Triage Setting Research Articles

Improving Triage Accuracy in Prehospital Emergency Telemedicine: Scoping Review of Machine Learning-Enhanced Approaches.

Prehospital telemedicine triage systems combined with machine learning (ML) methods have the potential to improve triage accuracy and safely redirect low-acuity patients from attending the emergency department. However, research in prehospital settings is limited but needed; emergency department overcrowding and adverse patient outcomes are increasingly common. In this scoping review, we sought to characterize the existing methods for ML-enhanced telemedicine emergency triage. In order to support future research, we aimed to delineate what data sources, predictors, labels, ML models, and performance metrics were used, and in which telemedicine triage systems these methods were applied. A scoping review was conducted, querying multiple databases (MEDLINE, PubMed, Scopus, and IEEE Xplore) through February 24, 2023, to identify potential ML-enhanced methods, and for those eligible, relevant study characteristics were extracted, including prehospital triage setting, types of predictors, ground truth labeling method, ML models used, and performance metrics. Inclusion criteria were restricted to the triage of emergency telemedicine services using ML methods on an undifferentiated (disease nonspecific) population. Only primary research studies in English were considered. Furthermore, only those studies using data collected remotely (as opposed to derived from physical assessments) were included. In order to limit bias, we exclusively included articles identified through our predefined search criteria and had 3 researchers (DR, JS, and KS) independently screen the resulting studies. We conducted a narrative synthesis of findings to establish a knowledge base in this domain and identify potential gaps to be addressed in forthcoming ML-enhanced methods. A total of 165 unique records were screened for eligibility and 15 were included in the review. Most studies applied ML methods during emergency medical dispatch (7/15, 47%) or used chatbot applications (5/15, 33%). Patient demographics and health status variables were the most common predictors, with a notable absence of social variables. Frequently used ML models included support vector machines and tree-based methods. ML-enhanced models typically outperformed conventional triage algorithms, and we found a wide range of methods used to establish ground truth labels. This scoping review observed heterogeneity in dataset size, predictors, clinical setting (triage process), and reported performance metrics. Standard structured predictors, including age, sex, and comorbidities, across articles suggest the importance of these inputs; however, there was a notable absence of other potentially useful data, including medications, social variables, and health system exposure. Ground truth labeling practices should be reported in a standard fashion as the true model performance hinges on these labels. This review calls for future work to form a standardized framework, thereby supporting consistent reporting and performance comparisons across ML-enhanced prehospital triage systems.

Assessing the utility of frailty scores in triage: a comparative study of validated scales.

Currently, there is conflicting evidence regarding the efficacy of frailty scales and their ability to enhance or support triage operations. This study aimed to assess the utility of three common frailty scales (CFS, PRISMA-7, ISAR) and determine their utility in the triage setting. This prospective observational monocentric study was conducted at Merano Hospital's Emergency Department (ED) from June 1st to December 31st, 2023. All patients attending this ED during the 80-day study period were included, and frailty scores were correlated with three outcomes: hospitalization, 30-day mortality, and severity of condition as assessed by ED physicians. Patients were categorized by age, and analyses were performed for the entire study population, patients aged 18-64, and those aged 65 or older. Univariate analysis was followed by multivariable analysis to evaluate whether frailty scores were independently associated with the outcomes. In multivariable analysis, none of the frailty scores were found to be associated with the study outcomes, except for the CFS, which was associated with an increased risk of 30-day mortality, with an odds ratio of 1.752 (95% CI 1.148-2.674; p = 0.009) in the general population and 1.708 (95% CI 1.044-2.793; p = 0.033) in the population aged ≥ 65. Presently, available frailty scores do not appear to be useful in the triage context. Future research should consider developing new systems for accurate frailty assessment to support risk prediction in the triage assessment.

Predicting sepsis at emergency department triage: Implementing clinical and laboratory markers within the first nursing assessment to enhance diagnostic accuracy.

