A comprehensive review of dose limits, triage systems and measurement tools for consequence management of nuclear and radiological emergencies.

During a radiological or nuclear emergency, occupational workers, members of the public, and emergency responders may be exposed to radionuclides, whether external or internal, through inhalation, ingestion, or wounds. In the case of internalized radiation exposure, prompt assessment of contamination is necessary to inform subsequent medical interventions. This review assembles the constituent considerations for managing nuclear and radiological incidents, focused on a parallel analysis of the evolution of radiation dose limits - notably in the emergency preparedness and response realm - alongside a discussion of triage systems and in vivo radionuclide detection tools. The review maps the development of international and national standards and regulations concerning radiation dose limits, illuminating how past incidents and accumulated knowledge have informed present emergency preparedness and response practices, specifically for internalized radiation. Additionally, the objectives and levels of radiation triage systems are explored in-depth, along with a global survey of practices and protocols. Finally, this review also focuses on in vivo detection systems and their capacities for radionuclide identification, prioritizing internalized gamma-emitting isotopes due to their broader relevance. Collectively, this study comprehensively addresses the intricacies of triage management following radiation emergencies, emphasizing the imperative for enhanced standardization and continued research in this critical domain.

A study on the impact of prioritising emergency department arrivals on the patient waiting time.

In the past decade, the crowding of the emergency department has gained considerable attention of researchers as the number of medical service providers is typically insufficient to fulfil the demand for emergency care. In this paper, we solve the stochastic emergency department workforce planning problem and consider the planning of nurses and physicians simultaneously for a real-life case study in Belgium. We study the patient arrival pattern of the emergency department in depth and consider different patient acuity classes by disaggregating the arrival pattern. We determine the personnel staffing requirements and the design of the shifts based on the patient arrival rates per acuity class such that the resource staffing cost and the weighted patient waiting time are minimised. In order to solve this multi-objective optimisation problem, we construct a Pareto set of optimal solutions via the 𝜖-constraints method. For a particular staffing composition, the proposed model minimises the patient waiting time subject to upper bounds on the staffing size using the Sample Average Approximation Method. In our computational experiments, we discern the impact of prioritising the emergency department arrivals. Triaging results in lower patient waiting times for higher priority acuity classes and to a higher waiting time for the lowest priority class, which does not require immediate care. Moreover, we perform a sensitivity analysis to verify the impact of the arrival and service pattern characteristics, the prioritisation weights between different acuity classes and the incorporated shift flexibility in the model.

Are Emergency Departments in the United States Following Recommendations by the Emergency Severity Index to Promote Quality Triage and Reliability?

INTRODUCTION: The purpose of this study was to explore and describe (1) the extent to which emergency departments in the United States are promoting the quality of triage and the reliability of triage systems according to recommendations in the Emergency Severity Index (ESI) Handbook and (2) if relationships existed between triage structure (policies) and process (procedures) in emergency departments that promote accuracy of triage decisions. METHODS: Donabedian's Structure, Process, Outcome model guided this descriptive, correlational study. Nurses were recruited from all geographic regions in the United States, and the ED TRiAGE Structure and Process Survey was developed to collect data. Χ2 tests of independence, Fisher's exact tests, and Kendall's τ were used to assess relationships of structure and process. RESULTS: The majority of emergency departments did not meet at least the minimum recommendations of the ESI triage system. Significant positive relationships were found when an emergency department had structure (policy) to guide process (procedures). Differences were reported in the type, amount, and focus of the policies and procedures. DISCUSSION: Donabedian's model emphasizes that good structure and process are antecedents of good outcomes. This study serves as a foundation on which to examine the consistency of emergency departments meeting the ESI guidelines that promote triage accuracy and maintaining the reliability of evidence-based triage acuity systems.

Five-level emergency triage systems: variation in assessment of validity.

INTRODUCTION: Triage systems are scales developed to rate the degree of urgency among patients who arrive at EDs. A number of different scales are in use; however, the way in which they have been validated is inconsistent. Also, it is difficult to define a surrogate that accurately predicts urgency. This systematic review described reference standards and measures used in previous validation studies of five-level triage systems. METHODS: We searched PubMed, EMBASE and CINAHL to identify studies that had assessed the validity of five-level triage systems and described the reference standards and measures applied in these studies. Studies were divided into those using criterion validity (reference standards developed by expert panels or triage systems already in use) and those using construct validity (prognosis, costs and resource use). RESULTS: A total of 57 studies examined criterion and construct validity of 14 five-level triage systems. Criterion validity was examined by evaluating (1) agreement between the assigned degree of urgency with objective standard criteria (12 studies), (2) overtriage and undertriage (9 studies) and (3) sensitivity and specificity of triage systems (7 studies). Construct validity was examined by looking at (4) the associations between the assigned degree of urgency and measures gauged in EDs (48 studies) and (5) the associations between the assigned degree of urgency and measures gauged after hospitalisation (13 studies). Particularly, among 46 validation studies of the most commonly used triages (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System), 13 and 39 studies examined criterion and construct validity, respectively. CONCLUSION: Previous studies applied various reference standards and measures to validate five-level triage systems. They either created their own reference standard or used a combination of severity/resource measures.

