Remote Triage Research Articles

TeleTriage at a high-volume specialty cancer center: Aligning patient volume and need with available resource.

2085 Background: The Memorial Sloan Kettering (MSK) Urgent Care Center (UCC) functions as the emergency room for MSK. With 23,000+ visits annually, increasing volume and acuity means more days over capacity. Patients experience increased wait times to see clinicians, complete evaluation, and transfer to an inpatient bed. The UCC TeleTriage Program is a remote triage program which aims to align patient volume and need with available resources, improve patient experience, and streamline flow through the UCC. By managing resources more efficiently and expediting initial evaluation, the program promotes timely patient access to care, while maintaining MSK's standard of care. Methods: UCC TeleTriage began July 2018 with the Gastrointestinal Medical Oncology service. The Service Nurse refers patients to TeleTriage on weekdays, from 9a.m.- 4:30p.m. The TeleTriage clinician contacts each patient within 30 minutes of referral, takes the history, and determines the initial plan. Patients are directed to a local ER, clinic, or UCC based on level of acuity, real-time GPS, and specific need. For stable patients coming to UCC, TeleTriage focuses on initiating testing prior to registration in UCC. Results: TeleTriage patients have (virtual) contact with a UCC clinician within 30 minutes of referral, whereas non-TeleTriage patients wait 110 minutes or more. TeleTriage patients are discharged from UCC up to 42 minutes more rapidly. TeleTriage patients who receive imaging prior to registration in UCC receive a final disposition up to 93 minutes sooner. About 4% of TeleTriage patients are managed at home. In a small number of TeleTriage patients with severe complications of cancer-treatment, significant morbidity was avoided due to early intervention and coordination of care. Conclusions: TeleTriage patients have contact with a UCC clinician measurably faster than non-TeleTriage patients. Their evaluation is also started earlier. By managing less acute patients at remote sites or at home, TeleTriage can help patients avoid unnecessary travel, (time) expenditure, and hospital contact. TeleTriage patients who come to UCC, spend less time in UCC than non-TeleTriage patients and they discharge faster. By utilizing cancer care expertise, TeleTriage can significantly impact patient outcomes and utilize resources more effectively.

The new coronavirus disease: what do we know so far?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus that causes the new disease COVID-19. Symptoms range from mild to severe with a higher incidence of severe cases in patients with risk factors such as older age and comorbidities. COVID-19 is mainly spread through the inhalation of respiratory droplets from coughing or sneezing or via contact with droplet-contaminated surfaces. Paramedics should be aware that some aerosol-generating procedures may put them at a higher risk of contracting the virus via possible airborne transmission. Use of remote triage clinical assessment is likely to increase as a result of the pandemic. There is no curative drug treatment for the virus and some medications may exacerbate its effects or make patients more susceptible to it. Evidence and guidelines are evolving on SARS-CoV-2 and COVID-19. Paramedics should keep up to date with the latest clinical guidance from their employers.

Remote triage in paediatric critical care: A Canadian provincial-wide cohort study.

To describe remote triage of 'potentially' critically ill or injured children in a western Canadian province and to examine the associated factors with 'missings' in vital sign items recorded in centralized telephone triage consultations. This is a provincial-wide prospective cohort study. We included all children under 17 years of age consulted through the central transport coordination centres in Alberta from June 2016 to July 2017. We labeled a value as 'missing' when the actual value was not identified in the audio records. In total, 429 cases were included in this study. The median duration of triage calls was 6.8 minutes. Although the patients' demographics and primary diagnoses were similar, backgrounds of the referring physicians and hospitals were significantly different between the two cohorts (i.e., patients referred to Calgary versus Edmonton). The proportion of 'missings' among the vital sign items varied significantly, in which capillary refilling time (60%), pupils (86%), Glasgow Coma Scale (GCS) (79%), and level of respiratory effort (50%) were not well recorded, whereas heart rate (proportion of 'missings': 12%), SpO2 (20%), and respiratory rate (26%) were recorded reasonably well. The lower proportion of 'missings' was observed in older aged patients for several vital sign items including systolic blood pressure and GCS. The proportion of missing vital signs recorded varied significantly. The 'missings' could be associated with referring physician's background and patients' demographics such as 'age' that should be considered for the improvement of triage quality in the future.

