1. MET Mobile Emergency Triage Saving Lives. Saving Dollars. Poznań University of Technology, Poland University of Ottawa, Canada CHEO (Children’s Hospital of Eastern Ontario), Canada

2. 2 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

3. 3 Process of Emergency Triage Prioritization (Triage nurse) Medical assessment and disposition (Physician) Consult Observation/ further investigation Discharge Priority categories Canadian Triage Acuity Scale (CTAS) CTAS1 – Immediate CTAS2 –  15 min. CTAS3 –  30 min. CATS4 –  1 hour CTAS5 –  2 hours

4. 4 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.)

5. 5 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)

6. 6 Pain Presentations Abdominal 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

7. 7 Pain Presentations Scrotal 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

8. 8 Pain Presentations Hip 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

9. 9 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)

10. 10 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

11. 11 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;...

12. 12 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

13. 13 MET – History  1998 – 2000 Web-based application for entering data and triaging patients with abdominal pain

14. 14 MET History  2001 The first Palm-based application (MAT  Mobile Abdominal pain Triage)

15. 15 MET History  2002 – 2003 More presentations of pain (MAT  MET1) Support for Palm and Pocket PC

16. 16 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)

17. 17 MET Architecture  Extended client-server architecture for weak- connectivity conditions and integration Shell Local database MET Client Presentation modules ADT/EPRS Interface engine HIS #1HIS #2 Presentation modules Integrator Temporal database MET Server HL7 wired or wireless communication

18. 18 MET Architecture #2  Separation of knowledge and solvers for flexibility and reusability Presentation module Domain model Decision model Shell

19. 19 MET Client MET Operations Interface EngineMET Server Pateint registered Receive, decode and store patient data Admission message Synchronize patient data Synchronization requested Synchornize patient data Patient data Synchronize presentation modules Presentation modules Observation report „Hospital-wide” patient data updated Encode and send patient data Patient data available Observation report

20. 20 Health Level 7

21. 21 Health Level 7 (cont.)

22. 22 Database Organization Entity-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

23. 23 Database Organization Entity-Attribute-Value Patients (Entities) AttributesValues 36.7 RLQ Carl Chang Temperature John Doe Joan Smith present other acute Location of pain Vomiting Onset of pain PatientTemperatureVomitingLocation of pain Onset of pain John Doe36.7presentRLQ Joan Smithother... Carl Changacute

24. 24 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…