Comparative Analysis of META and SALT Disaster Triage in an Adult Trauma Population: A Retrospective Observational Study.

BACKGROUND: Medical professionals can use mass-casualty triage systems to assist them in prioritizing patients from mass-casualty incidents (MCIs). Correct triaging of victims will increase their chances of survival. Determining the triage system that has the best performance has proven to be a difficult question to answer. The Advanced Prehospital Triage Model (Modelo Extrahospitalario de Triaje Avanzado; META) and Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) algorithms are the most recent triage techniques to be published. The present study aimed to evaluate the META and SALT algorithms' performance and statistical agreement with various standards. The secondary objective was to determine whether these two MCI triage systems predicted patient outcomes, such as mortality, length-of-stay, and intensive care unit (ICU) admission. METHODS: This retrospective study used patient data from the trauma registry of an American College of Surgeons Level 1 trauma center, from January 1, 2018 through December 31, 2020. The sensitivity, specificity, and statistical agreement of the META and SALT triage systems to various standards (Revised Trauma Score [RTS]/Sort Triage, Injury Severity Score [ISS], and Lerner criteria) when applied using trauma patients. Statistical analysis was used to assess the relationship between each triage category and the secondary outcomes. RESULTS: A total of 3,097 cases were included in the study. Using Sort triage as the standard, SALT and META showed much higher sensitivity and specificity in the Immediate category than for Delayed (Immediate sensitivity META 91.5%, SALT 94.9%; specificity 60.8%, 72.7% versus Delayed sensitivity 28.9%, 1.3%; specificity 42.4%, 28.9%). With the Lerner criteria, in the Immediate category, META had higher sensitivity (77.1%, SALT 68.6%) but lower specificity (61.1%) than SALT (71.8%). For the Delayed category, SALT showed higher sensitivity (META 61.4%, SALT 72.2%), but lower specificity (META 75.1%, SALT 67.2%). Both systems showed a positive, though modest, correlation with ISS. For SALT and META, triaged Immediate patients tended to have higher mortality and longer ICU and hospital lengths-of-stay. CONCLUSION: Both META and SALT triage appear to be more accurate with Immediate category patients, as opposed to Delayed category patients. With both systems, patients triaged as Immediate have higher mortality and longer lengths-of-stay when compared to Delayed patients. Further research can help refine MCI triage systems and improve accuracy.

Associated Factors of Under and Over-Triage Based on The Emergency Severity Index; a Retrospective Cross-Sectional Study.

Introduction: Under-triage increases patients' risks for morbidity and mortality, whereas over-triage limits the resources available to sicker patients. This study aimed to determine the rates as well as associated factors of under-triage and over-triage in emergency department (ED), based on Emergency Severity Index (ESI) triage system. Methods: In this retrospective cross-sectional study, triage level of ED patients based on the ESI version 4, was studied during a 9-month period in 2019. Patients' ESI level, which were examined by triage nurses were reevaluated by 3 emergency physicians and the rate of correct, under-, and over-triage as well as their associated factors were analyzed. Results: 1000 cases of triage were evaluated. Triage was correct in 69.1% of cases. The rate of under-triage was 4.9%, and that of over-triage was 26.0%. Over-triage was significantly more common among patients aged 18-30 years than for those aged ≥65 years (adjusted odds ratio [OR] = 1.73; 95% confidence interval [CI]: 1.07-2.81; p = 0.026); those with traumatic injuries (adjusted OR = 1.80; 95% CI: 1.29-2.52; p = 0.001); those arriving at the hospital during the evening shift (adjusted OR = 1.42; 95% CI: 1.01-2.0; p = 0.046); patients who were hospitalized (adjusted OR = 0.35; 95% CI: 0.22-0.54; p < 0.001); and those with severe pain (adjusted OR = 0.28; 95% CI: 0.10-0.84; p = 0.023). Younger age was also significantly associated with under-triage. Patients aged 18-30 years were under-triaged more often than those aged ≥65 years (adjusted OR = 3.05; 95% CI: 1.16-8.00; p = 0.023). Conclusions: Over-triage was substantially more common than under-triage in Vajira Hospital. Factors associated with over-triage were younger age, traumatic injury, arrival time, hospital admission, and severe pain. Younger age was the only factor related to under-triage.

Diagnostic Tests for Hypofibrinogenemia Resulting from Green Pit Viper (Trimeresurus albolabris) Envenomation: A Simulated In Vitro Study.

