Beirut Blast 2020: Cries and Bloodshed at the Busiest Hospital

On August 4, 2020, Beirut experienced a large explosion when 2750 tons of ammonium nitrate detonated in the Beirut port resulting in more than 220 deaths, 76 000 injuries, 300 000 people displaced, and 15 billion dollars loss in property damage. Hôtel-Dieu de France (HDF), one of the largest university hospitals in the capital, has an emergency department that typically accommodates 25 patients. On that night, it received the largest number of injuries and had to accommodate more than 700 casualties within a few hours of the blast. This article describes HDF’s preparedness, emergency response, as well as the distribution of admissions to the emergency department, operation rooms, and the general ward. Surge capacity and the triage system are also detailed.

Improving the Safety of the Manchester Triage System for Children with Congenital Heart Disease

This study is a prospective evaluation of the validity of a Manchester Triage System (MTS) modification for detecting under-triaged pediatric patients with congenital heart disease (CHD). Children with CHD visiting the emergency unit of the Department of Pediatrics and Adolescent Medicine, Vienna General Hospital, in 2014 were included. The MTS modification updated the prioritization of patients with complex syndromic diseases, specific symptoms related to chronic diseases, decreased general condition (DGC), profound language impairment, unknown medical history, or special needs. A four-level outcome severity index based on diagnostic and therapeutic interventions, admission to hospital, and follow-up strategies, was defined as a reference standard for the correct clinical classification of the MTS urgency level. Of the 19,264 included children, 940 had CHD. Of this group, 266 fulfilled the inclusion criteria for the modified triage method. The MTS modification was significantly more often applied in under-triaged (65.9%) than correctly or over-triaged (25%) children with CHD (p-value χ²test <0.0001, OR 5.848 95% CI: 3.636-9.6).Conclusion: The MTS urgency level upgrade modification could reduce under-triage in children with CHD. Applying a safety strategy concept to the MTS could mitigate under-triage in such a high-risk patient group.

The SALT and START Triage System for Classifying Patient Acuity Level: A Systematic Review

Background: Two common triage systems have been widely used in mass casualty incidents (MCIs) and disaster situations, namely START (simple triage algorithm and rapid treatment) and SALT (sort, assess, lifesaving, intervention, and treatment/transport). There is currently controversy regarding the effectiveness of SALT over the START triage system.Purpose: This systematic review aims to compare the accuracy of the SALT and START triage systems in disaster and MCI settings.Methods: The literature was searched using a systematic search strategy for articles published from 2009 to 2020 in the Medline, CINAHL, Web of Science, Scopus, PubMed, ProQuest databases, and the grey literature. This review included simulation-based and medical record-based studies investigating the accuracy and applicability of the SALT and START triage systems in adult and child populations during MCIs and disasters. All types of studies were included. The PRISMA flowchart was used to retain the articles, and the Joanna Briggs Institute critical appraisal tools were used to assess the quality of the reviewed studies.Results: Of 1,450 articles identified in the search, 10 articles were included. It was found that the START triage system had a wide range and inconsistent levels of accuracy (44% to 94.2%) compared to the SALT triage system (70% to 83%). The under-triage error of the START triage system ranged from 2.73% to 20%, which was slightly lower than the SALT triage system (7.6% to 23.3%). The over-triage error of the START triage system (2% to 53%) was slightly higher than the SALT triage system (2% to 22%). However, the time taken to apply START triage system (70 to 72.18 seconds) was faster than for the SALT triage system (78 seconds).Conclusion: The START triage system was simpler and faster than SALT. Conversely, the SALT triage system appeared to be slightly more accurate, more consistent, and had a lower rate of under- and over-triage error than START. It appears that neither the SALT nor the START triage system is superior to the other. Further research is needed to establish the most appropriate disaster and MCI triage system, especially for the Indonesian context.

The impact of the Covid-19 pandemic on care of women with ectopic pregnancy in a tertiary London hospital

Background: In response to the COVID-19 pandemic, a central London tertiary referral hospital’s nurse-led Early Pregnancy & Acute Gynaecology Unit (EPAGU) suspended its walk-in service in favour of a telephone triage system with scheduled appointments. Objective: To assess if the pandemic and this adaptation to clinical services had an impact on the presentation, management and complication rate of ectopic pregnancies. Materials and Methods: A retrospective review was performed of ectopic pregnancies diagnosed in the EPAGU between 5th of March 2020 – 15th of July 2020 (pandemic) and 5th of March 2019 – 15th of July 2019 (pre-pandemic). Main outcome measures: Ultrasound findings, patient demographics, serum hCG concentrations, operative findings and complications. Results: There was a 36% reduction in attendances to the unit during the pandemic. Allowing for this, there was no significant difference in the diagnosis rate between the two periods. There was no significant difference in the gestation at diagnosis, serum hCG concentration or volume of mass at presentation. There was also no significant difference in rate of surgical intervention or complications including rupture of fallopian tube, haemoperitoneum or need for blood transfusion. Conclusion: This study suggests this is a safe means of caring for women with ectopic pregnancies which does not limit management options nor lead to higher complication rates. What is new: Other EPAGUs may choose to adopt a telephone triage system with reassurance of its safety.

Sudanese emergency departments: a study to identify the barriers to a well-functioning triage

Background: Triage system is a sorting system that categorizes patients on the basis of the severity of their condition and the availability of the resources in the emergency department. There has been little attention in the public literature to triage systems in Sudan. The aim of this study was to explore the triage system and identify the barriers in its application in hospitals in Sudan. Methods: A cross-sectional hospital based study was conducted at eight hospitals in Khartoum during December 2020. A multi-stage cluster sampling was applied. Data were obtained by interviewing emergency department staff using a structured questionnaire. The data were analyzed using statistical package for social sciences to find the association between various variables by chi-square test. Results: Most of the respondents stated that the triage system was deficient. Most of the participants of this study agreed that the role played by the administration in taking legislative decisions is crucial in improving the triage system. Among the factors found to be significant to a well-functioning triage system were, the need for substantial capital expenditure, p-value: 0.026, prudent legislative decisions, p-value: 0.026, adequate training of staff on means of performing efficient triaging, p-value: 0.017 and raising the awareness of the staff on the correct application of triage guidelines, p-value: 0.007. Conclusion: Currently there is no formal triage system in the State of Khartoum and has yet to be established. Policy making by administrators will play an important role in its implementation. It is suggested that prompt executive orders on improving the current triage system in Khartoum, should be carried out sooner than later, as the ripple effects of a well-functioning triage will decrease the average length of stay, mortality and morbidity rates and will eventually increase the patient’s satisfaction.