Every day, emergency room workers use triage to prioritize patient care — but exhausted personnel in under-resourced hospitals can easily make deadly errors in diagnostic tests and symptom scoring. South African emergency room doctor Mohammed Dalwai witnessed such avoidable tragedy firsthand while working with Médicins sans Frontières in Pakistan. He resolved never to let it happen again.
Dalwai urged MSF to apply a standard triaging system — the paper-based South African Triage Scale — in his emergency room in Pakistan. This led to an 86% improvement in successful triaging, and to MSF adopting this standard in emergency rooms around the world. It also led to a big idea for Dalwai. Now, with The Open Medicine Project (TOMPSA), he and his team have made an app that is freely available. They are planning to roll it out across many regions.
Here, Dalwai tells the TED Blog about the app’s development, and its possible future uses — including the ability to track realtime data of disease outbreak.
How did you end up joining Médicins sans Frontières and creating the Mobile Triage App?
I actually always wanted to be a biomechanical engineer! But then I started studying medicine, and fell in love with it after the third year, when I began seeing patients. That was it for me. I finished med school at Stellenbosch University, and afterwards went into rural medicine. I went into the bush to work at Manguzi Hospital, on the border of Mozambique and South Africa.
There, I met an MSF doctor, who told me about the organization. The idea of going into low-resource settings and helping to make an impact in the system appealed to me, and I wanted to experience medicine outside of South Africa. So I went on multiple missions with MSF — to Pakistan, Afghanistan, Libya, Syria, Haiti and Sierra Leone.
It was in Pakistan in 2011, on my first assignment, that I saw patients dying due to incorrect triaging. One day, I lost a patient. A young woman, 22 years old, came in with abdominal pain. She was incorrectly triaged, and she waited for eight hours. She had something called an ectopic pregnancy — a pregnancy outside the uterus — and she was bleeding internally. When I found her, she was barely alive, and we tried everything to resuscitate her. But she died — and it really affected me. She was a woman, she was sidelined, she was put in a corner — no one cared, no one did the triage properly. If she’d been triaged correctly, we would have realized she was pregnant, and we would have prioritized her.
From that day on, I became determined to sort out the triage problem. I was part of a team that implemented the South African Triage Scale in my emergency room, and it was the first time it had been used in an MSF hospital. It was the first time the South African Triage Scale was ever implemented in Southeast Asia.
What is the South African Triage Scale?
It’s a paper-based system based on a composite score — including complaints and vital signs — and one of the only triage scales made for the developing world to evaluate both adults and children. It was developed in a small but busy hospital in Cape Town in a low socio-economic area in response to massive patient loads, understaffing and high death rates. It was introduced in 2008, and shown to be effective when implemented.
MSF had never had a standard triage system in place before this. We lobbied hard for change and standardization. They let us try it, and we did a study that showed a successful implementation. It was at that point that MSF realized how valuable it was, and they started implementing it in every emergency center around the world.
But this is not necessarily a one-size-fits-all solution. The South African Triage Scale (SATS), being relatively new, has been tested extensively in South Africa, but not yet rigorously tested outside of the country. I’m now working on my PhD, documenting the SATS’s validity and reliability in other sectors and countries. For the last two years, I’ve been collecting data on the SATS and how it’s been implemented globally. We proved that it works in Pakistan, and we proved that it works in certain African countries. But Afghanistan and Haiti are different. What are those differences, and how can we adapt the system for local circumstances? In Sierra Leone, for instance, there was a massive malaria population, which has lower hemoglobin levels. Because of that, the triage scale wouldn’t pick up certain patients, so we would have to adjust one or two discriminators after research so that the triage scale is more sensitive for these people. Small things like that make a massive difference in patient care.
Why create a mobile app, when it sounds like the paper-based system works very well to correct the possibility of human error?
Even though the SATS works, it still needs to be implemented correctly across a variety of situations, so we need to standardize the format to further avoid human error. Health care workers are trained to various degrees across different countries. One of the easiest ways to standardize things is through technology. When I came home from Pakistan, I discussed my experiences with my friend Yaseen Khan. Together we decided we had to tackle health system problems using technology — and that’s how we formed The Open Medicine Project (TOMPSA).
When you look at the way the nurses or health care workers make mistakes, it’s usually one of two areas: it’s either they don’t understand the discriminator — so the first symptom that the patient comes in with. The paper-based version of the SATS offers no additional information, whereas a mobile app can. They also make mistakes in calculation. In the SATS, the vital signs are all linked to a composite score, and each one is different. So say, for example, you have a heart rate of 98 beats per minute, that’s zero point. If you have a heart rate of 101, that’s one point. It’s easy to make mistakes, and a massive number of errors are happening in that scoring system alone. So digitizing systems offers more information as prompts for medical care depending on the score. Nurses were forgetting to do pregnancy tests, for example.
The app is essentially a digital checklist. Checklists make massive differences in both the airline aviation industry as well as in medicine. You see the same thing with the WHO surgical checklist. It saves lives.
To read the full interview, visit the TED Blog >>>