Early identification of sepsis in the emergency department (ED) triage is both valuable and challenging. Numerous studies have endeavored to pinpoint clinical and biochemical criteria to assist clinicians in the prompt diagnosis of sepsis, but few studies have assessed the efficacy of these criteria in the ED triage setting. The aim of the study was to explore the accuracy of clinical and laboratory markers evaluated at the triage level in identifying patients with sepsis. A prospective study was conducted in a large academic urban hospital, implementing a triage protocol aimed at early identification of septic patients based on clinical and laboratory markers. A multidisciplinary panel of experts reviewed cases to ensure accurate identification of septic patients. Variables analyzed included: Charlson comorbidity index, mean arterial pressure (MAP), partial pressure of carbon dioxide (PetCO2), white cell count, eosinophil count, C-reactive protein to albumin ratio, procalcitonin, and lactate. A total of 235 patients were included. Multivariable analysis identified procalcitonin ≥1 ng/mL (OR 5.2; p < 0.001); CRP-to-albumin ratio ≥32 (OR 6.6; p < 0.001); PetCO2 ≤ 28 mmHg (OR 2.7; p = 0.031), and MAP <85 mmHg (OR 7.5; p < 0.001) as independent predictors for sepsis. MAP ≥85 mmHg, CRP/albumin ratio <32, and procalcitonin <1 ng/mL demonstrated negative predictive values for sepsis of 90%, 89%, and 88%, respectively. Our study underscores the significance of procalcitonin and mean arterial pressure, while introducing CRP/albumin ratio and PetCO2 as important variables to consider in the very initial assessment of patients with suspected sepsis in the ED. Early identification of sepsis since the emergency department (ED) triage is challenging Implementing the ED triage protocol with simple clinical and laboratory markers allows to recognize patients with sepsis with a very good discriminatory power (AUC 0.88).

Utilizing ultra-early continuous physiologic data to develop automated measures of clinical severity in a traumatic brain injury population

Determination of prognosis in the triage process after traumatic brain injury (TBI) is difficult to achieve. Current severity measures like the Trauma and injury severity score (TRISS) and revised trauma score (RTS) rely on additional information from the Glasgow Coma Scale (GCS) and the Injury Severity Score (ISS) which may be inaccurate or delayed, limiting their usefulness in the rapid triage setting. We hypothesized that machine learning based estimations of GCS and ISS obtained through modeling of continuous vital sign features could be used to rapidly derive an automated RTS and TRISS. We derived variables from electrocardiograms (ECG), photoplethysmography (PPG), and blood pressure using continuous data obtained in the first 15 min of admission to build machine learning models of GCS and ISS (ML-GCS and ML-ISS). We compared the TRISS and RTS using ML-ISS and ML-GCS and its value using the actual ISS and GCS in predicting in-hospital mortality. Models were tested in TBI with systemic injury (head abbreviated injury scale (AIS) ≥ 1), and isolated TBI (head AIS ≥ 1 and other AIS ≤ 1). The area under the receiver operating characteristic curve (AUROC) was used to evaluate model performance. A total of 21,077 cases (2009–2015) were in the training set. 6057 cases from 2016 to 2017 were used for testing, with 472 (7.8%) severe TBI (GCS 3–8), 223 (3.7%) moderate TBI (GCS 9–12), and 5913 (88.5%) mild TBI (GCS 13–15). In the TBI with systemic injury group, ML-TRISS had similar AUROC (0.963) to TRISS (0.965) in predicting mortality. ML-RTS had AUROC (0.823) and RTS had AUROC 0.928. In the isolated TBI group, ML-TRISS had AUROC 0.977, and TRISS had AUROC 0.983. ML-RTS had AUROC 0.790 and RTS had AUROC 0.957. Estimation of ISS and GCS from machine learning based modeling of vital sign features can be utilized to provide accurate assessments of the RTS and TRISS in a population of TBI patients. Automation of these scores could be utilized to enhance triage and resource allocation during the ultra-early phase of resuscitation.

Rapid detection of heart failure using a spectroscopic liquid biopsy

Heart disease is growing annually across the globe with numbers expected to rise to 46% of the population by 2030. Early detection is vital for several reasons, firstly it improves the long-term prognosis of the patient by admitting them through the appropriate pathway faster, secondly it reduces healthcare costs by streamlining diagnosis and finally, in combination with management or treatment, it can prevent the progression of the disease which in turn improves the patient’s quality of life. Therefore, there lies an increasing need to develop assays which can rapidly detect heart disease at an early stage. The Dxcover® liquid biopsy platform employs infrared spectroscopy and artificial intelligence, to quickly analyse minute amounts of patient serum. In this study, discrimination between healthy controls and diseased patients was obtained with an area under the receiver operating characteristic curve (AUC) of 0.89. When assessing the heart failure vs all patients, which is most akin to what would be observed in a triage setting, the model when tuned to a minimum of 45% specificity yielded a sensitivity of 89% and an NPV of 0.996, conversely when sensitivity was set at a 45% minimum, the specificity was 96%, giving an NPV of 0.991 when using a 1.5% prevalence. Other models were assessed in parallel, but the performance of the ORFPLS model was overall superior to the other models tested. In this large scale (n = 404) proof-of-concept study, we have shown that the Dxcover liquid biopsy platform has the potential to be a viable triage tool in emergency and routine situations for the diagnosis of heart failure.

