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Pandemic Respiratory Infection Emergency System Triage (PRIEST) Study
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University of Sheffield
Academic Institute
No
Safe Projects
DARS-NIC-377644-X9J4P-v1.2
The Pandemic Respiratory Infection Emergency System Triage (PRIEST) study is a National Institute for Health Research (NIHR) funded project aimed at evaluating and optimising the triage of people using the emergency care system (111 and 999 calls, ambulance conveyance, or hospital emergency department) with suspected respiratory infections during the COVID-19 pandemic. By the 17th of June 2020 231,889 people in the UK had been confirmed to have been infected with the COVID-19 virus and over 40,000 people had died because of infection. At the peak of the pandemic NHS 111 received nearly twice the normal number of calls and over 3000 patients were admitted to hospital daily in the UK due to COVID-19 infection. It is currently unknown how safely and effectively the emergency care system (NHS 111, the ambulance service and hospital Emergency Departments) assessed patients with suspected COVID-19 infection during the pandemic and determined whether patients needed to attend hospital or required hospital admission. There are currently no validated evidence-based risk stratification tools that can be used by clinicians in the pre-hospital and Emergency Department environments to identify patients at higher risk for deterioration with suspected COVID-19 infection who require further assessment. In order to accurately assess whether patients with suspected COVID-19 infection who accessed the emergency care system during the pandemic had serious adverse outcomes it is necessary to link prehospital and Emergency Department cohorts with the proposed Emergency Care data Sets, Hospital Episode Statistics and Mortality data. Linking pre-hospital cohorts to GPES Data for Pandemic Planning and Research is also necessary to accurately identify patient factors associated with serious adverse outcomes. Given the possibility of a second peak of COVID-19 infections in the UK as “lock-down” measures are relaxed the proposed research is urgently needed. Early analysis of the pre-hospital and Emergency Department cohorts will identify the characteristics of any patients advised to self-care at home who subsequently deteriorated and patients who are at high risk for serious adverse outcomes. Study Governance The data controller is the University of Sheffield. The study sponsor is Sheffield Teaching Hospitals NHS Foundation Trust. The study funder is the National Institute for Health Research. The study has been recognised as a nationally prioritised study in response to the COVID19 pandemic. Background The term triage is often used to describe a brief initial assessment in the emergency department to determine patient order of priority in the queue to be seen. In this project, the research team will use the term triage more broadly to include the full process of emergency department and pre-hospital assessment (by 111 and the ambulance service) used in decision-making regarding whether patients should attend hospital, require hospital admission or be referred for high dependency or intensive care. On 26th March 2020, the PRIEST study began recruitment of patients with suspected COVID-19 attending Emergency Departments at participating NHS Trusts in England, Scotland, Wales and Northern Ireland. Data has been collected on over 20,000 patients. This work package (WP) is informally known as “core-PRIEST” and the data collected under this WP is known as the “core-PRIEST data”. Between 18 March 2020 and 9 April 2020, the NHS online service completed 1,911,161 COVID-19 online assessments across England, resulting in 348,125 triages to NHS 111 or 999. Data from NHS England report an average of 95,600 calls per day to NHS 111 in March 2020, compared to an average of 46,700 a day in March 2019. Ambulance Services in England received a record number of calls per day to 999 in March 2020, possibly influenced by the COVID-19 pandemic. NHS 111 call handlers use structured questions and clinical advice to determine whether a 999 response is required. If no response is required, the patient is advised to self-care or contact their GP. If a 999 response is required, the attending ambulance personnel can use their clinical judgement to determine whether transport to hospital is needed. There has not yet been any research into the appropriateness of prehospital triage decisions with respect to patients with suspected COVID-19 and the researchers are not aware of any validated tools applicable to this situation. Emergency department triage methods need to accurately predict an individual patient’s risk of death or severe illness. The predicted risk can then guide decision-making. Patients with a low risk may be discharged home, those with a high risk admitted to hospital, and those with a very high risk referred for high dependency or intensive care. Current risk stratification tools used in the Emergency department to help triage hospital admissions for patients with respiratory infection are based upon research conducted on patients with bacterial pneumonia and seasonal influenza. The available research indicates that no single tool performs well enough to support its sole use to inform hospital triage decisions during a pandemic and the use of these existing tools has not yet been assessed in patients with suspected COVID 19. Research is therefore urgently needed to determine the accuracy of pre-hospital and Emergency Department triage decisions during the current COVID-19 pandemic and explore whether they could be improved. The specific objectives during the pandemic are: 1. To report any important emerging findings regarding the performance of the emergency care triage method (or methods) used for suspected