Maternal and Child Healthcare Service by Portable Health Clinic System Using a Triage Protocol

The number of deaths of a mother and child caused by maternal and child healthcare (MCH) issues has been greatly decreased recently, but still, the number is extremely high especially in developing countries. Although the governments have been given a priority in this issue, the lack of financial and human resources brings a limit. Thus, the use of low-cost but appropriate technology is required. Portable Health Clinic (PHC), a telemedicine system developed for providing primary healthcare, is such a technology. This study aimed to address this MCH issue with the aid of a low-cost PHC service involving a continuum-of-care protocol to the rural communities of Bangladesh. Moreover, this study introduces a triage protocol to distinguish high-risk patients from the early stage of the continuum of care who need special care and refer to specialized physicians to prevent unwanted deaths.

Abstract 1122‐000159: Area Deprivation Index and Transfer Likelihood Offer Insight into Improving Stroke Care Access Equity

Introduction : Time is brain for stroke care. Socioeconomic disparities may have an impact on timely access to stroke care. A well known factor that affects access to thrombectomy is the necessity for transfer from a non‐thrombectomy capable center to a thrombectomy capable center (TSC). The Area Deprivation Index (ADI) is a validated, neighborhood‐level composite measure (scored 1–100) which uses income, education, employment, housing quality, and other factors to identify geographic areas with increased need. We analyzed the association between ADI and requirement of transfer prior to thrombectomy to further understand how establishment of TSCs in areas with higher ADI and severity score bypass protocols can increase access to stroke care across all ranges of socioeconomic need. Methods : We obtained transfer status and the duration of the transfer time for all thrombectomy patients treated between 2016 and 2021 in a large, urban multi‐hospital health system and matched them with their respective census‐tract level ADI scores from Neighborhood Atlas, with a higher ADI score signifying lower socioeconomic status. Preliminary analysis utilized logistic regression to compare the ADI between transfer and non‐transfer cases. Further exploration observed temporal changes to the percentage of patients requiring transfer across 4 ADI ranges. Results : Among 513 cases for which we had a pick up address for between 2016–2021, the average ADI of pick‐up locations was 10.3 (range: 1 ‐ 70.5). ADI was significantly predictive of transfer status (p = 0.0004), with a 1 unit increase in ADI increasing the odds of being transferred by 1.035. Patients requiring transfer took an average of 2.7 hours longer to thrombectomy compared to non‐transfer patients. However, within the transfer population, a higher ADI did not correlate with increased transfer time. Across all ADI ranges, the likelihood of transfer began to decrease in 2018. This is likely due to the establishment of a new TSC in 2018 as well as the implementation of an EMS triage protocol transporting patients with a higher severity of stroke directly to TSCs. Notably, patients in the highest ADI range did not experience decreased likelihood of transfer until 2020, correlating with establishment of another TSC. Conclusions : Across urban census tracts, patients with a higher ADI had an increased likelihood of transfer, and hence delay in access to thrombectomy. Equity to access to thrombectomy improved over time. Expanding thrombectomy access as well as establishing EMS triage protocols appear to correlate with improvement in access to stroke thrombectomy care for patients with higher ADI.

Arizona Hospitals and Health Systems’ Statewide Collaboration Producing a Triage Protocol During the COVID-19 Pandemic

We describe the process by which all hospitals and health systems in Arizona, normally competitors, rapidly cooperated to develop a statewide protocol (“Addendum”) delineating how to allocate scarce resources during the COVID-19 pandemic should triage be required anywhere in the state. Eight physician ethicists from seven different health systems created the Addendum, which was accepted by all hospitals and health systems, approved by the State Disaster Medical Advisory Committee (SDMAC), and then formally adopted by the Arizona Department of Health Services (ADHS). In addition, the entire state developed a plan to “stick together” such that no facility would be forced to triage unless all were overwhelmed. Because we are unaware of any other state’s hospitals and health systems producing and committing to a shared triage protocol and plan, we believe this experience can serve as a model for other locales during the absence of sufficient state or federal guidance.

Establishment of a novel triage system for SARS-CoV-2 among trauma victims in trauma centers with limited facilities

ObjectivesThe triage of trauma patients with potential COVID-19 remains a major challenge given that a significant number of patients may be asymptomatic or pre-symptomatic. This study aimed to compare the specificity and sensitivity of available triage systems for COVID-19 among trauma patients. Furthermore, it aimed to develop a novel triage system for SARS-CoV-2 detection among trauma patients in centers with limited resources.MethodsAll patients referred to our center from February to May 2020 were enrolled in this prospective study. We evaluated the SARS-CoV-2 triage protocols from the WHO, the Iranian Ministry of Health and Medical Education (MOHME), and the European Centre for Disease Control and Prevention (ECDC) for their effectiveness in finding COVID-19 infected individuals among trauma patients. We then used these data to design a stepwise triage protocol to detect COVID-19 positive patients among trauma patients.ResultsAccording to our findings, the WHO protocol showed 100% specificity and 13.3% sensitivity. The MOHME protocol had 99% specificity and 23.3% sensitivity. While the ECDC protocol showed 93.3% sensitivity and 89.5% specificity, it did not prioritize patients based on traumatic injuries and unstable conditions. Our stepwise triage protocol, which prioritizes traumatic injuries, had 93.3% sensitivity and 90.3% specificity.ConclusionOur study shows that the triage protocols from the WHO, MOHME and ECDC are not best equipped to diagnose SARS-CoV-2 infected individuals among trauma patients. In our proposed stepwise triage system, patients are triaged according to their hemodynamic conditions, COVID-19 related clinical states, and COVID-19 related laboratory findings. Our triage model can lead to more accurate and resource-effective management of trauma patients with potential COVID-19 infection.Level of evidenceLevel Ⅲ.