Point-of-care prognostication in moderate Covid-19: Analytical validation and prognostic accuracy of a soluble urokinase plasminogen activator receptor (suPAR) rapid test.

The soluble urokinase plasminogen activator receptor (suPAR) has been proposed as a biomarker for risk stratification of patients presenting with acute infections. However, most studies evaluating suPAR have used platform-based assays, the accuracy of which may differ from point-of-care tests capable of informing timely triage in settings without established laboratory capacity. Using samples and data collected during a prospective cohort study of 425 patients presenting with moderate Covid-19 to two hospitals in India, we evaluated the analytical performance and prognostic accuracy of a commercially-available rapid diagnostic test (RDT) for suPAR, using an enzyme-linked immunosorbent assay (ELISA) as the reference standard. Our hypothesis was that the suPAR RDT might be useful for triage of patients presenting with moderate Covid-19 irrespective of its analytical performance when compared with the reference test. Although agreement between the two tests was limited (bias = -2.46 ng/mL [95% CI = -2.65 to -2.27 ng/mL]), prognostic accuracy to predict supplemental oxygen requirement was comparable, whether suPAR was used alone (area under the receiver operating characteristic curve [AUC] of RDT = 0.73 [95% CI = 0.68 to 0.79] vs. AUC of ELISA = 0.70 [95% CI = 0.63 to 0.76]; p = 0.12) or as part of a published multivariable prediction model (AUC of RDT-based model = 0.74 [95% CI = 0.66 to 0.83] vs. AUC of ELISA-based model = 0.72 [95% CI = 0.64 to 0.81]; p = 0.78). Lack of agreement between the RDT and ELISA in our cohort warrants further investigation and highlights the importance of assessing candidate point-of-care tests to ensure management algorithms reflect the assay that will ultimately be used to inform patient care. Availability of a quantitative point-of-care test for suPAR opens the door to suPAR-guided risk stratification of patients with Covid-19 and other acute infections in settings with limited laboratory capacity.

Satisfaction with maternity triage following implementation of the Birmingham Symptom-Specific Obstetric Triage System (BSOTS): Perspectives of women and staff.

To explore the satisfaction and experiences of women and staff with the BSOTS in an Australian hospital. Cross-sectional descriptive survey. Surveys were distributed to women and staff between February and May 2022. Survey questions reflected satisfaction with triage and provision of care under the BSOTS system (for women) and confidence in using the BSOTS system and its impact on triage-related care (for staff). Survey data were summarized using descriptive statistics, and qualitative responses were analysed using content analysis. There were 50 women and 40 staff (midwives and doctors) survey respondents. Most women were satisfied with triage wait times, the verbal information they received and the time it took for them to receive care. Nearly all midwife participants indicated they had high knowledge and confidence in using the BSOTS. Most staff indicated that the BSOTS supported the accurate assessment of women and had benefits for women, staff and the hospital. The findings showed that women and staff were satisfied with receiving and providing care in a maternity triage setting under the BSOTS system. Implementing standardized maternity triage approaches such as the BSOTS in health settings delivering care to pregnant women is recommended for improving flow of care and perceptions of care quality by women. Quality of maternity triage processes is likely to impact the satisfaction of women attending services and the staff providing care. The BSOTS was shown to improve maternity triage processes and was associated with satisfaction of women and staff. Maternity settings can benefit from implementing triage approaches such as the BSOTS as it standardizes and justifies the care provided to women. This is likely to result in satisfaction of women and staff engaged in maternity triage and improve the birth outcomes of women and babies. The reporting of this paper has followed SQUIRE guidelines. Women engaged with maternity services were participants in the study but did not contribute to the design, conduct or publication of the study.

