Triage Priorities Research Articles

Tradeoffs in Triage of Motor Vehicle Trauma by Rural 911 Emergency Medical Services Practitioners.

Identification and triage of severely injured patients to trauma centers is paramount to survival. Many patients are undertriaged in rural areas and do not receive proper care. The decision-making processes involved in triage are not well understood and should be assessed to improve the triage process and outcomes. Triage decision-making processes were explored through emergency medical services (EMS) practitioner focus groups and a discrete choice experiment (DCE). Attributes of trauma determined from focus groups and the literature included patient demography, injury mechanism, and trauma center distance. DCE data were analyzed using mixed logit models. High-risk mechanism, decreased age, multiple comorbidities, and pregnancy were found to increase the preference for triage. Greater trauma center distance was found to decrease preference for triage, but practitioners were willing to trade off up to 2 h of travel time to transport a third-trimester pregnancy and 48 min of travel time to transport a 25-y-old than they would a 50-y-old with the same comorbidities, injuries, and stability. Our findings suggest that current forms of EMS protocols may not be appropriately tailored to support the mechanisms underlying practitioner decision making. Public health professionals and researchers should consider using DCEs to better understand EMS practitioner decision making and identify structures and incentives that may improve patient outcomes and optimally guide appropriate triage decisions. Discrete choice experiments are an effective method to elicit prehospital practitioners' preferences around transport of the traumatized patient.Practitioner biases observed in EMS transport data are recovered in stated preference models incorporating individual preference heterogeneity.There is a discrepancy between the triage priorities recommended by protocol and those measured from prehospital practitioners' decisions-this may have implications in over- and undertriage rates and prehospital protocol design.

CRUSH SYNDROME IN EARTHQUAKES - STAY AND PLAY OR LOAD AND GO?

Earthquakes are unpredictable natural disasters accompanied by material damage and many victims. In the case of a person remaining trapped under the collapsed material, the development of crush syndrome can occur. Crush syndrome is the result of traumatic rhabdomyolysis and is present in 2%-15% of all injured persons in an earthquake. It is not easy to recognize, and proper treatment is challenging. Persons who have a clear crush injury and/or have been immobilized for more than four hours should be considered potential victims of crush syndrome. Therefore, knowledge about crush syndrome must be comprehensive and accessible to all parties involved. In this paper, the management of crush syndrome victims, which includes the principles of triage, and medical and logistic principles as well, is presented. Triage principles are presented at the level of triage priorities, places, and diagnoses. Medical principles, crucial for crush syndrome, are presented regarding the duration of compression and time before or after extraction of the patient. Logistic principles provide an overview of the priorities and modes of transport in relation to distance of health institutions, and the importance of management and education associated with crush syndrome. Each country with recognized disasters (natural or man-made) in which crush-related victims are expected, will benefit if the knowledge about triage, medical and logistic principles for crush syndrome is incorporated in their educational programs and regularly updated.

Generative Dissensus in a Youth-Led Coalition-Building Enterprise

Context: Rooted in the principles of Youth Participatory Action Research (YPAR), this article explores how a team of youth community activists extended their coalition virtually to produce a bill of demands for structural social change in their city and its surrounding county. Focus of Study: Our inquiry focuses on how the youth’s dialectic goal of arriving at consensus (through debate fiercely, and intentionally, tied to the country’s own internal reckonings) loomed, uncomfortably at times, over the dialogic process of inviting youth from across the city to share experiences, exchange ideas, and build relationships. Setting: The youth’s coalitional work extended outward from the Yamacraw Center, a community literacy center and social justice organization based in a historic coastal city in the southern United States. Participants: The primary team, reported on here, was made up of eight youth researchers and two adult allies/co-researchers responsible for supporting youth as they engaged in YPAR. Research Design: Our study is a reflexive thematic analysis of the interplay between youth during 11 planning and organizing sessions. Data Collection: The data collected for this study are video digital Google Hangout meetings recorded over a five-month period. Findings: Our findings consider key strategies youth exhibited in coming together to hear one another, triage priorities, and carefully attend to the ways they needed to craft their arguments to be taken seriously. Conclusions: We highlight the importance of process in building youth capacity, detail discursive moves youth made to maintain critical momentum, and situate the project within a larger ethos that recognizes the immanent value of cultivating youth capacity to engage in fierce and humanizing exchanges with their peers in pursuit of collective progress.

Predicting the Need for Intubation among COVID-19 Patients Using Machine Learning Algorithms: A Single-Center Study.