Effectiveness of Acute Care Remote Triage Systems: a Systematic Review

Technology-based systems can facilitate remote decision-making to triage patients to the appropriate level of care. Despite technologic advances, the effects of implementation of these systems on patient and utilization outcomes are unclear. We evaluated the effects of remote triage systems on healthcare utilization, case resolution, and patient safety outcomes. English-language searches of MEDLINE (via PubMed), EMBASE, and CINAHL were performed from inception until July 2018. Randomized and nonrandomized comparative studies of remote triage services that reported healthcare utilization, case resolution, and patient safety outcomes were included. Two reviewers assessed study and intervention characteristics independently for study quality, strength of evidence, and risk of bias. The literature search identified 5026 articles, of which eight met eligibility criteria. Five randomized, two controlled before-and-after, and one interrupted time series study assessed 3 categories of remote triage services: mode of delivery, triage professional type, and system organizational level. No study evaluated any other delivery mode other than telephone and in-person. Meta-analyses were unable to be performed because of study design and outcome heterogeneity; therefore, we narratively synthesized data. Overall, most studies did not demonstrate a decrease in primary care (PC) or emergency department (ED) utilization, with some studies showing a significant increase. Evidence suggested local, practice-based triage systems have greater case resolution and refer fewer patients to PC or ED services than regional/national systems. No study identified statistically significant differences in safety outcomes. Our review found limited evidence that remote triage reduces the burden of PC or ED utilization. However, remote triage by telephone can produce a high rate of call resolution and appears to be safe. Further study of other remote triage modalities is needed to realize the promise of remote triage services in optimizing healthcare outcomes. This study was registered and followed a published protocol (PROSPERO: CRD42019112262).

Medical Students' Response to the COVID-19 Pandemic: Experience and Recommendations from Five Countries.

The COVID-19 pandemic has provided medical students around the globe with unique challenges and opportunities. With formal medical school education and training interrupted, medical students sought innovative ways to contribute to their health-care systems and communities. Their responses could be organized into three categories: clinical (remote clinical care and triage, helping in COVID testing or treatment centers, and contact tracing), nonclinical (PPE acquisition, COVID-related policy and research, and supporting vulnerable groups in the community), and educational (creating materials to educate peers, the community, or community health workers). We present examples of responses developed by students from five countries: Brazil, Nepal, the Philippines, Rwanda, and the United States. We discuss the challenges, outcomes, and recommendations for each case. One critical opportunity for growth is strengthening international collaborations. We hope that these examples provide a framework for medical students to plan coordinated and effective responses to the next pandemic, and further medical student engagement in international collaboration.

Concussion and Mild-Traumatic Brain Injury in Rural Settings: Epidemiology and Specific Health Care Considerations.

Background Mild-traumatic brain injury (mTBI) and concussions cause significant morbidity. To date, synthesis of specific health care disparities and gaps in care for rural mTBI/concussion patients remains needed. Methods A comprehensive literature search was performed using PubMed database for English articles with keywords “rural” and (“concussion” or “mild traumatic brain injury”) from 1991 to 2019. Eighteen articles focusing on rural epidemiology ( n = 5), management/cost ( n = 5), military ( n = 2), and concussion prevention/return to play ( n = 6) were included. Results mTBI/concussion incidence was higher in rural compared with urban areas. Compared with urban patients, rural patients were at increased risk for vehicular injuries, lifetime number of concussions, admissions for observation without neuroimaging, and injury-related costs. Rural patients were less likely to utilize ambulatory and mental health services following mTBI/concussion. Rural secondary schools had decreased access to certified personnel for concussion evaluation, and decreased use of standardized assessment instruments/neurocognitive testing. While school coaches were aware of return-to-play laws, mTBI/concussion education rates for athletes and parents were suboptimal in both settings. Rural veterans were at increased risk for postconcussive symptoms and posttraumatic stress. Telemedicine in rural/low-resource areas is an emerging tool for rapid evaluation, triage, and follow-up. Conclusions Rural patients are at unique risk for mTBI/concussions and health care costs. Barriers to care include lower socioeconomic status, longer distances to regional medical center, and decreased availability of neuroimaging and consultants. Due to socioeconomic and distance barriers, rural schools are less able to recruit personnel certified for concussion evaluation. Telemedicine is an emerging tool for remote triage and evaluation.

