The application of smart technology has become an increasingly common practice in daily life, especially in medical treatment. Modern smart technology facilitates faster computation, has natural-command abilities, wider presentation screens and intelligent operation [1-4]. Advanced smart technology has also been found to be widely used in medical healthcare; for example, in monitoring patients, tracing their health conditions, consultations by experts or doctors, obtaining suggestions related to healthcare medication, and much more. [5-6]. The number of people who need to consult doctors or receive medical services could be reduced by substituting new technology as an alternative [7-8].
Although the trend of using smart technology in healthcare has increased on a global scale, thereby reducing the duties of medical staff, inadequate public health support and services are still problematic in Thailand. While applications of smart technology have been developed in an effort to ease the overcrowding of emergency care units, this has not solved all their operational problems.
According to the National Bureau of Statistics, there were 220 million out-patients in Thailand in 2018, who were served by 35,388 doctors, 180,589 service providers and various other hospital staff [9]. Based on these numbers, the Thai healthcare system should be better at aiding primary care doctors. An effective primary care regime should include a self-care system, a long-distance patient care system, an effective patient-screening system, and a channel to deliver self-care knowledge to alleviate the workload of the public health units. Technology could be used to effectively manage medical personnel, especially primary care doctors, and patients could be treated in the order of the available resources and medication. These are the key elements of the national strategic plan for public health, which will be implemented over 20 years based on policy 4.0 [10] of the Thai government.
However, the disproportion between doctors and patients is causing concern. There are many reasons for overcrowding in hospitals across Thailand; for example, it can be difficult to predict the symptoms of a disease, side effects are sometimes unclear and patients involved in an accident often require a quick assessment. Primary care physicians play an important role in assessing patients in order to provide them with appropriate and timely medical services, both for normal illnesses and emergencies [11-12].
Pre-hospital information provided by rescue teams, rescuers, community hospitals and emergency medical volunteers is invalid in many cases due to the incorrect Initial Dispatch Code (IDC), which leads to over-allocating or under-allocating emergency resources. The National Institute of Emergency Medicine of Thailand has reported that 60% of the patients who come to the Emergency Department (ED) do not require urgent treatment. This issue especially occurs in regions in which patients need immediate care from medical providers because they lack confidence in their access to primary care [13-14]. As a result, many patients are admitted to an emergency room, which leads to the overcrowding of emergency care units, including the Out Patient Department (OPD) and the ED. Therefore, an effective patient assessment during the pre-hospital process could reduce the overcrowding in hospitals. For example, in an emergency, the rescue teams, rescuers, community hospitals and emergency medical volunteers are responsible for assessing and analysing patients and requesting all the necessary emergency resources. When these medical professionals and volunteers have no experience of making a comprehensive health assessment, the classification of patients using Criteria Based Dispatch (CBD) could be misrepresented, leading to an incorrect IDC and the over- or under-utilisation of emergency resources.
The best way to correctly assess a potential patient is to ask the provincial emergency command unit CBD questions, which results in an IDC. This process can take at least 2-3 minutes or more by phone. When an IDC is identified, the provincial emergency command unit requests an emergency dispatch from the nearest hospital to collect the patient. Trying to reduce the time and optimise the performance of the pre-hospital process is a continuous challenge for the National Institute for Emergency Medicine of Thailand (NIEM). The systematic patient assessment programme it developed, which is currently used for patient assessment to triage patients for IDC, has been found to be too difficult to use because a computer is required to run the programme (Microsoft Access) and this is impractical for primary emergency medical unit operations. Hence, it is only used by the provincial emergency command units, which are the central emergency units. Due to its inefficiencies, this system can only be leveraged in central call centres and is not used in the field.
Moreover, most Thai medical doctors use imported medical applications. Popular systems like the Canadian Triage mobile application and the Mobile Emergency Severity Index (ESI), are the standard for the emergency medical service in Thailand. These applications are widely used by medical doctors for patient triage because they simplify triage protocol referencing by providing a mobile interface. Based on the results of the study, mobile applications may have improved benefits for medical professionals and volunteers experienced in triage [15]. However, these applications are restricted to users with medical knowledge due to their advanced medical terminology. This is important, since the pre-hospital process not only involves medical staff, but also volunteers with limited medical knowledge.
The purpose of this paper is to determine the kind of system that can provide optimal patient triaging for requesting an accurate IDC. Additionally, it is important to find a practical solution for real-life operations by rescue teams, rescuers, community hospitals and emergency medical volunteers.
Moreover, there are other concerns that should be considered when developing an optimised medial system, such as how the system can reduce the overcrowding of the ED, how it can increase patients’ knowledge when they discover suspicious symptoms, and whether they can assess those symptoms to determine if they need urgent treatment when they are at home.
Therefore, an ideal system is one that both primary care physicians and patients can use to screen illnesses in both normal and emergency cases. It should also be able to refer patients to appropriate emergency medical services by helping them to assess the severity of their symptoms and the need for urgent treatment. The system should enable patients to classify symptoms according to international standards.
The aim of this research it to develop a mobile medical application which is suitable for use in Thailand based on the aforementioned requirements. This application must be capable of enabling patients to triage medical conditions based on dispatch protocol-grade criteria. It must be suitable for use on mobile devices because it will serve as a tool for both primary emergency medical practitioners and general users. A prototype will be developed in this study by using patients’ assessment data from the NIEM. This application is expected to reduce the limitations of existing systems that require specialised knowledge to effectively triage patients.
1.1 Triage Medical System
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 [18-21]. 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 [22].
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 [23].
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 minutes 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 [24-25].
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 [26]. Patients are able to self-identify their dental problem and complete a triage report within 4 minutes 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) [27]. 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 [28]. 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 [24-28], 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.
1.2 Thai Triage 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 [29] and, according to the National Institute for Emergency Medicine [30-32], 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 [30][33]. This CBD protocol enables the status of patients who request pre-hospital resources to be rapidly identified as unstable or "sick" [34] 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.