Background: Owing to the shortage of ventilators, there is a crucial demand for an objective and accurate prognosis for 2019 coronavirus disease (COVID-19) critical patients, which may necessitate a mechanical ventilator (MV). This study aimed to construct a predictive model using machine learning (ML) algorithms for frontline clinicians to better triage endangered patients and priorities who would need MV. Methods: In this retrospective single-center study, the data of 482 COVID-19 patients from February 9, 2020, to December 20, 2020, were analyzed by several ML algorithms including, multi-layer perception (MLP), logistic regression (LR), J-48 decision tree, and Naïve Bayes (NB). First, the most important clinical variables were identified using the Chi-square test at P < 0.01. Then, by comparing the ML algorithms' performance using some evaluation criteria, including TP-Rate, FP-Rate, precision, recall, F-Score, MCC, and Kappa, the best performing one was identified. Results: Predictive models were trained using 15 validated features, including cough, contusion, oxygen therapy, dyspnea, loss of taste, rhinorrhea, blood pressure, absolute lymphocyte count, pleural fluid, activated partial thromboplastin time, blood glucose, white cell count, cardiac diseases, length of hospitalization, and other underline diseases. The results indicated the J-48 with F-score = 0.868 and AUC = 0.892 yielded the best performance for predicting intubation requirement. Conclusion: ML algorithms are potentials to improve traditional clinical criteria to forecast the necessity for intubation in COVID-19 in-hospital patients. Such ML-based prediction models may help physicians with optimizing the timing of intubation, better sharing of MV resources and personnel, and increase patient clinical status.

Risk of mortality and cardiopulmonary arrest in critical patients presenting to the emergency department using machine learning and natural language processing.

Emergency department triage is the first point in time when a patient’s acuity level is determined. The time to assign a priority at triage is short and it is vital to accurately stratify patients at this stage, since under-triage can lead to increased morbidity, mortality and costs. Our aim was to present a model that can assist healthcare professionals in triage decision making, namely in the stratification of patients through the risk prediction of a composite critical outcome—mortality and cardiopulmonary arrest. Our study cohort consisted of 235826 adult patients triaged at a Portuguese Emergency Department from 2012 to 2016. Patients were assigned to emergent, very urgent or urgent priorities of the Manchester Triage System (MTS). Demographics, clinical variables routinely collected at triage and the patients’ chief complaint were used. Logistic regression, random forests and extreme gradient boosting were developed using all available variables. The term frequency–inverse document frequency (TF-IDF) natural language processing weighting factor was applied to vectorize the chief complaint. Stratified random sampling was used to split the data into train (70%) and test (30%) data sets. Ten-fold cross validation was performed in train to optimize model hyper-parameters. The performance obtained with the best model was compared against the reference model—a regularized logistic regression trained using only triage priorities. Extreme gradient boosting exhibited good calibration properties and yielded areas under the receiver operating characteristic and precision-recall curves of 0.96 (95% CI 0.95-0.97) and 0.31 (95% CI 0.26-0.36), respectively. The predictors ranked with higher importance by this model were the Glasgow coma score, the patients’ age, pulse oximetry and arrival mode. Compared to the reference, the extreme gradient boosting model using clinical variables and the chief complaint presented higher recall for patients assigned MTS-3 and can identify those who are at risk of the composite outcome.

An Expert Delphi study to derive a tool for mental health triage in emergency departments

ObjectiveThis study aimed to investigate and collate the opinions of experts regarding the triage of patients in mental health crisis presenting to EDs.DesignA three-round e-Delphi study was conducted between November...

Patient Characteristics from an Emergency Care Center in Rural Western Kenya

BackgroundEmergency care is a neglected area of focus in many low- and middle-income countries. There is a paucity of research on types and frequencies of acute illnesses and injuries in low-resource settings. ObjectiveThe primary objective of this study was to describe the demographic characteristics and emergency conditions of patients that presented to a new emergency care center (ECC) at Sagam Community Hospital in Luanda, Kenya. MethodsPatient demographic characteristics, modes of arrival, chief symptoms, triage priorities, self-reported human immunodeficiency virus status, tests performed, interventions, discharge diagnoses, and dispositions were collected for all patients that presented to the Sagam Community Hospital ECC. ResultsBetween October 1, 2016 and September 30, 2017, 14,518 patients presented to the ECC. The most common mode of arrival to Sagam Community Hospital was by foot (n = 12,605 [86.8%]). There were 8931 (61.5%) female patients and 5571 (38.4%) male patients. Of the total visits, 12,668 (87.3%) were triaged Priority III (lowest priority), 1239 (8.5%) were Priority II, and 293 (2.0%) were Priority I (highest priority). The most common chief symptoms were headache (n = 3923 [15.2%]), hotness of body or chills (n = 2877 [8.8%]), and cough (n = 1827 [5.5%]). The three most common discharge diagnoses were malaria (n = 3692 [18.9%]), acute upper respiratory infection (n = 1242 [6.3%]), and gastritis/duodenitis (n = 1210 [6.2%]). ConclusionsAlthough opening an ECC in rural Kenya attracted patients in need of care, access was limited primarily to those that could arrive on foot. ECCs in rural sub-Saharan Africa have the potential to provide quality care and support attainment of Sustainable Development Goals.

