Previous studies deriving and validating triage scores for patients with suspected COVID-19 in Emergency Department settings have been conducted in high- or middle-income settings. We assessed eight ...triage scores’ accuracy for death or organ support in patients with suspected COVID-19 in Sudan.
We conducted an observational cohort study using Covid-19 registry data from eight emergency unit isolation centres in Khartoum State, Sudan. We assessed performance of eight triage scores including: PRIEST, LMIC-PRIEST, NEWS2, TEWS, the WHO algorithm, CRB-65, Quick COVID-19 Severity Index and PMEWS in suspected COVID-19. A composite primary outcome included death, ventilation or ICU admission.
In total 874 (33.84 %, 95 % CI:32.04 % to 35.69 %) of 2,583 patients died, required intubation/non-invasive ventilation or HDU/ICU admission . All risk-stratification scores assessed had worse estimated discrimination in this setting, compared to studies conducted in higher-income settings: C-statistic range for primary outcome: 0.56–0.64. At previously recommended thresholds NEWS2, PRIEST and LMIC-PRIEST had high estimated sensitivities (≥0.95) for the primary outcome. However, the high baseline risk meant that low-risk patients identified at these thresholds still had a between 8 % and 17 % risk of death, ventilation or ICU admission.
None of the triage scores assessed demonstrated sufficient accuracy to be used clinically. This is likely due to differences in the health care system and population (23 % of patients died) compared to higher-income settings in which the scores were developed. Risk-stratification scores developed in this setting are needed to provide the necessary accuracy to aid triage of patients with suspected COVID-19.
Globally, there has been an increase in the prevalence and scale of disasters with low- and middle-income countries (LMICs) tending to be more affected. Consequently, disaster risk reduction has been ...advocated as a global priority. However, the evidence base for disaster management in these settings is unclear.
This study is a scoping review of the evidence base for disaster management in LMIC. Potentially relevant articles between 1990 and 2011 were searched for, assessed for relevance and subsequently categorised using a thematic coding framework based on the US Integrated Emergency Management System model.
Out of 1545 articles identified, only 178 were from LMIC settings. Most were of less robust design such as event reports and commentaries, and 66% pertained to natural disasters. There was a paucity of articles on disaster mitigation or recovery, and more were written on disaster response and preparedness issues.
Considerably more articles were published from high-income country settings that may reflect a publication bias. Current grey literature on disaster management tends not to be peer reviewed, is not well organised and not easy to access. The paucity of peer-reviewed publications compromises evidence review initiatives that seek to provide an evidence-base for disaster management in LMIC. As such, there is an urgent need for greater research and publication of findings on disaster management issues from these settings.
Abstract
Background
Approximately 75,000 people fracture a hip each year in the UK. This painful injury can be devastating—with a high associated mortality rate—and survivors likely to be more ...dependent and less mobile. Pain relief at the scene of injury is known to be inadequate. Intravenous morphine is usually given by paramedics, but opioids are less effective for dynamic pain and can cause serious side effects, including nausea, constipation, delirium and respiratory depression. These may delay surgery, require further treatment and worsen patient outcomes. We completed a feasibility study of paramedic-provided fascia iliaca compartment block (FICB), testing the intervention, trial methods and data collection. The study (RAPID) demonstrated that a full trial was feasible. In this subsequent study, we aim to test safety, clinical and cost-effectiveness of paramedic-provided FICB as pain relief to patients with suspected hip fracture in the prehospital environment.
Methods
We will conduct a pragmatic multi-centre individually randomised parallel-group trial, with a 1:1 allocation between usual care (control) and FICB (intervention). Hospital clinicians in five sites (paired ambulance services and receiving hospitals) in England and Wales will train 220 paramedics to administer FICB. The primary outcome is change in pain score from pre-randomisation to arrival at the emergency department. One thousand four hundred patients are required to find a clinically important difference between trial arms in the primary outcome (standardised statistical effect ~ 0.2; 90% power, 5% significance). We will use NHS Digital (England) and the SAIL (Secure Anonymised Information Linkage) databank (Wales) to follow up patient outcomes using routine anonymised linked data in an efficient study design, and questionnaires to capture patient-reported outcomes at 1 and 4 months. Secondary outcomes include mortality, length of hospital stay, job cycle time, prehospital medications including morphine, presence of hip fracture, satisfaction, mobility, and NHS costs. We will assess safety by monitoring serious adverse events (SAEs).
Discussion
The trial will help to determine whether paramedic administered FICB is a safe, clinically and cost-effective treatment for suspected hip fracture in the pre-hospital setting. Impact will be shown if and when clinical guidelines either recommend or reject the use of FICB in routine practice in this context.
Trial registration
ISRCTN15831813
. Registered on 22 September 2021.
The majority of patients with suspected acute coronary syndrome presenting to the emergency department will be discharged once myocardial infarction has been ruled out, although a proportion will ...have unrecognised coronary artery disease. In this setting, high-sensitivity cardiac troponin identifies those at increased risk of future cardiac events. In patients with intermediate cardiac troponin concentrations in whom myocardial infarction has been ruled out, this trial aims to investigate whether outpatient computed tomography coronary angiography (CTCA) reduces subsequent myocardial infarction or cardiac death.
