methodology applied to better align the response allocated to MPDS determinant codes with patient acuity. Data between October 2013 and August 2014 were extracted from the Ambulance Victoria data warehouse. The decision to allocate MPDS determinant codes to a lower response priority and/or secondary triage was based on epidemiological profiling and, in some cases, expert panel review. The review identified 105 MPDS codes receiving a Code 1 response as suitable for a Code 2 (urgent) response, and 221 Code 1 or 2 codes as suitable for secondary triage. Data analysis estimated a reduction in Code 1 responses by 28%, and an increase in the secondary triage caseload by 120%. Modelling also predicted a 2.6 percentage point improvement in the proportion of Code 1 cases attended within 15 min. Analysis of a large EMS dataset supported changes to the EMS response priority for a number of MPDS determinant codes. Such changes should improve the alignment between EMS response and patient acuity, and improve response times to time-critical patients. Other EMS with electronic data could consider testing this methodology.

Meditation, not medication, to relieve anxiety.

Lou Ann Cettina is a primary care triage nurse at Weill Cornell Medicine in New York, N.Y. She is also certified in Clinical Meditation and Imagery. The author has disclosed no financial relationships related to this article.

A Comparison Between Differently Skilled Prehospital Emergency Care Providers in Major-Incident Triage in South Africa.

This was a cross-sectional study involving differently trained prehospital providers: Advanced Life Support (ALS); Intermediate Life Support (ILS); and Basic Life Support (BLS). Participants wrote a validated 20-question pre-test before completing major-incident training. Two post-tests were also completed: a 20-question written test and a three-question face-to-face evaluation. Outcomes measured were triage accuracy and duration of triage. The effect of level of training, gender, age, previous major-incident training, and duration of service were determined. A total of 129 prehospital providers participated. The mean age was 33.4 years and 65 (50.4%) were male. Most (n=87; 67.4%) were BLS providers. The overall correct triage score pre-training was 53.9% (95% CI, 51.98 to 55.83), over-triage 31.4% (95% CI, 29.66 to 33.2), and under-triage 13.8% (95% CI, 12.55 to 12.22). Post-training, the overall correct triage score increased to 63.6% (95% CI, 61.72 to 65.44), over-triage decreased to 17.9% (95% CI, 16.47 to 19.43), and under-triage increased to 17.8% (95% CI, 16.40 to 19.36). The ALS providers had both the highest likelihood of a correct triage score post-training (odds ratio 1.21; 95% CI, 0.96-1.53) and the shortest duration of triage (median three seconds, interquartile range two to seven seconds; P=.034). Participants with prior major-incident training performed better (P=.001). Accuracy of major-incident triage across all levels of prehospital providers in South Africa is less than optimal with non-significant differences post-major-incident training. Prior major-incident training played a significant role in triage accuracy indicating that training should be an ongoing process. Although ALS providers were the quickest to complete triage, this difference was not clinically significant. The BLS and ILS providers with major-incident training can thus be utilized for primary major-incident triage allowing ALS providers to focus on more clinical roles. AlenyoAN, SmithWP, McCaulM, Van HovingDJ. A comparison between differently skilled prehospital emergency care providers in major-incident triage in South Africa. Prehosp Disaster Med. 2018;33(6):575-580.

Primary mass casualty incident triage: evidence for the benefit of yearly brief re-training from a simulation study

BackgroundTriage is a mainstay of early mass casualty incident (MCI) management. Standardized triage protocols aim at providing valid and reproducible results and, thus, improve triage quality. To date, there is little data supporting the extent and content of training and re-training on using such triage protocols within the Emergency Medical Services (EMS). The study objective was to assess the decline in triage skills indicating a minimum time interval for re-training. In addition, the effect of a one-hour repeating lesson on triage quality was analyzed.MethodsA dummy based trial on primary MCI triage with yearly follow-up after initial training using the ASAV algorithm (Amberg-Schwandorf Algorithm for Primary Triage) was undertaken. Triage was assessed concerning accuracy, sensitivity, specificity, over-triage, under-triage, time requirement, and a comprehensive performance measure. A subgroup analysis of professional paramedics was made.ResultsNine hundred ninety triage procedures performed by 51 providers were analyzed. At 1 year after initial training, triage accuracy and overall performance dropped significantly. Professional paramedic’s rate of correctly assigned triage categories deteriorated from 84 to 71%, and the overall performance score decreased from 95 to 90 points (maximum = 100). The observed decline in triage performance at 1 year after education made it necessary to conduct re-training. A brief didactic lecture of 45 min duration increased accuracy to 88% and the overall performance measure to 97.ConclusionsTo improve disaster preparedness, triage skills should be refreshed yearly by a brief re-education of all EMS providers.

Supporting decision-making in patient risk assessment using a hierarchical fuzzy model

In this paper, we present a hierarchical fuzzy model to support patient triage in primary health care. In developing countries like Brazil, public health must usually cover degraded territories; thus, allocating patients to health services is very hard due low availability, enormous demands, and the complexity of assessing patient conditions—which must account for more then physical aspects of patients, but their social conditions as well. This approach combines the fuzzy set theory under the AHP framework in order to illustrate the inherent imprecision in the evaluation of patient risk. Fieldwork was conducted in a primary healthcare facility in Brazil to demonstrate the applicability of the proposed approach. The proposed approach represents criterion in the formation of patients’ risk scores encompassing important aspects of primary care triage such as the structure of families, the conditions of residences, exposure to urban violence, and other aspects of patients’ lives, taking the risk assessment beyond the simple evaluation of symptoms and physiological conditions. Our approach focuses on enforcing decisions of public health workers by improving the awareness of patients’ conditions, which we believe will make the employment of triage criteria uniform and capable of showing tendencies on patients’ risks, as well as avoiding bias in patient triage.

Telehealth at the US Department of Veterans Affairs after Hurricane Sandy

Background Like other integrated health systems, the US Department of Veterans Affairs has widely implemented telehealth during the past decade to improve access to care for its patient population. During major crises, the US Department of Veterans Affairs has the potential to transition healthcare delivery from traditional care to telecare. This paper identifies the types of Veterans Affairs telehealth services used during Hurricane Sandy (2012), and examines the patient characteristics of those users. Methods This study conducted both quantitative and qualitative analyses. Veterans Affairs administrative and clinical data files were used to illustrate the use of telehealth services 12 months pre- and 12 months post- Hurricane Sandy. In-person interviews with 31 key informants at the Manhattan Veterans Affairs Medical Center three-months post- Hurricane Sandy were used to identify major themes related to telecare. Results During the seven-month period of hospital closure at the Manhattan Veterans Affairs Medical Center after Hurricane Sandy, in-person patient visits decreased dramatically while telehealth visits increased substantially, suggesting that telecare was used in lieu of in-person care for some vulnerable patients. The most commonly used types of Veterans Affairs telehealth services included primary care, triage, mental health, home health, and ancillary services. Using qualitative analyses, three themes emerged from the interviews regarding the use of Veterans Affairs telecare post- Hurricane Sandy: patient safety, provision of telecare, and patient outreach. Conclusion Telehealth offers the potential to improve post-disaster access to and coordination of care. More information is needed to better understand how telehealth can change the processes and outcomes during disasters. Future studies should also evaluate key elements, such as adequate resources, regulatory and technology issues, workflow integration, provider resistance, diagnostic fidelity and confidentiality, all of which are critical to telehealth success during disasters and other crises.