INTRODUCTION: The green pit viper (GPV) Trimeresurus albolabris is found in Southeast Asia. Its venom has a thrombin-like activity that can cause hypofibrinogenemia. Fibrinogen measurement is not always available. We aimed to establish a more available diagnostic tool indicating hypofibrinogenemia caused by GPV envenomation. METHODS: This was an in vitro study, in which healthy subjects aged 20 to 45 y were enrolled. There were 2 experiments. In Experiment 1, blood samples from 1 subject had varying amounts of T albolabris venom added to determine its effect on the fibrinogen level (FL). In Experiment 2, 3 sets of blood samples were obtained from another 25 subjects. The 2 venom doses established in Experiment 1 were used on 2 sets of the samples to simulate severe (FL <1.0 g·L-1) and mild hypofibrinogenemia (FL 1.0-1.7 g·L-1). The third set of samples was venom-free. All samples were used for platelet counts, prothrombin time (PT)/international normalized ratio (INR)/activated partial thromboplastin time (aPTT), and 2 bedside clotting tests. Diagnostic parameters were calculated against the target FL of <1.0 g·L-1 and <1.7 g·L-1. RESULTS: Twenty-five subjects were enrolled in Experiment 2. On referencing normal cutoff values (platelet count >150,000 cells/mm3, venous clotting time <15 min, normal 20-min whole blood clotting time, INR <1.2, aPTT <30), we found abnormalities of 5, 0, 0, 3, and 22%, respectively. The highest correlation with hypofibrinogenemia was provided by PT/INR. For an FL of <1.0 g·L-1, PT and INR revealed the highest areas under the receiver operating characteristic curve, 0.76 (95% CI, 0.55-0.97) and 0.76 (95% CI, 0.57-0.97), respectively. The highest accuracy and the highest sensitivity were provided by PT/INR. CONCLUSIONS: PT/INR could be used as a diagnostic test for severe hypofibrinogenemia in GPV envenomation because of its high accuracy and area under the receiver operating characteristic curve.

How the ARCH Project has Contributed to the Development of the ASEAN Regional Collaboration Mechanism on Disaster Health Management.

OBJECTIVE: This paper aims to clarify how the Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) strengthened regional collaboration mechanisms on disaster health management (DHM) in ASEAN. METHODS: The political process and the relevant documents of the ARCH Project were reviewed. RESULTS: The ARCH Project established the Regional Coordination Committee as a coordination platform for providing strategic direction to the project and strengthening the regional coordination of DHM. Also, the Project Working Groups and Sub-Working Groups were set up as implementation bodies for the project activities with representatives of ASEAN Member States (AMS). With support from DHM experts of Japan and Thailand, a series of discussions were conducted for the development of a Standard Operating Procedure (SOP) for the Coordination of International Emergency Medical Teams (I-EMTs), regional tools, and collective measures supporting AMS to overcome challenges, and thereby meeting the minimum requirements set by the WHO EMT Initiative. The progress and outputs of the ARCH Project are subsequently elevated to the ASEAN Health Sector for endorsement, the updates are further shared to the Joint Task Force to Promote Synergy with Other Relevant ASEAN Bodies on Humanitarian Assistance and Disaster Relief (JTF-HADR) for the implementation of the ASEAN Declaration on One ASEAN One Response. The initiation of the ARCH Project in July 2016 has resulted in the development of the ASEAN regional collaboration framework, including the establishment of the Regional Coordination Committee on Disaster Health Management (RCCDHM), the SOP for ASEAN I-EMT coordination, and regional tools, such as forms for Medical Record for Emergency and Disaster and Health Needs Assessment. Moreover, further discussions on ASEAN Collective Measures that aim to support AMS to meet the WHO EMT minimum standards and strengthening I-EMT coordination capacity were also conducted. As adopted by the ASEAN Health Ministers Meeting (AHMM) in 2019, the RCCDHM was established as one of the mechanisms to operationalize the Plan of Action to implement the ASEAN Leaders' Declaration on DHM. CONCLUSION: The contribution of the ARCH Project to strengthen the ASEAN regional capacity in DHM has enhanced the regional coordination platform, with a formalization of RCCDHM as ASEAN's official regional mechanism, and of the on-going integration process of the SOP for EMT coordination into the ASEAN SASOP.

Diagnostic Accuracy of Extended Focused Assessment with Sonography for Trauma Performed by Paramedic Students: A Simulation-Based Pilot Study.

BACKGROUND: Training on how to perform a prehospital extended focused assessment with sonography in trauma (EFAST) has resulted in improved outcomes for trauma patients in several countries. The result of previous studies showed good accuracy despite minimal training. However, data on the diagnostic accuracy among untrained paramedic students and the course length in middle-income countries is scarce. In Thailand, the current paramedic education does not include training on prehospital ultrasounds. In the present study, we aimed to investigate the diagnostic accuracy of EFAST among ultrasound-naïve paramedic students and factors that are associated with successful posttest training. METHODS: Final-year paramedic students attending a 4-year university program were included in this study. A 2-h didactic training session and 1-h hands-on workshop were led by experienced emergency physicians. The diagnostic indices for EFAST interpretation were obtained pretraining and posttraining. The participants' ultrasound image acquisition was also evaluated individually on a mannequin model using a standardized assessment tool. RESULTS: In total, 47 paramedic students were voluntarily enrolled and underwent EFAST training. Of these participants, 31 (66%) reported having >1 year of experience in the prehospital field. Four were advanced emergency medical technicians before becoming paramedic students. The sensitivity, specificity, positive predictive value, and negative predictive value after training were 85.7% (95% CI, 81.5-89.3), 81.6% (95% CI, 74.2-87.6), 91.6% (95% CI, 87.9-94.4), and 71% (95% CI, 63.3-77.8), respectively. Previous prehospital experience was not associated with accuracy. CONCLUSION: This study demonstrated that paramedic students in Thailand were able to achieve a competency comparable with that of other medical professionals in a simulated environment. The total 3 h training course was sufficient for them to acquire EFAST skills.