Performance of the Interagency Integrated Triage Tool in a resource-constrained emergency department during the COVID-19 pandemic.

BACKGROUND: The Interagency Integrated Triage Tool (IITT) is a three-tier triage instrument recommended by the World Health Organization, but only the pilot version of the tool has been comprehensively assessed for its validity and reliability. This study sought to evaluate the performance of the IITT in a resource-constrained emergency department (ED) during the COVID-19 pandemic. METHODS: This prospective observational study was conducted at ANGAU Memorial Provincial Hospital in Lae, Papua New Guinea. The study period commenced approximately six weeks after introduction of the IITT, coinciding with a major COVID-19 wave. The primary outcome was sensitivity for the detection of time-critical illness, defined by eight pre-specified conditions. Secondary outcomes included the relationship between triage category and disposition. Inter-rater reliability was assessed using Cohen's Kappa. RESULTS: There were 759 eligible presentations during the study period. Thirty patients (4.0%) were diagnosed with one of the eight pre-specified time-critical conditions and 21 were categorised as red or yellow, equating to a sensitivity of 70.0% (95%CI 50.6-85.3). There was a clear association between triage category and disposition, with 22 of 53 red patients (41.5%), 72 of 260 yellow patients (27.7%) and 22 of 452 green patients (4.9%) admitted (p = <0.01). Negative predictive values for admission and death were 95.1% (95%CI 92.7-96.9) and 99.3% (95%CI 98.1-99.9) respectively. Among a sample of 106 patients, inter-rater reliability was excellent (κ = 0.83) and the median triage assessment time was 94 seconds [IQR 57-160]. CONCLUSION: In this single-centre study, the IITT's sensitivity for the detection of time-critical illness was comparable to previous evaluations of the tool and within the performance range reported for other triage instruments. There was a clear relationship between triage category and disposition, suggesting the tool can predict ED outcomes. Health service pressures related to COVID-19 may have influenced the findings.

Multimodal learning for emergency department triage implementation: experiences from Papua New Guinea during the COVID-19 pandemic.

Background: Triage implementation in resource-limited emergency departments (EDs) has traditionally relied on intensive in-person training. This study sought to evaluate the impact of a novel digital-based learning strategy focused on the Interagency Integrated Triage Tool, a three-tier triage instrument recommended by the World Health Organization. Methods: A mixed methods study utilising pre-post intervention methods was conducted in two EDs in Papua New Guinea. The primary outcome was the mean change in knowledge before and after completion of a voluntary, multimodal training program, primarily delivered through a digital learning platform accessible via smartphone. Secondary outcomes included the change in confidence to perform selected clinical tasks, and acceptability of the learning methods. Findings: Among 136 eligible ED staff, 91 (66.9%) completed the digital learning program. The mean knowledge score on the post-training exam was 87.5% (SD 10.4), a mean increase of 12.9% (95% CI 10.7-15.1%, p < 0.0001) from the pre-training exam. There were statistically significant improvements in confidence for 13 of 15 clinical tasks, including undertaking a triage assessment and identifying an unwell patient.In an evaluation survey, 100% of 30 respondents agreed or strongly agreed the online learning platform was easy to access, use and navigate, and that the digital teaching methods were appropriate for their learning needs. In qualitative feedback, respondents reported that limited internet access and a lack of dedicated training time were barriers to participation. Interpretation: The use of digital learning to support triage implementation in resource-limited EDs is feasible and effective when accompanied by in-person mentoring. Adequate internet access is an essential pre-requisite. Funding: Development of the Kumul Helt Skul learning platform was undertaken as part of the Clinical Support Program (Phase II), facilitated by Johnstaff International Development on behalf of the Australian Government Department of Foreign Affairs and Trade through the PNG-Australia Partnership. RM is supported by a National Health and Medical Research Council Postgraduate Scholarship and a Monash Graduate Excellence Scholarship, while PC is supported by a Medical Research Future Fund Practitioner Fellowship. Funders had no role in study design, results analysis or manuscript preparation.