Outsourcing the Remote Management of Cardiac Implantable Electronic Devices: Medical Care Quality Improvement Project.

BackgroundRemote management is partially replacing routine follow-up in patients implanted with cardiac implantable electronic devices (CIEDs). Although it reduces clinical staff time compared with standard in-office follow-up, a new definition of roles and responsibilities may be needed to review remote transmissions in an effective, efficient, and timely manner. Whether remote triage may be outsourced to an external remote monitoring center (ERMC) is still unclear.ObjectiveThe aim of this health care quality improvement project was to evaluate the feasibility of outsourcing remote triage to an ERMC to improve patient care and health care resource utilization.MethodsPatients (N=153) with implanted CIEDs were followed up for 8 months. An ERMC composed of nurses and physicians reviewed remote transmissions daily following a specific remote monitoring (RM) protocol. A 6-month benchmarking phase where patients’ transmissions were managed directly by hospital staff was evaluated as a term of comparison.ResultsA total of 654 transmissions were recorded in the RM system and managed by the ERMC team within 2 working days, showing a significant time reduction compared with standard RM management (100% vs 11%, respectively, within 2 days; P<.001). A total of 84.3% (551/654) of the transmissions did not include a prioritized event and did not require escalation to the hospital clinician. High priority was assigned to 2.3% (15/654) of transmissions, which were communicated to the hospital team by email within 1 working day. Nonurgent device status events occurred in 88 cases and were communicated to the hospital within 2 working days. Of these, 11% (10/88) were followed by a hospitalization.ConclusionsThe outsourcing of RM management to an ERMC safely provides efficacy and efficiency gains in patients’ care compared with a standard in-hospital management. Moreover, the externalization of RM management could be a key tool for saving dedicated staff and facility time with possible positive economic impact.Trial RegistrationClinicalTrials.gov NCT01007474; http://clinicaltrials.gov/ct2/show/NCT01007474

P3769Rapid referral to a one-stop AF clinic following possible AF detection by community pharmacists leads to early diagnosis and appropriate anticoagulant treatment

Abstract Background Atrial fibrillation is the most common cardiac arrhythmia globally, responsible for one third of ischaemic strokes, often resulting in death or incapacity. This condition, frequently asymptomatic is estimated to be up to 50% undiagnosed. Reducing this risk with appropriate detection and management strategies offers substantial economic and patient benefits. Community pharmacists have been shown to be an accessible healthcare professional capable of detecting atrial fibrillation. Concerns raised utilising community pharmacists is the additional workload for primary care physicians, and lack of a clear pathway to ensure patients are adequate followed with assurance of initiation of anticoagulation therapy. Purpose To assess the feasibility of screening by community pharmacists with onward referral to an innovative one-stop AF clinic to enable identification of new cases of AF and subsequent initiation of anticoagulation within 2 weeks. Methods 21 pharmacies were recruited and trained on pathophysiology of AF and demonstration of pulse taking using pulse check and Kardia mobile device. Any person walking into a community pharmacy aged ≥65 years was offered a free pulse check. For any irregularity detected, individualised counselling was offered with a referral made to a one-stop AF clinic for confirmation and initiation of anticoagulation. Written patient consent was obtained. Results 672 people were recruited with an average age of 69±3.5 years and 58% female (n=389). There was a history of hypertension in 618 (92%) and diabetes in 242 (36%), the most common co-morbidities. 45 people were referred following an irregular pulse or abnormal ECG rhythm strip, of whom 11 (1.6% of total population) had a confirmed AF diagnosis within 30 day follow up. An additional 8 cases with known AF not receiving anticoagulation termed (actionable AF) were also referred. All 19 cases of new or untreated AF were prescribed anticoagulation by the one stop clinic in accordance with guideline recommendations Conclusions ESC guidance recommends opportunistic screening for AF by pulse taking or ECG rhythm strip in patients ≥65 years of age. The 1.6% incidence of new AF was in accordance with meta-analyses identifying 1.4% of those aged ≥65 on a single time point check for presence of AF. Our model utilises the un-tapped skills of community pharmacy to deliver pulse checks of ECG rhythm recordings in an accessible primary care location with a clear referral pathway that is effective in early review and ensuring suitable patients receive anticoagulation. The innovative pathway could provide remote triage at scale and help address the missing people with undiagnosed and actionable AF by opening new channels for identification by healthcare professionals managing long term conditions who like pharmacists have not been considered suitable healthcare professionals due to lack of an established pathway for confirming the potential diagnosis of AF. Acknowledgement/Funding NHS England Test Bed Programme