Responding to mental health crisis at a street level: mental health practitioners as street-level bureaucrats

Street triage practitioners, consisting of mental health social workers and nurses, act as a conduit between service users and emergency services, and have a significant amount of discretion in determining the care and treatment pathways for individuals experiencing mental health crises. However, this is set against a backdrop of neoliberal reforms that have resulted in an increased focus on risk management, accountability, responsibilisation and managing scarce resources. Based on ethnographic research undertaken in a street triage setting in the UK, this article examines the role of street triage practitioners as ‘street-level bureaucrats’ and explores the impact of neoliberal mental health reforms on street-level practice and how these shape and constrain the use of discretion in a street triage context. Revisiting the relevance of Lipsky through a neoliberal lens, the article identifies how street triage practitioners use their discretion to navigate practice dilemmas in a contemporary mental health landscape.

Results from healthy donors for novel point-of-care high-sensitivity troponin test

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction This study evaluates healthy donor values of a novel high-sensitivity troponin test, an 8-minute whole blood assay performed with fingerstick or Lithium-heparin samples using a handheld sized platform designed for Point-of-Care or in-lab measurements. In accordance with the Fourth Universal Definition of Myocardial Infarction, whole blood 99th percentile upper reference limits (URLs) and 50th percentile (median) values for healthy individuals were characterised per gender; values were established for fingerstick, venous whole blood, and plasma. Purpose To determine 99th percentile URLs for hs-cTnI in healthy donors as myocardial injury cut-off for use in clinical trials and clinical practice. The median values were determined to confirm high-sensitivity performance in all matrices. Methods Whole blood from consented healthy subjects, 22 to 85 years (n=810), were collected across 5 clinical sites. Subjects taking cardiac history/medications or having abnormal hemoglobin A1c, NT-proBNP, and eGFR values were excluded. hs-cTnI values were determined in capillary (fingerstick), Li-Heparin venous whole blood, and venous Li-Heparin plasma matrices. Sex-specific and overall 99th percentile URLs using the recommended non-parametric approach and median values for each sample matrix were determined. Results Statistical outliers were eliminated by the Dixon-Reed test, prior to calculating the 99th percentile and median values. There was no significant difference between the three sample types. The median results are tabulated below: as expected, the female values are lower than the male values (p &amp;lt;0.01). These data additionally show that &amp;gt;50% of results exceed the assays limit of detection [ref .1] for all matrices, confirming this assay is a high-sensitive assay for troponin-I. Conclusion The novel hs-cTnI system is the first that demonstrates high-sensitivity cTnI performance in fingerstick, whole blood and plasma matrices. Quality measurements in all three matrices translates to use with confidence in emergency department and other diagnosis and triage settings. Hence, the data presented here are of relevance to current and future studies and clinical implementation of this device. Table 1: median hs-cTnI values in healthy subject, % of subjects above LoD (limit of detection) and %CV at 99th URL.

Addressing Suicide Risk: A Systematic Review of Motivational Interviewing Infused Interventions

Purpose: Brief interventions have been applied to the problem of suicide. This systematic review quantitatively and qualitatively examined the effectiveness of motivational interviewing (MI)-infused interventions. Methods: PRISMA guidelines were followed throughout. Results: 147 studies were initially identified, with nine meeting the final inclusion criteria. All studies blended MI with other interventions and were primarily located in triage settings. MI-infused interventions were not significantly stronger in lowering suicidal ideation or behavior. However, such interventions were significantly more likely to result in follow-up care post intervention. Discussion: MI-infused interventions are not linked to statistically significantly lowered risk for suicide ideation or behavior despite increased mental health-seeking behavior post intervention. However, MI-infused interventions may be valuable for suicidal behavior in hospital settings because they increase a key intervention target: following up with mental health care. The literature on MI-infused interventions for suicide is in an early stage with many unanswered questions.

Outcome of preterm pregnancies evaluated in triage settings

Obstetrical care frequently involves evaluation in hospital triage setting for conditions associated with adverse pregnancy outcomes (APOs), but little is known about the outcomes of these visits. Our objective was to implement a registry of triage visits for possible APOs and evaluate the outcomes of these pregnancies.

Button battery injury: An update.