Novel Approach to Personalized Physician Recommendations Using Semantic Features and Response Metrics: Model Evaluation Study.

BACKGROUND: The rapid growth of web-based medical services has highlighted the significance of smart triage systems in helping patients find the most appropriate physicians. However, traditional triage methods often rely on department recommendations and are insufficient to accurately match patients' textual questions with physicians' specialties. Therefore, there is an urgent need to develop algorithms for recommending physicians. OBJECTIVE: This study aims to develop and validate a patient-physician hybrid recommendation (PPHR) model with response metrics for better triage performance. METHODS: A total of 646,383 web-based medical consultation records from the Internet Hospital of the First Affiliated Hospital of Xiamen University were collected. Semantic features representing patients and physicians were developed to identify the set of most similar questions and semantically expand the pool of recommended physician candidates, respectively. The physicians' response rate feature was designed to improve candidate rankings. These 3 characteristics combine to create the PPHR model. Overall, 5 physicians participated in the evaluation of the efficiency of the PPHR model through multiple metrics and questionnaires as well as the performance of Sentence Bidirectional Encoder Representations from Transformers and Doc2Vec in text embedding. RESULTS: The PPHR model reaches the best recommendation performance when the number of recommended physicians is 14. At this point, the model has an F1-score of 76.25%, a proportion of high-quality services of 41.05%, and a rating of 3.90. After removing physicians' characteristics and response rates from the PPHR model, the F1-score decreased by 12.05%, the proportion of high-quality services fell by 10.87%, the average hit ratio dropped by 1.06%, and the rating declined by 11.43%. According to whether those 5 physicians were recommended by the PPHR model, Sentence Bidirectional Encoder Representations from Transformers achieved an average hit ratio of 88.6%, while Doc2Vec achieved an average hit ratio of 53.4%. CONCLUSIONS: The PPHR model uses semantic features and response metrics to enable patients to accurately find the physician who best suits their needs.

Are 5-level triage systems improved by using a symptom based approach?-a Danish cohort study.

BACKGROUND: Five-level triage systems are being utilized in Danish emergency departments with and without the use of presenting symptoms. The aim of this study was to validate and compare two 5-level triage systems used in Danish emergency departments: "Danish Emergency Process Triage" (DEPT) based on a combination of vital signs and presenting symptoms and a locally adapted version of DEPT (VITAL-TRIAGE) using vital signs only. METHODS: This was a retrospective cohort using data from five Danish emergency departments. All patients attending an emergency department during the period of 1 April 2012 until 31 December 2015 were included. Validity of the two triage systems was assessed by comparing urgency categories determined by each triage system with critical outcomes: admission to Intensive care unit (ICU) within 24 h, 2-day mortality, diagnosis of critical illness, surgery within 48 h, discharge within 4 h and length of hospital stay. RESULTS: We included 632,196 ED contacts. Sensitivity for 24-h ICU admission was 0.79 (95% confidence interval 0.78-0.80) for DEPT and 0.44 (0.41-0.47) for VITAL-TRIAGE. The sensitivity for 2-day mortality was 0.69 (0.67-0.70) for DEPT and 0.37 (0.34-0.41) for VITAL-TRIAGE. The sensitivity to detect diagnoses of critical illness was 0.48 (0.47-0.50) for DEPT and 0.09 (0.08-0.10) for VITAL-TRIAGE. The sensitivity for predicting surgery within 48 h was 0.30 (0.30-0.31) in DEPT and 0.04 (0.04-0.04) in VITAL-TRIAGE. Length of stay was longer in VITAL-TRIAGE than DEPT. The sensitivity of DEPT to predict patients discharged within 4 h was 0.91 (0.91-0.92) while VITAL-TRIAGE was higher at 0.99 (0.99-0.99). The odds ratio for 24-h ICU admission and 2-day mortality was increased in high-urgency categories of both triage systems compared to low-urgency categories. CONCLUSIONS: High urgency categories in both triage systems are correlated with adverse outcomes. The inclusion of presenting symptoms in a modern 5-level triage system led to significantly higher sensitivity measures for the ability to predict outcomes related to patient urgency. DEPT achieves equal prognostic performance as other widespread 5-level triage systems.

