Providing Remote Aid During a Humanitarian Crisis.

Humanitarian crises create opportunities for both in-person and remote aid. Durable, complex, and team-based care may leverage a telemedicine approach for comprehensive support within a conflict zone. Barriers and enablers are detailed, as is the need for mission expansion due to initial program success. Adapting a telemedicine program initially designed for critical care during the severe acute respiratory syndrome coronavirus 2 pandemic offers a solution to data transfer and data analysis issues. Staffing efforts and grouped elements of patient care detail the kinds of remote aid that are achievable. A multiprofessional team-based approach (clinical, administrative, nongovernmental organization, government) can provide comprehensive consultation addressing surgical planning, critical care management, infection and infection control management, and patient transfer for complex care. Operational and network security create parallel concerns relevant to avoid geolocation and network intrusion during consultation. Deliberate approaches to address cultural differences that influence relational dynamics are also essential for mission success.

Prolonged wait time is associated with increased mortality for Chilean waiting list patients with non-prioritized conditions.

BACKGROUND: Most data on mortality and prognostic factors of universal healthcare waiting lists come from North America, Australasia, and Europe, with little information from South America. We aimed to determine the relationship between medical center-specific waiting time and waiting list mortality in Chile. METHOD: Using data from all new patients listed in medical specialist waitlists for non-prioritized health problems from 2008 to 2015 in three geographically distant regions of Chile, we constructed hierarchical multivariate survival models to predict mortality risk at two years after registration for each medical center. Kendall rank correlation analysis was used to measure the association between medical center-specific mortality hazard ratio and waiting times. RESULT: There were 987,497 patients waiting for care at 77 medical centers, including 33,546 (3.40%) who died within two years after registration. Male gender (hazard ratio [HR] = 1.17, 95% confidence interval [CI] 1.1-1.24), older age (HR = 2.88, 95% CI 2.72-3.05), urban residence (HR = 1.19, 95% CI 1.09-1.31), tertiary care (HR = 2.2, 95% CI 2.14-2.26), oncology (HR = 3.57, 95% CI 3.4-3.76), and hematology (HR = 1.6, 95% CI 1.49-1.73) were associated with higher risk of mortality at each medical center with large region-to-region variations. There was a statistically significant association between waiting time variability and death (Z = 2.16, P = 0.0308). CONCLUSION: Patient wait time for non-prioritized health conditions was associated with increased mortality in Chilean hospitals.

Accuracy of emergency department triage using the Emergency Severity Index and independent predictors of under-triage and over-triage in Brazil: a retrospective cohort analysis.

BACKGROUND: Emergency department (ED) triage is performed to prioritize care for patients with critical and time-sensitive illness. Triage errors create opportunity for increased morbidity and mortality. Here, we sought to measure the frequency of under- and over-triage of patients by nurses using the Emergency Severity Index (ESI) in Brazil and to identify factors independently associated with each. METHODS: This was a single-center retrospective cohort study. The accuracy of initial ESI score assignment was determined by comparison with a score entered at the close of each ED encounter by treating physicians with full knowledge of actual resource utilization, disposition, and acute outcomes. Chi-square analysis was used to validate this surrogate gold standard, via comparison of associations with disposition and clinical outcomes. Independent predictors of under- and over-triage were identified by multivariate logistic regression. RESULTS: Initial ESI-determined triage score was classified as inaccurate for 16,426 of 96,071 patient encounters. Under-triage was associated with a significantly higher rate of admission and critical outcome, while over-triage was associated with a lower rate of both. A number of factors identifiable at time of presentation including advanced age, bradycardia, tachycardia, hypoxia, hyperthermia, and several specific chief complaints (i.e., neurologic complaints, chest pain, shortness of breath) were identified as independent predictors of under-triage, while other chief complaints (i.e., hypertension and allergic complaints) were independent predictors of over-triage. CONCLUSIONS: Despite rigorous and ongoing training of ESI users, a large number of patients in this cohort were under- or over-triaged. Advanced age, vital sign derangements, and specific chief complaints-all subject to limited guidance by the ESI algorithm-were particularly under-appreciated.

Accuracy and Reliability of Emergency Department Triage Using the Emergency Severity Index: An International Multicenter Assessment.

STUDY OBJECTIVE: We assess accuracy and variability of triage score assignment by emergency department (ED) nurses using the Emergency Severity Index (ESI) in 3 countries. In accordance with previous reports and clinical observation, we hypothesize low accuracy and high variability across all sites. METHODS: This cross-sectional multicenter study enrolled 87 ESI-trained nurses from EDs in Brazil, the United Arab Emirates, and the United States. Standardized triage scenarios published by the Agency for Healthcare Research and Quality (AHRQ) were used. Accuracy was defined by concordance with the AHRQ key and calculated as percentages. Accuracy comparisons were made with one-way ANOVA and paired t test. Interrater reliability was measured with Krippendorff's α. Subanalyses based on nursing experience and triage scenario type were also performed. RESULTS: Mean accuracy pooled across all sites and scenarios was 59.2% (95% confidence interval [CI] 56.4% to 62.0%) and interrater reliability was modest (α=.730; 95% CI .692 to .767). There was no difference in overall accuracy between sites or according to nurse experience. Medium-acuity scenarios were scored with greater accuracy (76.4%; 95% CI 72.6% to 80.3%) than high- or low-acuity cases (44.1%, 95% CI 39.3% to 49.0% and 54%, 95% CI 49.9% to 58.2%), and adult scenarios were scored with greater accuracy than pediatric ones (66.2%, 95% CI 62.9% to 69.7% versus 46.9%, 95% CI 43.4% to 50.3%). CONCLUSION: In this multinational study, concordance of nurse-assigned ESI score with reference standard was universally poor and variability was high. Although the ESI is the most popular ED triage tool in the United States and is increasingly used worldwide, our findings point to a need for more reliable ED triage tools.