Preliminary study on the management model of smart triage diagnosis of nervous system diseases

Objective To develop an effective decision tree management model for smart triage of nervous system diseases based on artificial neural networks and Bayesian decision theory. Methods Bayesian decision theory was used as the theoretical basis, and convolutional neural network was used to complete the rapid specialist / sub-specialist machine learning. For the specialist or sub-specialist triage data, circular neural network and Bayesian algorithm were performed to complete the probability distribution and convergence of disease symptoms and diagnosis. Results The decision tree management model and theoretical demonstration were established. According to the characteristics of the transfer learning, the rapid learning of nervous system diseases and accurate triage system, and the remote smart triage system were successfully constructed. Conclusions The management model could provide theoretical references for further use, and alleviate to some extent the currently high rate of outpatient appointment withdrawal and changes. Key words: Nervous system diseases; Smart triage; Artificial neural network; Bayesian decision theory; Management model

Based Multiple Heterogeneous Wearable Sensors: A Smart Real-Time Health Monitoring Structured for Hospitals Distributor

This paper proposes a smart real-time health monitoring structured for hospitals' distributor based on wearable health data sensors. Health data were received from multiple heterogeneous wearable sensors, such as electrocardiogram (ECG), oxygen saturation sensor (SpO2), blood pressure monitor, and non-sensory measurement (text frame), from 500 patients with different symptoms. Triage level and healthcare services were identified based on the new four-level remote triage and package localization (4LRTPL). The numbers of healthcare services that represent hospital status were collected from 12 hospitals located in Baghdad city. This study constructed a decision matrix based on the crossover of “multi-healthcare services” and “hospital list” within Tier 4. The hospitals were then ranked using multi-criteria decision-making (MCDM) techniques, namely, integrated analytic hierarchy process (AHP) and vlsekriterijumskaoptimizacija i kompromisnoresenje (VIKOR). Mean ± standard deviation was computed to ensure that the hospital ranking undergoes systematic ranking for objective validation. This research provided scenarios and checklist benchmarking to evaluate the proposed and existing health recommender frameworks. Results corroborated that: 1) the integration of AHP and VIKOR effectively solved hospital selection problems; 2) in the objective validation, significant differences were recognized between the scores of groups, indicating that the ranking results were identical; 3) in evaluation, the proposed framework exhibited an advantage over the benchmark framework with a percentage of 56.25%; and 4) hospitals with multiple healthcare services received the highest ranks, whereas hospitals with fewer healthcare services received low ranks.

A data-driven artificial intelligence model for remote triage in the prehospital environment.