TARGET-CTCA is a multicentre prospective randomised open label with blinded endpoint parallel group event driven trial. After myocardial infarction and clear alternative diagnoses have been ruled out, participants with intermediate cardiac troponin concentrations (5 ng/L to 99th centile upper reference limit) will be randomised 1:1 to outpatient CTCA plus standard of care or standard of care alone. The primary endpoint is myocardial infarction or cardiac death. Secondary endpoints include clinical, patient-centred, process and cost-effectiveness. Recruitment of 2270 patients will give 90% power with a two-sided P value of 0.05 to detect a 40% relative risk reduction in the primary endpoint. Follow-up will continue until 97 primary outcome events have been accrued in the standard care arm with an estimated median follow-up of 36 months.
This randomised controlled trial will determine whether high-sensitivity cardiac troponin-guided CTCA can improve outcomes and reduce subsequent major adverse cardiac events in patients presenting to the emergency department who do not have myocardial infarction.
ClinicalTrials.gov Identifier: NCT03952351. Registered on May 16, 2019.
Risk stratification methods developed on the basis of predicting illness severity are often used to prioritise patients on the basis of urgency. Illness severity and urgency may not be ...interchangeable. Severe illness places patients at risk of adverse outcome, but treatment is only urgent if adverse outcome can be prevented by time-sensitive treatment. We aimed to develop a score to identify patients in need of urgent treatment, on the basis of potential to benefit from time-sensitive intervention, and to compare this with a severity score identifying patients at high risk of death.
A sequential cohort of adults presenting to one Emergency Department by ambulance and admitted to hospital was prospectively collected (2437 derivation, 2322 validation). Data on outcomes representing potential to benefit was collected retrospectively on a random subset (398 derivation, 227 validation). Logistic regression identified variables predictive of death and potential to benefit from urgent treatment.
Death was predicted using age, respiratory rate, diastolic blood pressure, oxygen saturations, temperature, GCS and respiratory disease (AUROC 0.84 (95 % CI 0.8-0.89) derivation and 0.74 (0.69-0.81) validation), while potential to benefit was predicted by pulse, systolic blood pressure and GCS (AUROC 0.74 (0.67-0.80) derivation and 0.71 (0.59-0.82) validation).
A score developed to predict the need for urgent treatment has a different composition to a score developed to predict illness severity, suggesting that triage methods based on predicting severity could lead to inappropriate prioritisation on the intended basis of urgency.
IntroductionSepsis is a common, potentially life-threatening complication of infection. The optimal treatment for sepsis includes prompt antibiotics and intravenous fluids, facilitated by its early ...and accurate recognition. Currently, clinicians identify and assess severity of suspected sepsis using validated clinical scoring systems. In England, the National Early Warning Score 2 (NEWS2) has been mandated across all National Health Service (NHS) trusts and ambulance organisations. Like many clinical scoring systems, NEWS2 should not be used without clinical judgement to determine either the level of acuity or a diagnosis. Despite this, there is a tendency to overemphasise the score in isolation in patients with suspected infection, leading to the overprescription of antibiotics and potentially treatment-related complications and rising antimicrobial resistance. The biomarker procalcitonin (PCT) has been shown to be useful in specific circumstances to support appropriate antibiotics prescribing by identifying bacterial infection. PCT is not routinely used in the care of undifferentiated patients presenting to emergency departments (EDs), and the evidence base of its optimal usage is poor. The PROcalcitonin and NEWS2 evaluation for Timely identification of sepsis and Optimal (PRONTO) study is a randomised controlled trial (RCT) in adults with suspected sepsis presenting to the ED to compare standard clinical management based on NEWS2 scoring plus PCT-guided risk assessment with standard clinical management based on NEWS2 scoring alone and compare if this approach reduces prescriptions of antibiotics without increasing mortality.Methods and analysisPRONTO is a parallel two-arm open-label individually RCT set in up to 20 NHS EDs in the UK with a target sample size of 7676 participants. Participants will be randomised in a ratio of 1:1 to standard clinical management based on NEWS2 scoring or standard clinical management based on NEWS2 scoring plus PCT-guided risk assessment. We will compare whether the addition of PCT measurement to NEWS2 scoring can lead to a reduction in intravenous antibiotic initiation in ED patients managed as suspected sepsis, with at least no increase in 28-day mortality compared with NEWS2 scoring alone (in conjunction with local standard care pathways). PRONTO has two coprimary endpoints: initiation of intravenous antibiotics at 3 hours (superiority comparison) and 28-day mortality (non-inferiority comparison). The study has an internal pilot phase and group-sequential stopping rules for effectiveness and futility/safety, as well as a qualitative substudy and a health economic evaluation.Ethics and disseminationThe trial protocol was approved by the Health Research Authority (HRA) and NHS Research Ethics Committee (Wales REC 2, reference 20/WA/0058). In England and Wales, the law allows the use of deferred consent in approved research situations (including ED studies) where the time dependent nature of intervention would not allow true informed consent to be obtained. PRONTO has approval for a deferred consent process to be used. Findings will be disseminated through peer-reviewed journals and presented at scientific conferences.Trial registration numberISRCTN54006056.