Paediatric button battery injuries present a challenge in the general practice setting. Although some children present with history or parental suspicion of button battery ingestion (BBI) or insertion, unwitnessed cases may present with non-specific symptoms thatcan mimic many respiratory and gastrointestinal pathologies. The aim of this article is to increase awareness of the fast onset of life-threatening tissue injury from BBI and the importance of timely referral as wellas provide an update on current management, including first aid management in the general practice setting. BBI is a medical emergency. The button battery requires urgent removal as it cancause caustic burn injury to its surrounding tissues in as little as 15minutes. Limited awareness of the time-critical nature of this presentation has been reported in multiple triage settings. Studies have shown a role for consumption of honey or sucralfate in delaying tissue injury while awaiting surgical removal.

Application of a Web-based Self-assessment Triage Tool During the COVID-19 Pandemic: Descriptive Study.

BackgroundThe COVID-19 pandemic has sped up the implementation of telehealth solutions in medicine. A few symptom checkers dedicated for COVID-19 have been described, but it remains unclear whether and how they can affect patients and health systems.ObjectiveThis paper demonstrates our experiences with the COVID-19 risk assessment (CRA) tool. We tried to determine who the user of the web-based COVID-19 triage app is and compare this group with patients in the infectious diseases ward’s admission room to evaluate who could benefit from implementing the COVID-19 online symptom checker as a remote triage solution.MethodsWe analyzed the answers of 248,862 people interacting with an online World Health Organization–based triage tool for assessing the probability of SARS-CoV-2 infection. These users filled in an online questionnaire between April 7 and August 6, 2020. Based on the presented symptoms, risk factors, and demographics, the tool assessed whether the user’s answers were suggestive of COVID-19 and recommended appropriate action. Subsequently, we compared the sociodemographic and clinical characteristics of tool users with patients admitted to the Infectious Diseases Admission Room of J. Gromkowski Hospital in Wrocław.ResultsThe CRA tool tended to be used by asymptomatic or oligosymptomatic individuals (171,226 [68.80%] of all users). Most users were young (162,432 [65.27%] were below 40 years of age) and without comorbidities. Only 77,645 (31.20%) of the self-assessment app users were suspected of COVID-19 based on their reported symptoms. On the contrary, most admission room patients were symptomatic—symptoms such as fever, cough, and dyspnea were prevalent in both COVID-19-positive and COVID-19-negative patients. COVID-19-suspected patients in the CRA tool group presented similar COVID-19 symptoms as those who presented to the admission room. These were cough (25,062/40,007 [62.64%] in the CRA tool group vs 138/232 [59.48%] in the admission room group), fever (23,123/40,007 [57.80%] in the CRA tool group vs 146/232 [62.93%] in the admission room group), and shortness of breath (15,157/40,007 [37.89%] in the CRA tool group vs 87/232 [37.50%] in the admission room group).ConclusionsThe comparison between the symptomatology of the users interacting with the CRA tool and those visiting the admission room revealed 2 major patient groups who could have benefited from the implementation of the self-assessment app in preclinical triage settings. The primary users of the CRA tool were young, oligosymptomatic individuals looking for screening for COVID-19 and reassurance early in the COVID-19 pandemic. The other group were users presenting the typical symptoms suggestive of COVID-19 at that time. The CRA tool recognized these individuals as potentially COVID-19 positive and directed them to the proper level of care. These use cases fulfil the idea of preclinical triage; however, the accuracy and influence on health care must be examined in the clinical setting.

Evaluation of the HemoCue® WBC System as a Point of Care Diagnostic Tool for White Blood Cell Quantification in Pinnipeds

