Thailand medical mobile application for patients triage base on criteria based dispatch protocol

The use of technology via smart devices has transformed many aspects of the clinical practices of healthcare professionals. Mobile devices such as tablets are now commonly used in healthcare, which has led to the rapid development of medical software applications (apps). Mobile technology plays a significant role in terms of patient care by enabling users to track their health condition and suggesting suitable medication, as well as providing tools for medical providers to monitor their patients [16, 17].

The use of systems based on smartphones facilitates the effective tracking and managing of patients’ health [1, 2, 18, 19]. A variety of research that has been conducted in relation to applications associated with emergency cases will be discussed in this section.

The incorporation of information technology into the worldwide medical field via smartphones has become increasingly common due to its accuracy. For example, based on Scott’s study, the application of electronic triage increased the accuracy of the triage protocol. The probability of clinical care, emergency surgery and hospitalisation was indicated when applying the e-triage predictor and algorithms [20].

Tadahiro recently developed a system to optimise emergency department operations. Since the prediction of the ED disposition at the triage level remains challenging, this system is expected to enhance it, as well as improve the ability to predict the disposition of patients and support various medical duties [21].

Lei and his team studied the use of triage to identify patients who require immediate resuscitation, assign them to a pre-designed patient care area, and administer the appropriate diagnostic/therapeutic measures based on the use of ESI in a paediatric emergency room. According to the results, nurses improved their performance, taking approximately 2 min for triage, which was similar to that of doctors for ESI. Patients in levels 1–3, who require immediate, life-saving intervention without delay are at great risk of deterioration due to time-critical problems. This causes an urgent demand for resources to investigate and treat them and, according to the findings of this study, nurses are able to identify severe paediatric cases [22, 23].

Moreover, triage mobile applications have been developed and applied to dental science. For instance, Corey developed a mobile application for triaging dental emergencies based on the need to analyse and assess captured intraoral images [24]. Patients are able to self-identify their dental problem and complete a triage report within 4 min by selecting the most appropriate scenario that describes their discomfort. This application helps both dentists and patients to save time prior to a visit.

In Thailand, Sumrumeram developed a medical application that can track high-risk stroke and stemi patients who need time-sensitive Emergency Medical Services (EMS) [25]. This application can be operated on both Android and iOS systems and a Global Positioning System (GPS) Tracker is used to indicate the transmitter’s real-time location. The researchers studied the use of a GPS Tracker through GPS satellites and transmissions over the 3G mobile phone network with a focus on programming to integrate them with the system for semi-automatic usage. The programme was tested in urban areas where there was Internet access to enable the system to accurately locate patients. This study provided further assurance that emergency medical services could be optimised by the application of information technology for the benefit of patient safety.

Ruangtananurak developed an emergency alert system including maps for the positioning of emergency medical services [26]. Victims or witnesses of an accident can use this application on a smart phone to send information from the scene, such as the location or other salient information, to emergency centres in the area so that the Emergency Medical Services (EMS) can quickly dispatch emergency ambulances to the right location. It also includes directions to the nearest hospital.

As can be seen from the aforementioned examples [22‐26], mobile-based systems can optimise triage by enabling severe medical cases to be identified quickly for accurate and immediate intervention. However, patients should also be able to describe and determine the severity of their symptoms based on the proposed mobile application and it should contain a function to sort symptoms based on the Thai dispatch standard.

Triage is a process that involves determining and prioritising patients’ treatment based on the severity of their condition to facilitates the efficient use of limited resources. It may also be used when patients arrive at the emergency department or in telephone medical advice systems [27] and, according to the National Institute for Emergency Medicine [28‐30], it can increase the accuracy of the pre-hospital process by reducing the subjectivity of an initial diagnosis.

The criteria-based initial dispatch code used as the standard in Thailand is based on 25 main categories of patients’ signs and symptoms (National Institute for Emergency Medicine [28, 31]. This CBD protocol enables the status of patients who request pre-hospital resources to be rapidly identified as unstable or “sick” [32] by questioning them in an interview and assigning them one of five colour codes. The IDC is shown in Table 1 with details of the triage criteria and corresponding colours, while Table 2 contains the 25 main categories of symptoms. According to the CBD protocol, the results of the patient’s interview will be presented as an IDC; for example, patients will be triaged by considering each criterion of their symptoms and the result will show the main symptom code, a colour code and a triage criterion. A result of “12 red 1” represents a critical emergency patient with cardiac arrest so that the emergency staff can request emergency medical resources and operate based on the corresponding essential response.

A medical mobile application based on CBD was developed for patient triage in Thailand to resolve the aforementioned problems associated with the pre-hospital process. The adapted waterfall methodology software was applied as a 7-step guideline for the development process [33, 34].

The application was developed using the Ionic Framework and evaluated based on compatibility, errors, missing information and quality. The final version that was released consisted of four main functions, including triage, finding the responsible emergency care unit, patient triage log file, and export IDC information.

The functions of the application were tested using iPhone 6 s and Huawei Android phone (P20Pro). At the time of the study, smartphone specifications were defined for medium- and large-screen display devices, due to visibility concerns [37].

The application procedure starts when the user opens the application, and screen A in Fig. 2 appears, showing the title and welcome graphics. The main menu screen is then displayed. The buttons on screen B support the application login and triage history. Screen L contains icons for the 25 symptom symbols for triage which are demonstrated in a table view (screen D) and list view (screen C), respectively.