More than half of deaths in low- and middle-income countries (LMICs) result from conditions that could be treated with emergency care - an integral component of universal health coverage (UHC) - ...through timely access to lifesaving interventions.
The World Health Organization (WHO) aims to extend UHC to a further 1 billion people by 2023, yet evidence supporting improved emergency care coverage is lacking. In this article, we explore four phases of a research prioritisation setting (RPS) exercise conducted by researchers and stakeholders from South Africa, Egypt, Nepal, Jamaica, Tanzania, Trinidad and Tobago, Tunisia, Colombia, Ethiopia, Iran, Jordan, Malaysia, South Korea and Phillipines, USA and UK as a key step in gathering evidence required by policy makers and practitioners for the strengthening of emergency care systems in limited-resource settings.
The RPS proposed seven priority research questions addressing: identification of context-relevant emergency care indicators, barriers to effective emergency care; accuracy and impact of triage tools; potential quality improvement via registries; characteristics of people seeking emergency care; best practices for staff training and retention; and cost effectiveness of critical care - all within LMICs.
Convened by WHO and facilitated by the University of Sheffield, the Global Emergency Care Research Network project (GEM-CARN) brought together a coalition of 16 countries to identify research priorities for strengthening emergency care in LMICs. Our article further assesses the quality of the RPS exercise and reviews the current evidence supporting the identified priorities.
Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether ...patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers.
A patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England.
Four tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15.
The cost-effective triage tool depends on the English decision maker's MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.
COVID-19 infection rates remain high in South Africa. Clinical prediction models may be helpful for rapid triage, and supporting clinical decision making, for patients with suspected COVID-19 ...infection. The Western Cape, South Africa, has integrated electronic health care data facilitating large-scale linked routine datasets. The aim of this study was to develop a machine learning model to predict adverse outcome in patients presenting with suspected COVID-19 suitable for use in a middle-income setting. A retrospective cohort study was conducted using linked, routine data, from patients presenting with suspected COVID-19 infection to public-sector emergency departments (EDs) in the Western Cape, South Africa between 27th August 2020 and 31
st
October 2021. The primary outcome was death or critical care admission at 30 days. An XGBoost machine learning model was trained and internally tested using split-sample validation. External validation was performed in 3 test cohorts: Western Cape patients presenting during the Omicron COVID-19 wave, a UK cohort during the ancestral COVID-19 wave, and a Sudanese cohort during ancestral and Eta waves. A total of 282,051 cases were included in a complete case training dataset. The prevalence of 30-day adverse outcome was 4.0%. The most important features for predicting adverse outcome were the requirement for supplemental oxygen, peripheral oxygen saturations, level of consciousness and age. Internal validation using split-sample test data revealed excellent discrimination (C-statistic 0.91, 95% CI 0.90 to 0.91) and calibration (CITL of 1.05). The model achieved C-statistics of 0.84 (95% CI 0.84 to 0.85), 0.72 (95% CI 0.71 to 0.73), and 0.62, (95% CI 0.59 to 0.65) in the Omicron, UK, and Sudanese test cohorts. Results were materially unchanged in sensitivity analyses examining missing data. An XGBoost machine learning model achieved good discrimination and calibration in prediction of adverse outcome in patients presenting with suspected COVID19 to Western Cape EDs. Performance was reduced in temporal and geographical external validation.
To estimate the cost-effectiveness of delayed troponin testing for myocardial infarction compared with troponin testing at presentation.
Decision analysis modelling of cost-effectiveness using ...secondary data sources.
Acute hospitals in the UK.
Patients attending hospital with suspected myocardial infarction but a normal or non-diagnostic ECG and no major comorbidities requiring admission.
Delayed troponin testing (10 h after symptom onset) compared with standard and high-sensitivity troponin testing at presentation and no testing. Sensitivity analysis evaluated high-sensitivity troponin testing 3 h after initial assessment.
The incremental cost per quality-adjusted life year (QALY) gained by each strategy, compared with the next most effective alternative, and the probability of each strategy being cost-effective at varying willingness-to-pay per QALY gained.
In all scenarios tested, presentation high-sensitivity troponin testing was the most effective strategy with an incremental cost-effectiveness ratio below the £20 000/QALY threshold. 10 h troponin testing was only likely to be cost-effective if a discharge decision could be made as soon as a negative result was available and the £30 000/QALY threshold was used, or if a lower sensitivity estimate for presentation high-sensitivity troponin was assumed. Sensitivity analysis showed that including high-sensitivity troponin testing at presentation and 3 h in the analysis makes this the most cost-effective strategy.
Delayed troponin testing is unlikely to be cost-effective compared with high-sensitivity troponin testing at presentation in most scenarios. Current NICE chest pain guidelines do not promote cost-effective care.
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