Point of care (POC) hematology testing can be valuable in triage and field settings. We assessed the accuracy between the HemoCue® WBC system and two comparative analyzers, as well as the precision of the HemoCue® WBC system in five different pinniped species: Zalophus californianus, Arctocephalus townsendi, Callorhinus urcinus, Phoca vitulina, and Mirounga angustirostris for white blood cell (WBC) quantification. In Zalophus (n = 164; 106 from U.S. Navy Marine Mammal Program (Navy); 58 from The Marine Mammal Center (TMMC)), the HemoCue® was compared to two hematology analyzers, Sysmex Xe-5000 and Vet ABC Plus. In Phoca (n = 50; TMMC), Callorhinus (n = 29; TMMC), Arctocephalus (n = 17; TMMC), and Mirounga (n = 67; TMMC), the HemoCue® was compared to Vet ABC Plus only. Bland–Altman and Passing–Bablok agreement of HemoCue® with Sysmex Xe-5000 and Vet ABC Plus analyzers were good for Zalophus, Arctocephalus, Phoca, and Mirounga but marginal with Callorhinus; bias = 0.56 × 109/L (Zalophus; Navy), −2.13 × 109/L (Zalophus; TMMC), −1.59 × 109/L (Arctocephalus), −2.48 × 109/L 0.917 (Phoca), −0.01 × 109/L (Mirounga), and −6.05 × 109/L (Callorhinus). The coefficient of variation from triplicate runs of samples were within acceptable limits for all species (2.50% ± 1.63 (Zalophus; TMMC), 3.09% ± 2.14 (Arctocephalus), 2.47% ± 1.35 (Callorhinus), 2.88% ± 1.75 (Phoca), and 3.44% ± 2.53 (Mirounga)), respectively. The presence of nucleated red blood cells (nRBC; 1–37 nRBC/100 WBC) did not significantly interfere with WBC counts in Zalophus, Callorhinus, and Phoca at the population level, but their presence should be evaluated at the individual level. The HemoCue® provides an accurate method for WBC quantification with WBC counts up to 30 × 109/L (upper limit of linearity of the analyzer) in Zalophus, Arctocephalus, Phoca, and Mirounga, but is less accurate in Callorhinus, and showed good precision in all species.

Modified Shock Index as a Predictor for Mortality and Hospitalization Among Patients With Dementia

BackgroundOne in four older adults in the Emergency Department (ED) suffers from severe cognitive impairment, creating great difficulty for the emergency physicians who determine the urgency of their patients’ condition, which informs decisions regarding discharge or hospitalization. ObjectiveOur objective was to determine whether modified shock index (MSI) can be a clinical mortality and hospitalization predictor when applied to older patients with dementia in the ED. MethodsIncluded in the research were all patients with dementia, > 65 years old, who arrived at the Soroka University Medical Center ED during 2014–2017. The population was divided into three groups according to their MSI score, calculated as heart rate/mean arterial pressure: MSI < 0.7; 0.7 > MSI < 1.3; and MSI > 1.3. We performed multivariable logistic regression as a predictor of death within 30 days, Cox analysis for number of days to death, and a negative binominal regression for predicting the number of admission days. ResultsIncluded were 1437 patients diagnosed with dementia. Patients with an MSI > 1.3 vs. those with MSI < 0.7 had an odds ratio of 8.23 (95% confidence interval [CI] 4.64–4.54) for mortality within 30 days, increased mortality risk within 180 days (hazard ratio 4.42; 95% CI 2.64–7.41), and longer hospitalization duration (incidence rate ratio 1.8; 95% CI 1.32–2.45). ConclusionsHigh MSI scores were associated with high mortality rates and longer hospitalization duration for patients diagnosed with dementia who were > 65 years old. We suggest performing prospective studies utilizing the MSI score as an indicator in ED triage settings to classify patients with dementia by their severity of risk, to determine if this benefits health, minimizes expenses, and prevents unnecessary hospitalizations.

Adding a Correction Factor to the Allocation of Scarce Life-saving Resources in a Pandemic

Adding a Correction Factor to the Allocation of Scarce Life-saving Resources in a Pandemic

Shock Index in COVID Era

AbstractThe health care burden and risks to health care workers imposed by novel coronavirus disease 2019 (COVID-19) mandated the need for a simple, noninvasive, objective, and parsimonious risk stratification system predicting the level of care, need for definitive airway, and titration of the ongoing patient care. Shock index (SI = heart rate/systolic blood pressure) has been evaluated in emergency triage, sepsis, and trauma settings including different age group of patients. The ever accumulating girth of evidences demonstrated a superior predictive value of SI over other hemodynamic parameters. Inclusion of respiratory and/or neurological parameters and adjustment of the cutoffs appropriate to patient age increase the predictability in the trauma and sepsis scenario. Being reproducible, dynamic, and simple, SI can be a valuable patient risk stratification tool in this ongoing era of COVID-19 pandemic.

Performance of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score among patients with COVID-19 pneumonia in an emergency department triage setting: a retrospective study.