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Abstract : We are very grateful to Dr. Pasquier and colleagues for their thought provoking letter, discussing the role of cardiopulmonary resuscitation (CPR) on the battlefield. First, it is important to differentiate between cardiac arrest and circulatory arrest as a cause for the loss of a palpable central pulse. Primary cardiac arrest generally relates to nontraumatic causes such as arrhythmias, electrocutions and so on and reflects a primary problem with cardiac contractility. CPR is appropriate because there is a circulating volume present with which to perfuse the systemic circulation. Circulatory arrest, as in exsanguination from hemorrhagic shock, does not initially relate to a failure of cardiac contraction but reduced cardiac preload. Untreated circulatory arrest will eventually progress to cardiac arrest owing to a failure of systemic oxygenation. Circulatory arrest from hemorrhage is the leading cause of potentially preventable death among battlefield casualties and served as the main indication for resuscitative thoracotomy in our recent study. We are of the opinion that the management priorities in circulatory arrest are hemorrhage control and restoration of circulating volume. We do not believe that CPR is of benefit in such cases because there is no circulating volume with which to perfuse the systemic circulation. We reported 10 cases of arrest in the field; however, this does not mean that these patients received CPR. Indeed, as all the authors have deployed to Afghanistan, serving at all medical echelons, patients do not always receive CPR in the field, as per UK prehospital care guidelines. This largely relates to adverse tactical circumstances and other triage priorities. Furthermore, we are also unaware of any injuries sustained by a first-line care giver sustained during the performance of field CPR.

Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents

Terrorist violence has emerged as an increasingly common cause of mass casualty incidents (MCI) due to the sequelae of explosive devices and shooting massacres. A proper emergency medical system disaster plan for dealing with an MCI is of paramount importance to salvage lives. Because the number of casualties following a MCI is likely to exceed the medical resources of the receiving health care facilities, patients must be appropriately sorted to establish treatment priorities. By necessity, clinical signs are likely to prove cornerstones of triage during MCI. An appropriate and effective application of experiences learned from the use of selective nonoperative management (SNOM) techniques may prove essential in this triage process. The present appraisal of the available literature strongly supports that the appropriate utilization of these clinical indicators to identify patients appropriate for SNOM is essential, critical, and readily applicable. We also review the initial emergent triage priorities for penetrating injuries to the head, neck, torso, and extremities in a mass casualty setting.

Explosions and Radioactive Material: A Primer for Responders

A comprehensive primer on the threat posed by radiological dispersion devices, or “dirty bombs,” and the management challenges for first responders is presented. The discussion is scenario-driven, presenting guidance for medical responders as to triage and treatment priorities in the face of radiation risk. Key questions are posed that present the need for operational and tactical planning, equipping, and training around this scenario. Decontamination priorities and potential medical management are discussed for both victims and responders.

A procedure based alternative to the injury severity score for major incident triage of children: results of a Delphi consensus process

Background: Triage at the site of a major incident is key to effective scene management. A number of triage algorithms have been suggested to assist the triage officer to determine...

What happens if we cannot fix it? Triage, palliative care and setting priorities in salinising landscapes

It is increasingly recognised that rising saline water tables present an unprecedented threat to both agricultural production and biodiversity conservation in the agricultural areas of Australia. In Western Australia, hydrological analysis is increasingly indicating that treatment of the problem will be difficult and costly, perhaps even impossible in some cases. Given the limited resources available for conservation management, there is a need to prioritise efforts and ensure that the level and type of management applied is both appropriate and likely to be effective. We discuss options for this in terms of ideas borrowed from healthcare provision, including triage and palliative care. We examine the range of management responses available in salinising landscapes in relation to the degree of threat, the relative value of the remnant or landscape and the likelihood of successful management intervention. While we certainly need to make a concerted effort to limit damage and loss as far as is possible, we also have to face the possibility that we cannot do this effectively everywhere, and that some areas will not be treated or treatable.

