Institute for Community Medicine, Section Epidemiology of Health Care and Community Health, University Medicine Greifswald, Greifswald, Germany.
Department for Paediatrics, Sana-Hospital Ruegen, Bergen, Germany.
PLoS One. 2022 May 26;17(5):e0269058. doi: 10.1371/journal.pone.0269058. eCollection 2022.
In the German health care system, parents with an acutely ill child can visit an emergency room (ER) 24 hours a day, seven days a week. At the ER, the patient receives a medical consultation. Many parents use these facilities as they do not know how urgently their child requires medical attention. In recent years, paediatric departments in smaller hospitals have been closed, particularly in rural regions. As a result of this, the distances that patients must travel to paediatric care facilities in these regions are increasing, causing more children to visit an ER for adults. However, paediatric expertise is often required in order to assess how quickly the patient requires treatment and select an adequate treatment. This decision is made by a doctor in German ERs. We have examined whether remote paediatricians can perform a standardised urgency assessment (triage) using a video conferencing system.
Only acutely ill patients who were brought to a paediatric emergency room (paedER) by their parents or carers, without prior medical consultation, have been included in this study. First, an on-site paediatrician assessed the urgency of each case using a standardised triage. In order to do this, the Paediatric Canadian Triage and Acuity Scale (PaedCTAS) was translated into German and adapted for use in a standardised IT-based data collection tool. After the initial on-site triage, a telemedicine paediatrician, based in a different hospital, repeated the triage using a video conferencing system. Both paediatricians used the same triage procedure. The primary outcome was the degree of concordance and interobserver agreement, measured using Cohen's kappa, between the two paediatricians. We have also included patient and assessor demographics.
A total of 266 patients were included in the study. Of these, 227 cases were eligible for the concordance analysis. In n = 154 cases (68%), there was concordance between the on-site paediatrician's and telemedicine paediatrician's urgency assessments. In n = 50 cases (22%), the telemedicine paediatrician rated the urgency of the patient's condition higher (overtriage); in 23 cases (10%), the assessment indicated a lower urgency (undertriage). Nineteen medical doctors were included in the study, mostly trained paediatric specialists. Some of them acted as an on-site doctor and telemedicine doctor. Cohen's weighted kappa was 0.64 (95% CI: 0.49-0.79), indicating a substantial agreement between the specialists.
Telemedical triage can assist in providing acute paediatric care in regions with a low density of paediatric care facilities. The next steps are further developing the triage tool and implementing telemedicine urgency assessment in a larger network of hospitals in order to improve the integration of telemedicine into hospitals' organisational processes. The processes should include intensive training for the doctors involved in telemedical triage.
DRKS00013207.
在德国的医疗保健系统中，父母可以在每天 24 小时，每周 7 天的时间内带患有急性病的孩子去急诊室（ER）就诊。在 ER，患者会接受医疗咨询。许多父母会使用这些设施，因为他们不知道孩子的病情有多紧急。近年来，较小医院的儿科部门已关闭，尤其是在农村地区。因此，这些地区的患者前往儿科护理设施的距离增加，导致更多的儿童去成人 ER 就诊。但是，通常需要儿科专业知识来评估患者需要治疗的速度，并选择适当的治疗方法。在德国的 ER，这一决定由医生做出。我们研究了远程儿科医生是否可以使用视频会议系统对标准紧迫性评估（分诊）进行操作。
本研究仅纳入由父母或照顾者直接带到儿科急诊室（paedER）就诊，且未经事先医疗咨询的急性病患儿。首先，现场的儿科医生使用标准化分诊对每个病例的紧急程度进行评估。为此，将儿科加拿大分诊和急症严重程度评分（PaedCTAS）翻译成德语，并适应于标准化基于 IT 的数据收集工具。在初始现场分诊之后，位于另一家医院的远程医疗儿科医生使用视频会议系统重复分诊。两位儿科医生均使用相同的分诊程序。主要结局是两名儿科医生之间的一致性和观察者间一致性的程度，使用 Cohen's kappa 进行测量。我们还包括了患者和评估者的人口统计学信息。
共有 266 名患者入组该研究。其中，227 例病例符合一致性分析的条件。在 n = 154 例（68％）中，现场儿科医生和远程医疗儿科医生的紧急程度评估具有一致性。在 n = 50 例（22％）中，远程医疗儿科医生对患者病情的紧急程度评估更高（过度分诊）；在 23 例（10％）中，评估表明紧急程度较低（分诊不足）。19 名医生参与了该研究，其中大多数是受过培训的儿科专家。他们中的一些人担任现场医生和远程医疗医生。Cohen 的加权 kappa 值为 0.64（95％CI：0.49-0.79），表明专家之间存在实质性一致性。
远程医疗分诊可帮助在儿科护理设施密度较低的地区提供急性儿科护理。下一步是进一步开发分诊工具，并在更大的医院网络中实施远程医疗紧急评估，以提高远程医疗在医院组织流程中的整合程度。该过程应包括对参与远程医疗分诊的医生进行强化培训。
DRKS00013207。