Healthcare institutions are confronted with large numbers of patient admissions during large-scale or long-term public health emergencies like pandemics. Appropriate and effective triage is needed for effective resource use. To evaluate the effectiveness of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 years (CURB-65) score in an emergency department (ED) triage setting. Retrospective study in the ED of a tertiary-care university hospital in Düzce, Turkey. PMEWS, STSS and CURB-65 scores of patients diagnosed with COVID-19 pneumonia were calculated. Thirty-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) need and outcomes were recorded. The predictive accuracy of the scores was assessed using receiver operating characteristic curve analysis. One hundred patients with COVID-19 pneumonia were included. The 30-day mortality was 6%. PMEWS, STSS and CURB-65 showed high performance for predicting 30-day mortality (area under the curve: 0.968, 0.962 and 0.942, respectively). Age > 65 years, respiratory rate > 20/minute, oxygen saturation (SpO2) < 90% and ED length of stay > 4 hours showed associations with 30-day mortality (P < 0.05). CURB-65, STSS and PMEWS scores are useful for predicting mortality, ICU admission and MV need among patients diagnosed with COVID-19 pneumonia. Advanced age, increased respiratory rate, low SpO2 and prolonged ED length of stay may increase mortality. Further studies are needed for developing the triage scoring systems, to ensure effective long-term use of healthcare service capacity during pandemics.

Midwife-performed checklist and ultrasound to identify obstetric conditions at labour triage in Uganda: A quasi-experimental study

ObjectiveThe aim of this study was to evaluate the effect of a midwife-performed checklist and limited obstetric ultrasound on sensitivity and positive predictive value for a composite outcome comprising multiple gestation, placenta praevia, oligohydramnios, preterm birth, malpresentation, abnormal foetal heart rate. DesignQuasi-experimental pre-post intervention study. SettingMaternity unit at a district hospital in Eastern Uganda. InterventionsInterventions were implemented in a phased approach: standardised labour triage documentation (Phase 1), a triage checklist (Phase 2), and checklist plus limited obstetric ultrasound (Phase 3). ParticipantsConsenting women presenting to labour triage for admission after 28 weeks of gestation between February 2018 and June 2019 were eligible. Women not in labour or those requiring immediate care were excluded. 3,865 women and 3,937 newborns with similar sample sizes per phase were included in the analysis. Measurement and findingsOutcome data after birth were used to determine true presence of a complication, while intake and checklist data were used to inform diagnosis before birth. Compared to Phase 1, Phase 2 and 3 interventions improved sensitivity (Phase 1: 47%, Phase 2: 68.8%, Phase 3: 73.5%; p ≤ 0.001) and reduced positive predictive value (65.9%, 55%, 48.7%, p ≤ 0.001) for the composite outcome. No phase differences in adverse maternal or foetal outcomes were observed. ConclusionBoth a triage checklist and a checklist plus limited obstetric ultrasound improved accurate identification of cases with some increase in false positive diagnosis. These interventions may be beneficial in a resource-limited maternity triage setting to improve midwives' diagnoses and clinical decision-making.

Chest radiography or computed tomography for COVID-19 pneumonia? Comparative study in a simulated triage setting.

IntroductionFor the management of patients referred to respiratory triage during the early stages of the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic, either chest radiography or computed tomography (CT) were used as first-line diagnostic tools. The aim of this study was to compare the impact on the triage, diagnosis and prognosis of patients with suspected COVID-19 when clinical decisions are derived from reconstructed chest radiography or from CT.MethodsWe reconstructed chest radiographs from high-resolution CT (HRCT) scans. Five clinical observers independently reviewed clinical charts of 300 subjects with suspected COVID-19 pneumonia, integrated with either a reconstructed chest radiography or HRCT report in two consecutive blinded and randomised sessions: clinical decisions were recorded for each session. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and prognostic value were compared between reconstructed chest radiography and HRCT. The best radiological integration was also examined to develop an optimised respiratory triage algorithm.ResultsInterobserver agreement was fair (Kendall's W=0.365, p<0.001) by the reconstructed chest radiography-based protocol and good (Kendall's W=0.654, p<0.001) by the CT-based protocol. NPV assisted by reconstructed chest radiography (31.4%) was lower than that of HRCT (77.9%). In case of indeterminate or typical radiological appearance for COVID-19 pneumonia, extent of disease on reconstructed chest radiography or HRCT were the only two imaging variables that were similarly linked to mortality by adjusted multivariable modelsConclusionsThe present findings suggest that clinical triage is safely assisted by chest radiography. An integrated algorithm using first-line chest radiography and contingent use of HRCT can help optimise management and prognostication of COVID-19.