Oligoanalgesia in the emergency setting - An Indian review.

Pain is a result of nociceptive tissue injury and results in acute and chronic impact to patients. Acute pain management is the need of the hour as untreated or under-treated pain may progress to chronic pain. Pain irrespective of its temporality causes a negative impact on the quality of life of the patients. Many Indian emergency settings are not adequately equipped to handle pain due to the heavy load of patients and the lack of awareness about the pain management guidelines. This leads to undertreatment of pain or 'oligoanalgesia'. A pain management protocol can help prevent oligoanalgesia in an emergency setting. Proper utilization of triage systems that incorporate pain as one of the vital signs is necessary. The categorization of pain with the help of a pain scale helps determine the severity of pain and its appropriate management. Pain management is an ongoing process that does not end with the discharge of the patient. Post discharge management of pain is also an important factor to prevent chronic pain. This may involve various modalities for pain management under the preview of multimodal management of pain.

Factors affecting emergency nurses' perceptions of the triage systems.

Background: Emergency services use a triage system to prioritize patients according to their level of diagnosis. Triage is one of the mandated skills to be owned by an emergency unit nurse. This research aims to identify factors affecting emergency nurses' perceptions of the triage systems. Design and Methods: 90 nurses were chosen based on quota sampling. Data were analyzed using Chi Square test (α 0.05) and logistic regression analysis. Results: The results show that nurses perceptions were influenced by knowledge (p = 0.017), working experience (p = 0.023), and training (p = 0.041). The factor that had the strongest influence in the formation of nurses' perceptions was knowledge (p = 0.020 and OR = 3.19). Conclusions: It can be concluded that knowledge, working experience and training influenced emergency nurses' perceptions on triage systems.

Applying a Human-Centered Design to Develop a Patient Prioritization Tool for a Pediatric Emergency Department: Detailed Case Study of First Iterations.

BACKGROUND: Overcrowding in the emergency departments has become an increasingly significant problem. Patient triage strategies are acknowledged to help clinicians manage patient flow and reduce patients' waiting time. However, electronic patient triage systems are not developed so that they comply with clinicians' workflow. OBJECTIVE: This case study presents the development of a patient prioritization tool (PPT) and of the related patient prioritization algorithm (PPA) for a pediatric emergency department (PED), relying on a human-centered design process. METHODS: We followed a human-centered design process, wherein we (1) performed a work system analysis through observations and interviews in an academic hospital's PED; (2) deduced design specifications; (3) designed a mock PPT and the related PPA; and (4) performed user testing to assess the intuitiveness of the icons, the effectiveness in communicating patient priority, the fit between the prioritization model implemented and the participants' prioritization rules, and the participants' satisfaction. RESULTS: The workflow analysis identified that the PPT interface should meet the needs of physicians and nurses, represent the stages of patient care, and contain patient information such as waiting time, test status (eg, prescribed, in progress), age, and a suggestion for prioritization. The mock-up developed gives the status of patients progressing through the PED; a strip represents the patient and the patient's characteristics, including a delay indicator that compares the patient's waiting time to the average waiting time of patients with a comparable reason for emergency. User tests revealed issues with icon intuitiveness, information gaps, and possible refinements in the prioritization algorithm. CONCLUSIONS: The results of the user tests have led to modifications to improve the usability and usefulness of the PPT and its PPA. We discuss the value of integrating human factors into the design process for a PPT for PED. The PPT/PPA has been developed and installed in Lille University Hospital's PED. Studies are carried out to evaluate the use and impact of this tool on clinicians' situation awareness and prioritization-related cognitive load, prioritization of patients, waiting time, and patients' experience.

Irritants and corrosives.

This article reviews toxic chemicals that cause irritation and damage to single and multiple organ systems (corrosion) in an acute fashion. An irritant toxic chemical causes reversible damage to skin or other organ system, whereas a corrosive agent produces irreversible damage, namely, visible necrosis into integumentary layers, following application of a substance for up to 4 hours. Corrosive reactions can cause coagulation or liquefaction necrosis. Damaged areas are typified by ulcers, bleeding, bloody scabs, and eventual discoloration caused by blanching of the skin, complete areas of alopecia, and scars. Histopathology should be considered to evaluate questionable lesions.