A Symptom-Checker for Adult Patients Visiting an Interdisciplinary Emergency Care Center and the Safety of Patient Self-Triage: Real-Life Prospective Evaluation.

BACKGROUND: Symptom-checkers have become important tools for self-triage, assisting patients to determine the urgency of medical care. To be safe and effective, these tools must be validated, particularly to avoid potentially hazardous undertriage without leading to inefficient overtriage. Only limited safety data from studies including small sample sizes have been available so far. OBJECTIVE: The objective of our study was to prospectively investigate the safety of patients' self-triage in a large patient sample. We used SMASS (Swiss Medical Assessment System; in4medicine, Inc) pathfinder, a symptom-checker based on a computerized transparent neural network. METHODS: We recruited 2543 patients into this single-center, prospective clinical trial conducted at the cantonal hospital of Baden, Switzerland. Patients with an Emergency Severity Index of 1-2 were treated by the team of the emergency department, while those with an index of 3-5 were seen at the walk-in clinic by general physicians. We compared the triage recommendation obtained by the patients' self-triage with the assessment of clinical urgency made by 3 successive interdisciplinary panels of physicians (panels A, B, and C). Using the Clopper-Pearson CI, we assumed that to confirm the symptom-checkers' safety, the upper confidence bound for the probability of a potentially hazardous undertriage should lie below 1%. A potentially hazardous undertriage was defined as a triage in which either all (consensus criterion) or the majority (majority criterion) of the experts of the last panel (panel C) rated the triage of the symptom-checker to be "rather likely" or "likely" life-threatening or harmful. RESULTS: Of the 2543 patients, 1227 (48.25%) were female and 1316 (51.75%) male. None of the patients reached the prespecified consensus criterion for a potentially hazardous undertriage. This resulted in an upper 95% confidence bound of 0.1184%. Further, 4 cases met the majority criterion. This resulted in an upper 95% confidence bound for the probability of a potentially hazardous undertriage of 0.3616%. The 2-sided 95% Clopper-Pearson CI for the probability of overtriage (n=450 cases,17.69%) was 16.23% to 19.24%, which is considerably lower than the figures reported in the literature. CONCLUSIONS: The symptom-checker proved to be a safe triage tool, avoiding potentially hazardous undertriage in a real-life clinical setting of emergency consultations at a walk-in clinic or emergency department without causing undesirable overtriage. Our data suggest the symptom-checker may be safely used in clinical routine. TRIAL REGISTRATION: ClinicalTrials.gov NCT04055298; https://clinicaltrials.gov/study/NCT04055298.

[COVID-Guide: an app for covid-19 triage and self-assessment.] / COVID-Guide: una app per il triage e l'autovalutazione della covid-19.

INTRODUCTION: The unprecedented covid-19 pandemic has shown the weaknesses of health systems and opened new spaces for e-health and telemedicine. Recent literature states that chatbots, if implemented effectively, could be useful tools for quickly sharing information, promoting healthy behaviors, and helping reduce the psychological burden of isolation. The aim of this project is to develop and test a secure and reliable computerized decision support system (CDSS) in web-app and evaluate its use, usability and its outputs in a pre-specified way. METHODS: A multidisciplinary team was recruited to plan and design, based on the SMASS medical CDSS, the scenarios of the COVID-Guide web-app, a self-triage system for patients with suspected covid-19. The output data for the period May-September 2020 from Germany were analyzed. RESULTS: During the period under review, the total number of consultations in Germany was 96,012. 3,415 (3.56%) consultations indicated the need for immediate evaluation, by activating the emergency service (calling an ambulance) - 1,942, equal to 2.02% - or by advising the patient to go to hospital - 1,743, equal to 1.54%. CONCLUSIONS: Data seems to show good usability and a consistent number of consultations carried out. Regular use of COVID-Guide could help collect epidemiological data on the spread of (suspected) covid-19 cases, easily and quickly available in all countries where the tool will be used. Using the SSDC could help reduce the load on operators. Furthermore, the use of anonymous and geolocatable clinical data together with the generation of alerts and indicators produced by COVID-Guide could become a useful tool for epidemiological surveillance in the future phases of the pandemic (Telemedical Syndromic Surveillance).

Is computer-assisted telephone triage safe? A prospective surveillance study in walk-in patients with non-life-threatening medical conditions.

BACKGROUND: Patients often establish initial contact with healthcare institutions by telephone. During this process they are frequently medically triaged. PURPOSE: To investigate the safety of computer-assisted telephone triage for walk-in patients with non-life-threatening medical conditions at an emergency unit of a Swiss university hospital. METHODS: This prospective surveillance study compared the urgency assessments of three different types of personnel (call centre nurses, hospital physicians, primary care physicians) who were involved in the patients' care process. Based on the urgency recommendations of the hospital and primary care physicians, cases which could potentially have resulted in an avoidable hazardous situation (AHS) were identified. Subsequently, the records of patients with a potential AHS were assessed for risk to health or life by an expert panel. RESULTS: 208 patients were enrolled in the study, of whom 153 were assessed by all three types of personnel. Congruence between the three assessments was low. The weighted κ values were 0.115 (95% CI 0.038 to 0.192) (hospital physicians vs call centre), 0.159 (95% CI 0.073 to 0.242) (primary care physicians vs call centre) and 0.377 (95% CI 0.279 to 0.480) (hospital vs primary care physicians). Seven of 153 cases (4.57%; 95% CI 1.85% to 9.20%) were classified as a potentially AHS. A risk to health or life was adjudged in one case (0.65%; 95% CI 0.02% to 3.58%). CONCLUSION: Medical telephone counselling is a demanding task requiring competent specialists with dedicated training in communication supported by suitable computer technology. Provided these conditions are in place, computer-assisted telephone triage can be considered to be a safe method of assessing the potential clinical risks of patients' medical conditions.

