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Emergency Department Triage in a Resource Constrained Setting: Application of the World Health Organization Triage Scale in Regional Papua New Guinea

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ClinicalTrials.gov Identifier: NCT04098705
Recruitment Status : Recruiting
First Posted : September 23, 2019
Last Update Posted : September 23, 2019
Sponsor:
Collaborators:
Western Highlands Provincial Health Authority
Queensland Health
The Alfred
Information provided by (Responsible Party):
Rob Mitchell, Monash University

Brief Summary:

Triage is an important component of emergency care (EC). It aims to sort patients based on the urgency of their condition such that the highest acuity patients are prioritised for assessment and treatment. Grounded in the ethical principles of equity and justice, triage is necessary whenever there is a mismatch between demand for EC and the availability of resources.

Globally, a large number of triage scales are in use. These differ in the data required to categorise patients as well as the number of tiers. Developed settings tend to utilise five-tier systems.

Little is known about the prevalence of triage in low- and middle-income countries (LMICs), including in the Pacific region. There is also limited evidence about the utility, validity and reliability of triage scales in these contexts. While a landmark study in a paediatric Emergency Department (ED) in Malawi demonstrated that training staff in emergency skills, introducing triage and improving flow substantially reduced case fatality rates, the mortality reduction attributable to triage is unknown.

A small number of triage scales have been developed for resource-limited (RL) environments. The most widely studied is the four-tier South African Triage Scale (SATS), which has demonstrated reasonable reliability and validity. In the Pacific region, SATS has provided a foundation for the three-tier Solomon Islands Triage Scale (SITS), which has recently been piloted in Honiara. The World Health Organization (WHO) has also recently released a three-tier triage scale. Neither of these instruments has been validated.

Although the potential value of triage systems in resource-limited EDs is increasingly recognised, the current evidence base is limited. The impact on process indicators (eg, time to assessment) and clinical outcomes (eg, mortality) for time-critical conditions is largely unknown. This study aims to address this knowledge gap.


Condition or disease Intervention/treatment Phase
Emergencies Other: Introduction of the World Health Organization Triage Scale Not Applicable

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 16800 participants
Allocation: Non-Randomized
Intervention Model: Sequential Assignment
Intervention Model Description: Pre-post intervention methodology will be used
Masking: None (Open Label)
Primary Purpose: Health Services Research
Official Title: Emergency Department Triage in a Resource Constrained Setting: Application of the World Health Organization Triage Scale in Regional Papua New Guinea
Actual Study Start Date : August 30, 2019
Estimated Primary Completion Date : December 30, 2019
Estimated Study Completion Date : February 29, 2020

Arm Intervention/treatment
No Intervention: Pre-intervention
Pre-intervention period
Experimental: Post-intervention
Post-intervention period
Other: Introduction of the World Health Organization Triage Scale

The intervention will comprise implementation of a new triage and patient flow system facilitated through staff training and clinical redesign.

The three-tier World Health Organization Triage Scale (WHOTS) will be used as the triage instrument. This tool, developed collaboratively by the WHO, International Committee of the Red Cross (ICRC) and Médecins Sans Frontières (MSF), incorporates features of the South African Triage Scale but has been modified for application in a wide variety of RL settings. WHOTS documents are provided in the research protocol.





Primary Outcome Measures :
  1. Time-to-assessment (TTA) by an ED clinician for ten time-critical conditions [ Time Frame: Time interval between the patient's arrival in ED and assessment by a treating clinician, assessed up to 24 hours following arrival ]
    The primary outcome will be time-to-assessment (TTA) by an ED clinician for ten time-critical conditions: severe trauma, major burns, severe head injury, ruptured ectopic pregnancy, septic shock, myocardial infarction, severe asthma/COPD, severe pneumonia, meningitis and appendicitis.

  2. The proportion of patients selected clinical syndromes that are seen within a clinically appropriate timeframe [ Time Frame: Within 15 minutes of arrival ]
    The primary outcome will also be analysed by the proportion of patients with these clinical syndromes that are seen within a clinically appropriate timeframe (defined as 15 minutes)


Secondary Outcome Measures :
  1. Length of hospital stay [ Time Frame: The duration of the hospital stay at the point of hospital discharge, assessed up to 1 month following admission ]
    That total duration of the patient's hospital stay

  2. ED mortality [ Time Frame: Within the ED encounter, assessed up to approximately 7 days ]
    Death within the ED

  3. Inpatient mortality [ Time Frame: Prior to discharge from the hospital, assessed up to 1 month post-admission ]
    Death while a hospital in-patient


Other Outcome Measures:
  1. Validity - predictive ability for disposition [ Time Frame: The patient's ED encounter, assessed up to approximately 7 days following arrival in the ED ]
    Validity of the WHOTS will be assessed through its ability to predict admission

  2. Validity - predictive ability for death [ Time Frame: The patient's ED encounter, assessed up to approximately 7 days following arrival in the ED ]
    Validity of the WHOTS will be assessed through its ability to predict ED mortality

  3. Under- and over-triage rates [ Time Frame: The patient's ED encounter, assessed up to approximately 7 days following arrival in the ED ]
    Under- or over-triage rates will also be calculated using disposition as a reference standard. This approach has limitations (see below) but is widely used in triage research

  4. Reliability - inter-rater agreement (local staff) [ Time Frame: The point of the patient's ED triage assessment (likely to be within one hour of presentation) ]
    Reliability will be assessed through inter-rater agreement between two local triage nurses

  5. Reliability - inter-rater agreement (independent expert) [ Time Frame: The point of the patient's ED triage assessment (likely to be within one hour of presentation) ]
    Reliability will be assessed through inter-rater agreement between a local nurse and independent expert triage nurse



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Ages Eligible for Study:   Child, Adult, Older Adult
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion criteria:

All patients presenting to Mount Hagen Provincial Hospital during the study period.

The inclusion criteria for the primary outcome is any patient presenting to Mount Hagen Provincial Hospital diagnosed by the treating clinician with any of severe trauma, major burns, severe head injury, ruptured ectopic pregnancy, septic shock, myocardial infarction, severe asthma/COPD, severe pneumonia, meningitis or appendicitis.

Exclusion criteria:

None.


Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT04098705


Contacts
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Contact: Rob Mitchell, FACEM 03 9903 0444 robert.mitchell@monash.edu
Contact: Peter Cameron, FACEM 03 9903 0444 peter.cameron@monash.edu

Locations
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Papua New Guinea
Mount Hagen Provincial Hospital Recruiting
Mount Hagen, Western Highlands, Papua New Guinea
Contact: John McKup, MMed       john.mckup@whhs.gov.pg   
Sponsors and Collaborators
Monash University
Western Highlands Provincial Health Authority
Queensland Health
The Alfred
Investigators
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Principal Investigator: Peter Cameron, FACEM Monash University
  Study Documents (Full-Text)

Documents provided by Rob Mitchell, Monash University:
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Responsible Party: Rob Mitchell, PhD Scholar, School of Public Health & Preventive Medicine, Monash University
ClinicalTrials.gov Identifier: NCT04098705    
Other Study ID Numbers: 19106
First Posted: September 23, 2019    Key Record Dates
Last Update Posted: September 23, 2019
Last Verified: September 2019

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Additional relevant MeSH terms:
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Emergencies
Disease Attributes
Pathologic Processes