METMobile Emergency Triage

Saving Lives. Saving Dollars.

Poznań University of Technology, PolandUniversity of Ottawa, CanadaCHEO (Children’s Hospital of Eastern Ontario), Canada

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What Does Triage Mean? A process for sorting injured people into groups

based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocated

Triage Diagnosis

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Process of Emergency Triage

Prioritization(Triage nurse)

Medical assessment and disposition

(Physician)

ConsultObservation/

further investigationDischarge

Priority categories

Canadian Triage Acuity Scale (CTAS)CTAS1 – ImmediateCTAS2 – 15 min.CTAS3 – 30 min.CATS4 – 1 hourCTAS5 – 2 hours

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Triage Support

Why to support triage? To increase triage accuracy

Incorrect decision may be dangerous Incorrect decision is expensive (unnecessary

consultations and tests) To decrease triage duration

Examinations and observation may last several hours (150 – 180 min.)

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Pain Presentations A systematic review of common presentations in

the ED failed

Interest- and data-driven analysisDifficulties with finding „positive” (sick) patients – failure of the syncope project

Many CDSSs used in practice are based on knowledge extracted from medical textbooks – ISABEL (http://www.isabel.org.uk)

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Pain PresentationsAbdominal Pain Primary cause for consult

Appendicitis

Prevalence ( 623 charts) At CHEO 3300 visits per year (including trauma), i.e.

8-9 children seen daily Approximately 240 children per year are admitted

with acute appendicitis

Extensive studies in the past de Dombal, clinical trials with 16.000 patients

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Pain PresentationsScrotal Pain Primary cause for consult

Torsion of testis Torsion-detorsion syndrome

Prevalence ( 171 charts) A relatively uncommon complaint – 0.5% of total ER

visits, but a common source for consultation in a pediatric ER

Misdiagnosed testicular torsion is one of the most common sources of legal proceedings against urologists and general surgeons

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Pain PresentationsHip Pain Primary cause for consult

Acute septic arthritis Legg-calve-perthes Skipped capital femoral epiphysis

Prevalence ( 342 charts) Acute septic arthritis leads to rapid destruction of

the joint with long-term disability if not diagnosed and treated effectively

Other presentation require orthopedic consultation or intervention

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Development of a Decision Model

Rough set theory with cumulative indiscernibility Handles missing values without any changes to

original data Easily „integrates” with already developed algorithms

and methods Presents knowledge in form of comprehensive rules

(understood by physicians Ottawa Ankle Rule)

Decision models for abdominal pain, scrotal pain, hip pain and asthma (in progress)

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Ottawa Ankle Rule An Ankle X-Ray series is only required if:

There is any pain in the malleolar zone (defined (more or less) from the tibia and fibula 6 cm above the articulation with the talus, to the bones of the midfoot) AND any of these findings: Bone tenderness at the posterior edge or tip of the lateral malleolus OR Bone tenderness at the posterior edge or tip of the medial malleolus OR Inability to bear weight both immediately and in the ED

A foot X-Ray series is required only if: There is any pain in midfoot AND any of these findings:

Bone tenderness at the base of the 5th metatarsal OR Bone tenderness at the navicular OR Inability to bear weight both immediately and in the ED

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Ottawa Abdominal Pain Rule The diagnosis may be appendicitis and the management maybe consult when

one of the following occurs: A male patient experiences right lower quadrant abdominal pain and his white blood

cell count is above 20000/mm3; A male patient experiences right lower quadrant abdominal pain lasting between 4h

and 24h, combined with frequent (more than 3 times) vomiting; ...

The diagnosis maybe resolution and the management maybe discharge when one of the following occurs: A patient experiences abdominal pain (neither right lower quadrant nor suprapubic)

lasting between 4h and 24h; A patient experiences abdominal pain (neither right lower quadrant nor suprapubic)

of intermittent character; ...

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MET – Mobile Emergency Triage

Facilitates triaging recommendations for presentations of acute pain (abdominal and scrotal pain, hip pain – soon)

Supports triage decision with or without complete clinical information

Provides mobile support through handheld devices

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MET – History 1998 – 2000

Web-based application for entering data and triaging patients with abdominal pain

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MET History 2001

The first Palm-based application (MAT Mobile Abdominal pain Triage)

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MET History 2002 – 2003

More presentations of pain (MAT MET1) Support for Palm and Pocket PC

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MET History 2004 - future

New methodology – ontologies and solvers New technology – Java ( support for all Java

platforms, including tablet PC, desktop and web) Support for hip pain and asthma (work in progress)

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MET Architecture Extended client-server architecture for weak-

connectivity conditions and integration

Shell

Local database

MET Client

Presentation modules

ADT/EPRS

Interface engine

HIS #1 HIS #2Presentation

modules

Integrator

Temporal database

MET Server

HL7

HL7

HL7

wired or wireless communication

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MET Architecture #2

Separation of knowledge and solvers for flexibility and reusability

Presentation module

Domain model

Decision model

Shell

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MET Client

MET Operations

Interface Engine MET Server

Pateint registered

Receive, decode and store patient data

Admission message

Synchronize patient data

Synchronization requested

Synchornize patient data

Patient data

Synchronize presentation modules

Synchronize presentation modules

Presentationmodules

Observation report„Hospital-wide”

patient data updatedEncode and send

patient data

Patient data available

Observation report

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Health Level 7

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Health Level 7 (cont.)

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Database OrganizationEntity-Attribute-Value Typical (?) for medical applications

Support for storing heteregenous and volatile data Data structure can be easily modified (explicit meta-data

level) Efficient storage – only known values are kept in a database

More difficult to use than a classical (entity-centric) approach Inefficient attribute-centric queries

Select all male patients who visited the ER last year and had increased level of WBC

Efficient for object-at-a-time queriesSelect all examination results for patient X collected during all his visits in the ER

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Database OrganizationEntity-Attribute-Value

Patients (Entities)

Attributes Values

36.7

RLQ

Carl Chang

TemperatureJohn Doe

Joan Smith

present

other

acute

Location of pain

Vomiting

Onset of pain

Patient Temperature Vomiting Location of pain

Onset of pain

John Doe 36.7 present RLQ

Joan Smith other

...

Carl Chang acute

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Conclusions We have built a mobile clinical decision support

system that is quite usable in hospital setting (work still in progress)

Mobile devices form a promising platform for various clinical systems

Development is limited by technology infrastructure and sometimes by users…