Trends in diagnosis and surgical management of patients with perforated peptic ulcer.

INTRODUCTION: While the laparoscopic treatment of perforated peptic ulcers (PPU) has been shown to be feasible and safe, its implementation into routine clinical practice has been slow. Only a few studies have evaluated its overall utility. The aim of this study was to investigate changes in surgical management of PPU and associated outcomes. MATERIAL AND METHODS: The study was a retrospective, single institution, population-based review of all patients undergoing surgery for PPU between 2003 and 2009. Patient demographics, diagnostic evaluation, management, and outcomes were evaluated. RESULTS: Included were 114 patients with a median age of 67 years (range, 20-100). Women comprised 59% and were older (p < 0.001), had more comorbidities (p = 0.002), and had a higher Boey risk score (p = 0.036) compared to men. Perforation location was gastric/pyloric in 72% and duodenal in 28% of patients. Pneumoperitoneum was diagnosed by plain abdominal x-ray in 30 of 41 patients (75%) and by abdominal computerized tomography (CT) in 76 of 77 patients (98%; p < 0.001).Laparoscopic treatment was initiated in 48 patients (42%) and completed in 36 patients (75% of attempted cases). Laparoscopic treatment rate increased from 7% to 46% during the study period (p = 0.02). Median operation time was shorter in patients treated via laparotomy (70 min) compared to laparoscopy (82 min) and those converted from laparoscopy to laparotomy (105 min; p = 0.017). Postoperative complications occurred in 56 patients (49%). Overall 30-day postoperative mortality was 16%. No statistically significant differences were found in morbidity and mortality between open versus laparoscopic repair. CONCLUSION: This study demonstrates an increased use of CT as the primary diagnostic tool for PPU and of laparoscopic repair in its surgical treatment. These changes in management are not associated with altered outcomes.

Quality of life of survivors of paediatric intensive care.

OBJECTIVE: The mortality rate in paediatric intensive care units (PICU) has fallen over the last two decades. More advanced treatment is offered to children with life-threatening disease and there is substantial interest in knowing whether long term outcome and quality of life after intensive care are acceptable. SETTING: 12-bed paediatric and neonatal intensive care unit. INTERVENTION: Prospective follow-up study with telephone interview 1 and 2 years after discharge. METHODS: Four domains of quality of life (physical function, role function, social-emotional function and health problem) were recorded by calculating the health state classification (HSC) index. Outcome was classified good (HSC 1.0-0.7), moderate (HSC 0.69-0.3), poor (HSC 0.29-0) and very poor (HSC <0). RESULTS: 661 patients were admitted to the PICU in the year 2001 with a mortality within the unit of 3.9%. Over 2 years follow-up there were 21 additional deaths (3.2%). 574 patients could be followed up after 1 year and 464 patients after 2 years. After two years the outcome was good in 77%, moderate in 15% and poor in 8%. Patients with respiratory disease had the best outcome, similar to those admitted for neurological and medical reasons. Patients admitted for postoperative care and for cardiovascular disease had a poorer quality of life. 31% of the children had preexisting health care problems and 21% of all patients had new chronic disease after intensive care. CONCLUSION: The majority of survivors admitted to the PICU have a good outcome. The overall mortality rate doubled if assessed two years after discharge.

Medical telephone triage and patient behaviour: How do they compare?

QUESTIONS UNDER STUDY: In the medical call centre Medi-24, medical experts advise people with health problems on the optimal treatment. The purpose of the first part of this study was to answer two questions: To what extend do callers and medical experts differ in their judgement of a health problem, and to what degree are patients compliant to experts' advice. METHODS: 834 callers were selected for study inclusion. At the call centre, study participants were asked about their intended behaviour prior to the call and approximately 90% of these were interviewed one week later about their subsequent behaviour following the call. The standardised data were analysed fitting a logistic regression model. RESULTS: 61% of callers had not intended to behave the way they were subsequently advised to do. The compliance rate after the triage call was 56%. Non-compliance was largely due to the caller's recollection errors or to a change in the perceived intensity of the health problem. Advice on self-care resulted in an above average compliance. A high compliance was also found when the advice on emergency treatment coincided with the patient's own intended emergency treatment. CONCLUSION: The high compliance for the self-care advice showed that patients could be persuaded by the Medi-24 service that professional health care was not necessary. It appeared more difficult to persuade those patients to make an emergency consultation who had initially not intended to do so.