respiratory infections during a pandemic 2. To identify clinical characteristics and routine tests associated with under-triage (false negative assessment) or over-triage (false positive assessment) during a pandemic 3. To determine the discriminant value of alternative triage methods for predicting severe illness in patients presenting with suspected respiratory infection during a pandemic 4. To inform policy makers and practitioners during a pandemic of the study’s emerging findings. The specific objectives after the first wave and, potentially for subsequent waves, of the pandemic are, for the hospital (emergency department): 1. To determine the discriminant value of emergency department triage methods for predicting severe illness in patients presenting with suspected pandemic respiratory infection 2. To determine the accuracy of presenting clinical characteristics and routine tests for predicting severe illness 3. To determine the independent predictive value of presenting clinical characteristics and routine tests for severe illness 4. To develop new triage methods based upon presenting clinical characteristics alone or presenting clinical characteristics, electrocardiogram (ECG), chest X-ray and routine blood test results, depending upon the data available and the predictive value of variables evaluated in objective 3 The specific objectives after the first wave and, potentially for subsequent waves, of the pandemic are, for prehospital services (NHS 111 and emergency ambulance services): 1. To link NHS 111 calls, identified as potentially relating to COVID19, to participating hospital and NHS Digital data, to determine whether patients calling NHS 111 were appropriately advised or provided with an ambulance response, in terms of whether they were admitted to hospital or suffered an adverse outcome. 2. To link ambulance ePR data to hospital and NHS Digital data, to determine whether patients attended by ambulance were appropriately advised to self-care at home or transported to hospital, in terms of whether they were admitted to hospital or suffered an adverse outcome. 3. To use ambulance ePR data recording patient characteristics to determine which patient characteristics, when recorded prehospital, are useful in predicting adverse outcome and determine the discriminant value of early warning scores, such as NEWS2, for predicting adverse outcome. 4. To explore the potential for data mining to provide new insights into the prediction of adverse outcome among patients contacting NHS 111 or ambulance services with suspected COVID-19. Data is being processed under Article 6(1)(e) and Article 9(2)(j) as a task in the public interest as developing accurate risk stratification tools which are fair, robust, reproducible and allows the rapid identification of low risk patients with suspected COVID-19 infection who can safely self-care at home would help to mitigate the risk of services becoming overwhelmed and adverse patient outcomes.
Dissemination of such information could reduce the risk of patients with suspected COVID-19 infection being inappropriately advised to self-care and deteriorating. This would be of direct benefit to users of the emergency care system in the Health and Social care sector. During peaks in the COVID-19 pandemic emergency care services, especially pre-hospital services, are at risk of being overwhelmed. Developing accurate risk stratification tools which are fair, robust, reproducible and allows the rapid identification of low risk patients with suspected COVID-19 infection who can safely self-care at home would help to mitigate the risk of services becoming overwhelmed and adverse patient outcomes. If successfully developed accurate risk-stratification tools for patients with suspected COVID-19 infection in the pre-hospital and Emergency Department are likely to be adopted across the UK to aid the triage of patients in any subsequent peaks of the pandemic. Using data collected on patients attending Emergency Departments in the UK with suspected COVID-19 infection during the first peak, linked to HES and ONS mortality data, the researchers may have derived, validated and disseminated a risk-stratification tool to help triage in the Emergency Department by February 2021. If the risk stratification tool is found to improve upon current triage of suspected COVID-19 patients in the Emergency Department, it will be disseminated to the New and Emerging Respiratory Threats Advisory Group which advises the Chief Medical Officer and in publication in high impact clinical journals. A successful triage tool is likely to be incorporated by NICE guidelines for use by clinicians in the triage of patients with suspected COVID-19 and change clinical practice in the Emergency Department. This would benefit the Health and Social Care sector by reducing the risk of patients being discharged who subsequently deteriorate or unnecessarily admitting patients (using scarce health service resources during a pandemic) who are unlikely to deteriorate. If such tools were found to improve pre-hospital triage of patients with suspected COVID-19 infection results would be disseminated to the New and Emerging Respiratory Threats Advisory Group which advises the Chief Medical Officer and in high impact clinical journals. The findings could ultimately inform national clinical guidelines, such as NICE guidelines, and change clinical practice. Pre-hospital risk stratification tools could benefit the Health and Social Care sector by reducing the risk of patients being advised inappropriately to self-care at home or unnecessarily conveying patients to hospital who are at low risk of deteriorating.
01/11/2021
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Personally Identifiable
Health and Social Care Act 2012 – s261(7); National Health Service Act 2006 - s251 - 'Control of patient information'.
Section 251 NHS Act 2006
One-Off
Safe Setting
TRE