MET Mobile Emergency Triage

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METMobile Emergency Triage

• Saving Lives. Saving Dollars.

Poznan University of Technology,
Poland University of Ottawa, Canada CHEO
(Childrens 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
Canadian Triage Acuity Scale (CTAS) CTAS1
Immediate CTAS2 ? 15 min. CTAS3 ? 30
min. CATS4 ? 1 hour CTAS5 ? 2 hours
Prioritization (Triage nurse)
Priority categories
Medical assessment and disposition (Physician)
Consult
Observation/further investigation
Discharge
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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 analysis
• Difficulties 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

HIS 1
HIS 2
Presentation modules
Presentation modules
HL7
Integrator
Shell
Interface engine
HL7
wired or wireless communication
HL7
Local database
Temporal database
ADT/EPRS
MET Client
MET Server
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MET Architecture 2

• Separation of knowledge and solvers for
  flexibility and reusability

Domain model
Shell
Decision model
Presentation module
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MET Operations
MET Client
Interface Engine
MET Server
Admission message
Pateint registered
Receive, decode and store patient data
Synchronization requested
Patient data available
Observation report
Patient data
Synchronize patient data
Synchornize patient data
Presentation modules
Synchronize presentation modules
Synchronize presentation modules
Observation report
Hospital-wide patient data updated
Encode and send patient data
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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 queries
• Select all examination results for patient X
  collected during all his visits in the ER

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Database OrganizationEntity-Attribute-Value
Patient Temperature Vomiting Location of pain Onset of pain
John Doe 36.7 present RLQ
Joan Smith other
...
Carl Chang acute
John Doe
Temperature
36.7
Vomiting
present
Joan Smith
RLQ
Location of pain
other
Carl Chang
Onset of pain
acute
Patients (Entities)
Attributes
Values
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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