In a mass casualty incident, the factors that determine the survival rate of injured patients are diverse, but one of the key factors is the time for triage. Additionally, the main factor that determines the time of triage is the number of medical personnel. However, when relying on a small number of medical personnel, the ability to increase survivability is limited. Therefore, developing a classification model for survival prediction that can quickly and precisely triage via wearable devices without medical personnel is important. In this study, we designed a consciousness index to substitute the factor by manpower and improved the classification accuracy by applying a machine learning algorithm. First, logistic regression analysis using vital signs and a consciousness index capable of remote monitoring through wearable devices confirmed the high efficiency of the consciousness index. We then developed a classification model with high accuracy which corresponds to existing injury severity scoring systems through the machine learning algorithms. We extracted 460,865 cases which met our criteria for developing the survival prediction from the national sample project in the national trauma databank which contains 408,316 cases of blunt injury and 52,549 cases of penetrating injury. Among the dataset, 17,918 (3.9%) cases died while the other survived. The AUCs with 95% confidence intervals (CIs) for the different models with the proposed simplified consciousness score as follows: RTS (as baseline), 0.78 (95% CI = 0.775 to 0.785); logistic regression, 0.87 (95% CI = 0.862 to 0.870); random forest, 0.87 (95% CI = 0.862 to 0.872); deep neural network, 0.89 (95% CI = 0.882 to 0.890). As a result, we confirmed the possibility of remote triage using a wearable device. It is expected that the time required for triage can be effectively reduced by using the developed classification model of survival prediction.

Consensus guideline: Pre-hospital management of decompression illness: expert review of key principles and controversies

(Mitchell SJ, Bennett MH, Bryson P, Butler FK, Doolette DJ, Holm JR, Kot J, Lafère P. Pre-hospital management of decompression illness: expert review of key principles and controversies. Diving and Hyperbaric Medicine. 2018 March;48(1):45е.doi.10.28920/dhm48.1.45-55.) Guidelines for the pre-hospital management of decompression illness (DCI) had not been formally revised since the 2004 Divers Alert Network/Undersea and Hyperbaric Medical Society workshop held in Sydney, entitled "Management of mild or marginal decompression illness in remote locations." A contemporary review was initiated by the Divers Alert Network and undertaken by a multinational committee with members from Australasia, the USA and Europe. The process began with literature reviews by designated committee members on: the diagnosis of DCI; first aid strategies for DCI; remote triage of possible DCI victims by diving medicine experts; evacuation of DCI victims; effect of delay to recompression in DCI; pitfalls in management when DCI victims present at hospitals without diving medicine expertise and in-water recompression. This was followed by presentation of those reviews at a dedicated workshop at the 2017 UHMS Annual Scientific Meeting, discussion by registrants at that workshop and, finally, several committee meetings to formulate statements addressing points considered of prime importance to the management of DCI in the field. The committee placed particular emphasis on resolving controversies around the definition of "mild DCI" arising over 12 years of practical application of the 2004 workshop's findings, and on the controversial issue of in-water recompression. The guideline statements are promulgated in this paper. The full workshop proceedings are in preparation for publication.

Pre-hospital management of decompression illness: expert review of key principles and controversies.

Guidelines for the pre-hospital management of decompression illness (DCI) had not been formally revised since the 2004 Divers Alert Network/Undersea and Hyperbaric Medical Society workshop held in Sydney, entitled "Management of mild or marginal decompression illness in remote locations". A contemporary review was initiated by the Diver's Alert Network and undertaken by a multinational committee with members from Australasia, the USA and Europe. The process began with literature reviews by designated committee members on: the diagnosis of DCI; first aid strategies for DCI; remote triage of possible DCI victims by diving medicine experts; evacuation of DCI victims; effect of delay to recompression in DCI; pitfalls in management when DCI victims present at hospitals without diving medicine expertise and in-water recompression. This was followed by presentation of those reviews at a dedicated workshop at the 2017 UHMS Annual Meeting, discussion by registrants at that workshop and finally several committee meetings to formulate statements addressing points considered of prime importance to the management of DCI in the field. The committee placed particular emphasis on resolving controversies around the definition of "mild DCI" arising over 12 years of practical application of the 2004 workshop's findings, and on the controversial issue of in-water recompression. The guideline statements are promulgated in this paper. The full workshop proceedings are in preparation for publication.

An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

BackgroundOral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.Research questionsCan an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?DesignA mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.SettingThe ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.ParticipantsPatients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.InterventionsA consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.Main outcome measuresDiagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.ResultsIn the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.ConclusionsImplementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.Study limitationsThe geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.Future workThe findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Point-of-Care Ultrasound for Pulmonary Concerns in Remote Spaceflight Triage Environments.