VICTIMIZATION OF WOMEN AND ITS IMPACT ON ASSESSMENT AND TREATMENT IN THE PSYCHIATRIC EMERGENCY SETTING

An understanding of victimization is critical to the practice of emergency psychiatry. Victimization histories are disturbingly common among women presenting to the PES, particularly among frequent service users. The sequelae of victimization are both psychological and physical and often impair health and functioning across numerous domains. PTSD, BPD, and substance-use disorders are often seen among women with victimization histories, which can be particularly challenging for PES providers. Screening for trauma on PES presentation or history should not be overlooked in any person, including severely mentally ill, homeless, disabled, or elderly women. PES clinicians should remember to ask about victimization and pose questions privately in a direct and an open-ended format while conveying empathic validation. Clinical assessment of women with victimization histories in the PES should be guided by the principles of standard emergency psychiatry and be informed by an understanding of trauma. This includes a working knowledge of trauma dynamics, adherence to sound professional boundaries, and care not to retraumatize patients or re-enact perpetrator-victim dynamics. Voyeurism and regression should be avoided, particularly when eliciting trauma history. The PES should be a place for screening and acute intervention, not for conducting intensive trauma therapy. In the PES, the focus should remain on triage and treatment priorities, those of safety and stabilization, and carefully evaluating for substance use and psychosis. The PES ideally provides a "holding environment" that affords a balance of nurturing, limits, consistency, and communication. A basic knowledge of cognitive-behavioral interventions affording "crisis survival strategies," such as DBT, can be particularly useful to PES clinicians. Clinicians also need to monitor issues of countertransference and the potential to be dismissive to these women with complex, comorbid, and chronic problems and diseases. The role for the use of psychotropic medication in PES cohorts with victimization histories should target acute symptoms. Involving regular providers of these decisions is advised to coordinate care and minimize splitting and risks of polypharmacy. Although the SSRIs are effective in symptom management of disorders related to victimization, patients must be reminded of the side-effect profile, particularly sexual dysfunction and withdrawal and discontinuation syndromes.

Electrical shock and lightning strike

Cardiac arrest from electrical shock or lightning strike is associated with significant mortality and requires modification and extension of standard advanced life support measures to achieve successful resuscitation. Patients who experience electrical shock or lightning strike may sustain cardiac and respiratory arrest secondary to the direct effects of current. However, the majority of victims have associated multisystem involvement, including neurologic complications, cutaneous burns, and associated blunt trauma. As a result, a combination of advanced cardiac life support measures and advanced trauma life support techniques is indicated. Victims with cardiac arrest from electrical shock or lightning strike require prompt, aggressive resuscitation using standard methods for airway control, ventilation, and chest compressions, as well as usual measures for defibrillation and cardiac pharmacotherapy. Unique considerations include vigorous fluid resuscitation and spinal immobilization for victims of electrical shock and reversal of normal multiple casualty triage priorities when managing several lightning strike victims. Because the majority of victims are relatively young and seldom have significant underlying cardiac disease, the chance for successful resuscitation may be greater for patients who experience sudden death from electrical shock or lightning strike than for those with other causes of cardiac arrest, even among patients with initial rhythms traditionally unresponsive to therapy. Although numerous specialized aspects are required for the successful management of victims of electrical shock and lightning strike, the following article focuses on the unique considerations necessary for immediate care of cardiac arrest victims, with emphasis on the underlying mechanisms of sudden death and currently recommended guidelines for resuscitation.

Triage: in austere environments and echeloned medical systems.

Although triage as a medical sorting process was originally developed and applied to echeloned military field medical systems dealing with mass casualties, the term has now permeated most aspects of medical practice. This essay attempts to refocus on triage in military and disaster settings, emphasizing the relationship of the echeloned system organization to the triage process, and the various non-medical factors which may influence triage decisions and priorities. Due to the lack of any analogous civilian experience, it is essential that all health personnel who may be involved in an echeloned care system gain and maintain proficiency by frequent involvement in appropriate training exercises, the characteristics of which are described.

Triage By Emergency Medical Dispatchers

AbstractPurpose:This study is an evaluation of the ability of medically trained and controlled emergency medical dispatchers to use telephone triage techniques to direct the appropriate prehospital unit to an emergency scene.Methods:Emergency dispatchers, educated in a formal emergency medical dispatch program, were assigned one of four triage priorities to incoming 9-1-1 calls. The actual field management delivered for each patient was compared with the dispatcher's triage to determine the appropriateness of triage.Results:A total of 1,045 consecutive calls were reviewed with 74.4% sorted as needing advanced life support (ALS) units on scene; 65.3% (95% CI, 61.9 to 68.6%) of these calls required ALS intervention. A total of 3.4% of the runs sorted to the non-ALS response groups were identified to have required ALS intervention. Comparing the need for ALS intervention, a significant difference was found between the triage groups.Conclusion:Emergency medical dispatchers, using a formal system for telephone triage, are able to direct appropriate prehospital resources to the emergency scene.