As shown in Fig. 2, on screens E-G, users can search by typing the symptom name or keyword(s) into the textbox and select a symptom from the list of search results. The steps for the CBD questions are shown on screen F. Users have to select their answer to go to the next question, and then continue until the IDC is displayed on screen H or I. Screen I shows the triage screening result, which identifies the IDC code and emergency status. The screen colour will be the same as the IDC code pattern. Suppose the IDC pattern is displayed in the form of “X colour Y”, the first X refers to the group number of the symptoms corresponding to the information input in Table 2 and the last Y refers to the level of urgency (1 being the highest and 9 being the lowest). On screen K, users are advised of some actions they can take while waiting for the emergency services. Moreover, they can record the IDC code via the application to summarise their condition, as well as the level of urgency. This will enable the emergency doctors/staff to gather information for the pre-hospital process. Additionally, on screen J, the application supports the export of the details of patients/emergency cases in a .pdf format to other applications, such as Line and Short Message Service (SMS). On screen M, users are able to find their nearest emergency care unit and hospital, as well as the contact information (phone numbers as shown on screen N). This data is sorted by the shortest distance and shortest time to the destination. Furthermore, a map with directions to hospital locations is provided on screen O with an overview of the information.

The CBD questions used in the application were tested by evaluating the accuracy of the IDC results. All the 25 symptoms were tested in each question by following the flow in the CBD handbook. Emergency medical doctors tested the application by simulating a scenario and the results were compared with the handbook. After verifying and approving the flow of the CBD questions, the testing proceeded to the next step.

The application was used to triage patients in order to test its reliability and efficiency compared to various triage methodologies. 2 of the 25 symptoms, trauma and non-trauma, were tested in a simulated scenario and role-playing was used to communicate the patients’ condition to the medical staff. The accuracy of the resulting IDC was evaluated and it was confirmed to be suitable for requesting resources. This involved comparing the IDC and the triage time spent by the emergency staff in obtaining it using the above-mentioned process based on three different methods: 1) using the application, 2) following the CBD protocol from the handbook, and 3) relying on emergency medical staff’s experience. Four emergency medical staff participated in the pilot test.

The results of testing each method in each scenario are shown in Table 5. It is clear that using the application for triage was as fast as the time taken by experienced emergency staff and as accurate as following the CBD protocol from the handbook. Some IDC misrepresentations were found when performing triage by relying on the staff’s experience.

Another test was undertaken to confirm the triage time by comparing the results based on two methods, the first of which was using the application and the second was relying on the emergency staff’s experience. Please note that the hand book was not used to evaluate the triage condition. It was only used to test the reliability of the application, since it is not a practical process for real-world operation.

The test conditions were established based on the acquisition of sample data from the 12 emergency medical staff, each of whom had no more than 5 years’ work experience. The medical staff were split into two groups of six. Triage was performed by both of these groups using the application based on their experience. The test cases included 13 out of 20 scenarios, which covered the 25 main symptom categories (See Table 2). The average triage operational time was calculated.

The results of testing the triage time shown in Fig. 3 indicate that the use of the application was more efficient to triage non-trauma cases than relying on experienced staff; on the other hand, experienced staff were more efficient than the application in triaging trauma cases.

It was important to test the usability of the application to ensure its quality and reliability. The focus had been on developing a high-quality medical system based on reliable software in order to address the practical concerns that were the pain points of the previous system. Hence, the criteria of Jakob Nielsen’s usability test technique were applied in certain scenarios. The key points tested were the occurrence of difficulties, the doubt of visual representation, doubt of usage, missing information and confusion when using the application. Each function of the application was tested by 12 emergency medical staff, including doctors and nurses. The results of the findings for each criterion (based on user motivation), as well as the application’s functionality, are shown in Table 6.

The triage function was misunderstood in 12 instances (ranked 2nd in operational errors). Information was found to be missing when users wanted to repeat the CBD questions, which led to the duplication of the IDC of patients’ conditions in the log file. Doubt of the visual representation was found when users did not read the information shown on the left-hand side of the previous answer and it was sometimes difficult to find the answers to previous CBD questions. The second function, finding an emergency care unit, was found to be missing 4 times and this was ranked the 3rd overall operational error. This may have been due to the use of third party navigation applications because the list of available emergency care providers’ locations is displayed using navigation applications such as Google Maps. It is also possible that other errors arose from navigation applications. When testing the next function, the patient triage log file, doubt on its usage and misunderstanding were found in 3 cases. The logging file operated as a historical record of triage information to confirm the patient’s condition. The last function tested was the data export function to export IDC information to other applications, such as SMS, Line, WeChat, e-mail, etc., and its use was found to be problematic in 3 cases. Users encountered problems in sending information when the device was not connected to the internet. The function was found to be confusing in 4 cases because the users assumed that it was meant to be used to produce a medical report.

Confusion was found to be in the 1st ranking of the evaluation of users’ motivation based on a total of 13 cases. Doubt of usage, which occurred during the log file exportation of IDC information was ranked 2nd, while doubt of visual representation of some graphics and figures in the application during the triage function, finding the emergency care unit function, and the exporting of IDC information function were ranked 3rd, 4th and 5th respectively.