COVID-19 or not COVID-19, that is the question. The role of screening criteria and point-of-care lung ultrasound in the triage decision-making process in an Emergency Department during the phase 2 of the COVID-19 Italian epidemic

In the COVID-19 era the real challenge for the Emergency Departments (ED) is to avoid the spread of the viral infection within the so called “clean area” of the emergency room and the hospital. Different protocols have been proposed and adopted in the EDs to quickly identify suspected COVID-19 patients and to correctly manage these patients, all based on clinical and epidemiological criteria. To the best of our knowledge, our pre-triage decisional making-process first integrates the pre-triage interview with pointof- care Lung Ultrasound (LUS) performed in the triage area. The aim of our study is to assess the sensitivity and specificity of our screening clinical and/or epidemiological criteria, and to investigate the role of LUS in the triage decision-making process during the “phase 2” of the COVID-19 Italian epidemic. Our study confirms the pivotal role of the triage in the decision-making process and the management of the entire ED, and it demonstrates that further studies are necessary to validate the role of LUS as tool to promptly identify COVID-19 patients, if combined with a correct pre-triage interview.

Utility and acceptability of the EXCEEDS algorithm for oncology stakeholders: Results of a Delphi study.

e13538 Background: The Exercise in Cancer Decision Support (EXCEEDS) algorithm is an evidence-based, risk stratified framework. This framework allows for enhanced decision making for exercise pre-participation medical clearance and triage to cancer rehabilitation or exercise services across the cancer continuum. We conducted a Delphi study to examine utility and acceptability of the EXCEEDS algorithm for oncology stakeholders. Methods: Delphi study participants were randomized to two case studies, then made pre-participation medical clearance (yes/no) and intervention triage recommendations (cancer rehabilitation, clinically-supervised exercise, cancer-specific community-based exercise, and unsupervised exercise) in two conditions: independent (IND) and using EXCEEDS. Immediately following, participants rated algorithm acceptability in four domains using 4-point Likert scales (1- strongly disagree, to 4- strongly agree). We dichotomously coded accuracy (correct/incorrect) for each medical clearance and triage recommendation, then calculated the proportion of correct answers for each case to determine accuracy. We compared triage decision time (seconds) between conditions (IND vs. EXCEEDS) using paired-samples t-tests. We calculated the proportion of participants who ‘agreed’ (i.e., score ≥3) with each acceptability domain. Results: Oncology stakeholders (N=33) were mostly female (69.7%), 35-44 years old (42.4%), located in the United States (60.6%), and had at least 10 years of experience (60.6%). When using EXCEEDS, accuracy for medical clearance decisions improved in 3 of 4 cases (75%), triage decision accuracy improved in 4 of 4 (100%) cases, and triage time (seconds) improved significantly in 3 of 4 cases (75%, p<.05). Table shows average improvement in decision accuracy and triage time for each case study. Most participants agreed that the algorithm was acceptable in each domain: “meets my approval” (n=21, 63.6%), “is appealing” (n=29, 87.9%), “enjoyable to use” (n=19, 57.6%), and “welcomed in my discipline or practice” (n=24, 72.7%). Conclusions: Accuracy and efficiency of decision-making for medical clearance and triage to cancer rehabilitation or exercise services was enhanced when using the EXEECDS algorithm. Most participants agreed the algorithm was acceptable. Future research is needed to validate the tool and explore avenues for dissemination and clinical implementation. % difference between EXCEEDS and Individual condition (EXCEEDS – IND) for medical clearance decision, triage decision and mean (M) and standard deviation (SD) of triage decision time.[Table: see text]

Herding cats: ethics in prehospital triage

Objective: Triage can create an ethical slippery slope when providing prehospital emergency health care. In triage decisions, emergency management is like the idiom of “herding cats”, which refers to managing or controlling the chaos and organizing people toward common goals. The purpose of this literature review is to explore the ethical framework of prehospital triage and to provide a critical view of the subject. Methods: Published materials related to “triage”, “ethics”, and “prehospital emergency medicine” were extracted from online databases and books from 1985 until February 2021. The papers were handled in seven themes including the historical basis, the importance of the triage, ethical considerations in prehospital triage, justice, assessment and decision-making, the variability of triage assessment criteria, and the reliability of triage decisions. Except for the historical basis and the importance of triage, the other five groups were discussed with an ethical critique of the content. The methodology in this article is based on a critical interpretation of discussions on triage through ethical approaches. Results: There are three basic ethical approaches to triage: utilitarianism, beneficence, and justice. Due to the historical military basis of triage, results-focused approaches have become more prominent. Ethical values in prehospital triage include the issues of human rights, moral rights, social justice, and beneficence. Ethical difficulties in triage decision-making involve vulnerability, limited resources, the concern of safety, the urgency of the situation, and instability. Triage decisions may be affected by subjective approaches such as the personal values and beliefs of the decision-makers. Conclusions: Three predominant ethical concepts in triage are utilitarianism, beneficence, and justice. The unique dynamics of the field influence triage decision-making in a variety of ways. The way triage is structured makes it more amenable to subjective influences. Considering the differences in prehospital triage models and approaches, there is an important need for an ethical framework that expresses clear values and principles that will guide prehospital emergency caregivers. In this paper, it is suggested that an ethical framework should include the following six headings: basic bioethical principles, distributing scarce resources, decision-making process, community support, assessment criteria, and promote the common good.