With the development of the commercial space industry, growing numbers of spaceflight participants will engage in activities with a risk for pulmonary injuries, including pneumothorax, ebullism, and decompression sickness, as well as other concomitant trauma. Medical triage capabilities for mishaps involving pulmonary conditions have not been systematically reviewed. Recent studies have advocated the use of point-of-care ultrasound to screen for lung injury or illness. The operational utility of portable ultrasound systems in disaster relief and other austere settings may be relevant to commercial spaceflight. A systematic review of published literature was conducted concerning the use of point-of-care pulmonary ultrasound techniques in austere environments, including suggested examination protocols for triage and diagnosis. Recent studies support the utility of pulmonary ultrasound examinations when performed by skilled operators, and comparability of the results to computed tomography and chest radiography for certain conditions, with important implications for trauma management in austere environments. Pulmonary injury and illness are among the potential health risks facing spaceflight participants. Implementation of point-of-care ultrasound protocols could aid in the rapid diagnosis, triage, and treatment of such conditions. Though operator-dependent, ultrasound, with proper training, experience, and equipment, could be a valuable tool in the hands of a first responder supporting remote spaceflight operations.Johansen BD, Blue RS, Castleberry TL, Antonsen EL, Vanderploeg JM. Point-of-care ultrasound for pulmonary concerns in remote spaceflight triage environments. Aerosp Med Hum Perform. 2018; 89(2):122-129.

Supply and Perceived Demand for Teleophthalmology in Triage and Consultations in California Emergency Departments.

Determining the perceived supply and potential demand for teleophthalmology in emergency departments could help mitigate coverage gaps in emergency ophthalmic care. To evaluate the perceived current need for and availability of ophthalmologist coverage in California emergency departments and the potential effect of telemedicine for ophthalmology triage and consultation. Surveys were remotely administered to 187 of the 254 emergency departments throughout California via the telephone and Internet from June 30 to September 23, 2014. Emergency department nurse managers and physicians from all emergency departments listed in the California Office of Statewide Health Planning and Development database were individually surveyed to assess facility characteristics and resources as well as the perceived usefulness of teleophthalmology consultation. Data analysis was conducted from June 30, 2014, to March 11, 2015. Perceived availability of ophthalmology consultation coverage and perceived effect of telemedicine ophthalmology consultation at each facility. Of the 187 emergency departments surveyed, 18 of 37 rural facilities (48.6%) reported availability of emergency ophthalmology coverage, compared with 112 of 150 nonrural facilities (74.7%). Rural facilities reported a mean (SD) of 23.72 (14.15) miles between the facility and referral location, while nonrural facilities reported a mean of 4.41 (10.23) miles (19.3% difference). On a scale of 1 to 5 (where 1 signifies very low value and 5 signifies very high value), 124 of 187 nurse managers (66.3%) and 80 of 121 physicians (66.1%) rated teleophthalmology as having high or very high value for triage purposes. The most frequently cited potential advantage of emergency teleophthalmology was assistance in patient triage and immediate real-time electronic communication, and the most frequently cited potential disadvantages were unknown cost of contracting and maintenance and concern that eye trauma might make photographs or videos less conclusive. Availability of ophthalmology coverage for emergency eye care is limited, particularly among rural emergency departments in California. Surveyed emergency department nurse managers and physicians indicated moderately high interest and perceived value for a teleophthalmology solution for remote triage and consultation. Overall, the study suggests that teleophthalmology could play a role in mitigating coverage gaps in emergency ophthalmic care and could be further investigated through similar studies in other regions.

The accuracy and consistency of rural, remote and outpost triage nurse decision making in one Western Australia Country Health Service Region.