Revision of the Protocol of the Telephone Triage System in Tokyo, Japan

Introduction. The Emergency Telephone Consultation Center in Tokyo (#7119) was the first telephone triage system in Japan and has operated since 2007. This study examined the revision of the #7119 protocol by referring the linked data to each code of the triage protocol. Methods. We selected candidates based on the medical codes targeted by the revision, linking data from the nurses’ decisions in triage and the patients’ condition severity when the ambulance arrived at the hospital, gathering data from June 1, 2016, to December 31, 2017. Then, several emergency physicians evaluated the cases and decided whether the code should be moved to the more or less urgent category or if new protocols and codes would be established. Results. In this revision, 371 codes were moved to the less urgent category, 35 codes were moved to the more urgent category, and 128 codes were newly established. In all, 59 red codes (transfer to the ambulance dispatcher) were reduced, while 254 orange codes (attendance at hospital within 1 hour) and yellow codes (within 6 hours) were moved to less urgent, and 12 yellow and green codes (within 24 hours) were moved to more urgent. Conclusion. We adjusted the triage codes for the revision by linking the call data with the case data. This revision should decrease the inappropriate use of ambulances and reduce the primary care workload. To achieve a more accurate revision, we need to refine the process of evaluating the validity of patients’ acuity over the telephone during triage.

Reactivation of COVID-19 in a neurosurgical patient with early neuropsychiatric presentation. Does seroconversion mean immunity?

Background: In the aftermath of COVID-19 outbreak, there is a strong need to find strategies to monitor SARSCoV-2 transmission. While the application of screening techniques plays a major role to this end, there is evidence challenging the real significance of seroconversion. We reported a case of COVID-19 reactivation associated with a neurosurgical operation with early neuropsychiatric involvement presumably promoted by olfactory and gustatory impairment in the first infection. Case Descriptio: A 57-year-old man was referred for a 2-month history of progressive development of imbalance, dizziness, and vomiting. Magnetic resonance imaging showed two bilateral hemispheric cerebellar lesions. In line with our triage protocol, the patient underwent a nasopharyngeal swab for RNA of SARS-CoV-2 detection, which resulted positive. Of note, the patient had reported in the previous month hyposmia and hypogeusia. After a period of 14 days, three new swabs were performed with negative results, leading the way to surgery. In the early post-operative period, the patient manifested acute onset of psychotic symptoms with hyperactive delirium, followed by fever and acute respiratory failure. A chest computed tomography revealed a specific pattern of ground-glass opacities in the lower lobes bilaterally, suggesting a viral pneumonia. Serological tests demonstrated the seroconversion and a new nasopharyngeal swab confirmed SARS-CoV-2 infection. Conclusion: Our report highlights the importance of comprehensive screening assessments in sensitive cases highly susceptible to COVID-19 recurrence.

Stigma against COVID-19 among health care workers in Indonesia

ABSTRACT Objective: The aim of this study was to assess the stigma against coronavirus disease 2019 (COVID-19) among health care workers (HCWs) in Indonesia during the early phase of pandemic. Methods: A cross-sectional study was conducted in twelve hospitals across the country on March 2020. A logistic regression was employed to assess the association between stigma and explanatory variables. Results: In total, 288 HCWs were surveyed in which 93.4% of them had never experienced any outbreaks. Approximately 21.9% of the respondents had stigma against COVID-19. HCWs who were doctor, had not participating in trainings related to COVID-19, working at the capital of the province, working at private hospitals, and working at the hospital with COVID-19 triage protocol were likely to have no stigma against COVID-19. Conclusions: The stigma against COVID-19 is relatively high among HCWs in the early phase of COVID-19 pandemic in Indonesia. Adequate knowledge dissemination and adequate protection are necessary to reduce the stigma among HCWs.

A Catholic Perspective: Triage Principles and Moral Distress in Pandemic Scarcity

Striving to be faithful to the moral core of medicine and to spiritual, moral, and social teaching of the church, Catholic physicians see their role as an extension of the healing ministry of Jesus. When faced with a situation in which a large number of gravely ill people are seeking care, but optimal treatment such as ventilation in intensive care unit cannot be offered to all because of scarcity of resources, Catholic physicians recognize the need to consider the common good and to assign a priority to patients for whom such treatments would be most probably lifesaving. Making these evaluations, physicians will use only objective medical criteria regarding the benefits and risks to patients and will be mindful that all persons deserve equal respect for their dignity. Discrimination or prejudicial treatment against patients based on factors such as age, disability, race, gender, quality of life, and possible long-term survival cannot be morally justified. Triage process should incorporate respect for autonomy of both the patient and the professional and opportunity for an appeal of a triage decision. Other principles and values that will affect how a triage protocol is developed and applied are proportionality, equity, reciprocity, solidarity, subsidiarity, and transparency. The current coronavirus pandemic can provide valuable lessons and stimulus for reforms and renewal. Summary: Catholic physicians strive to continue the healing ministry of Jesus Christ and be faithful to the moral core of medicine. In situations such as pandemic, the scarcity of personnel and technological resources create serious challenges and even moral distress. Church teachings on dignity, the common good and protection of the vulnerable help guide decisions based on public medical criteria and shared decision-making.