The Australasian Triage Scale aims to ensure that the triage category allocated, reflects the urgency with which the patient needs medical assistance. This is dependent on triage nurse accuracy in decision making. The Australasian Triage Scale also aims to facilitate triage decision consistency between individuals and organisations. Various studies have explored the accuracy and consistency of triage decisions throughout Australia, yet no studies have specifically focussed on triage decision making in rural health services. Further, no standard has been identified by which accuracy or consistency should be measured. Australian emergency departments are measured against a set of standard performance indicators, including time from triage to patient review, and patient length of stay. There are currently no performance indicators for triage consistency. An online questionnaire was developed to collect demographic data and measure triage accuracy and consistency. The questionnaire utilised previously validated triage scenarios.(1) Triage decision accuracy was measured, and consistency was compared by health site type using Fleiss' kappa. Forty-six triage nurses participated in this study. The accuracy of participants' triage decision-making decreased with each less urgent triage category. Post-graduate qualifications had no bearing on triage accuracy. There was no significant difference in the consistency of decision-making between paediatric and adult scenarios. Overall inter-rater agreement using Fleiss' kappa coefficient, was 0.4. This represents a fair-to-good level of inter-rater agreement. A standard definition of accuracy and consistency in triage nurse decision making is required. Inaccurate triage decisions can result in increased morbidity and mortality. It is recommended that emergency department performance indicator thresholds be utilised as a benchmark for national triage consistency.

Emergency Department Management in Lazio, Italy

The assignment of service requests to emergency departments is of paramount importance both from a life-threatening and an economical viewpoints. In the process of a more general project that aims at defining optimal allocation policies of patients to regional hospital network facilities (together with the potential reorganization of the facilities), the Department of Epidemiology of the Regional Health Service of Lazio, Italy, was interested in obtaining a completely offline picture of the effect of an optimal assignment of requests to emergency departments. This is in the spirit of evaluating the so-called Price of Anarchy, where the fully centralized (admittedly unrealistic) allocation is used as a reference for both the state-of-the-art completely decentralized approach and future reorganization ideas.We have implemented and tested with real-world data of all service requests of 2012 a mixed-integer programming model that computes such an optimal request allocation by minimizing travel and waiting times and penalizing workload unbalance among emergency departments in the region. Within the development process we have studied special cases and relaxations of the complete model showing interesting mathematical properties that are, in turn, useful from a practical viewpoint, for example, in obtaining a real-time version of the approach.The present study is an important, quantitative step in the evaluation of centralized allocation strategies like remote triage that could have a remarkable impact in making the allocation process much more efficient and effective. More precisely, the developed methodology as well as the software tools are currently used by the DEP-Lazio for the reorganization of the regional networks of emergency healthcare.

Multi-sources data fusion framework for remote triage prioritization in telehealth.

The healthcare industry is streamlining processes to offer more timely and effective services to all patients. Computerized software algorithm and smart devices can streamline the relation between users and doctors by providing more services inside the healthcare telemonitoring systems. This paper proposes a multi-sources framework to support advanced healthcare applications. The proposed framework named Multi Sources Healthcare Architecture (MSHA) considers multi-sources: sensors (ECG, SpO2 and Blood Pressure) and text-based inputs from wireless and pervasive devices of Wireless Body Area Network. The proposed framework is used to improve the healthcare scalability efficiency by enhancing the remote triaging and remote prioritization processes for the patients. The proposed framework is also used to provide intelligent services over telemonitoring healthcare services systems by using data fusion method and prioritization technique. As telemonitoring system consists of three tiers (Sensors/ sources, Base station and Server), the simulation of the MSHA algorithm in the base station is demonstrated in this paper. The achievement of a high level of accuracy in the prioritization and triaging patients remotely, is set to be our main goal. Meanwhile, the role of multi sources data fusion in the telemonitoring healthcare services systems has been demonstrated. In addition to that, we discuss how the proposed framework can be applied in a healthcare telemonitoring scenario. Simulation results, for different symptoms relate to different emergency levels of heart chronic diseases, demonstrate the superiority of our algorithm compared with conventional algorithms in terms of classify and prioritize the patients remotely.

Assisting older people: from robots to drones

In order to provide assistance to older people, robots have been proposed, but projects carried out in that field identified barriers such as difficulties in moving or restricted view, thus limiting the quality of a remote medical triage. Unmanned aerial vehicles (UAV) commonly known as drones may bring an important added-value in that domain. Drones are now used in civilian purposes and many indoor models are commercialised. Their development in the near future for the health area (mainly for surveillance purposes) will benefit older adults and thus empower older persons as well as disabled persons to remain independent.