Integration of Information Technology, Wireless Networks, and ...

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TELEMEDICINE AND e-HEALTH Volume 12, Number 4, 2006 © Mary Ann Liebert, Inc.

Original Research Integration of Information Technology, Wireless Networks, and Personal Digital Assistants for Triage and Casualty XIAOMING ZHAO, Ph.D.,1,2 AZHAR RAFIQ, M.D.,1 RUSSEL HUMMEL, M.S.,1 DING-YU FEI, Ph.D.,2 and RONALD C. MERRELL, M.D.1

ABSTRACT The purpose of this study was to evaluate a portable tool for use by first responders in documenting triage of victims in a mass casualty incident (MCI) more effectively. The tool presented in this study allows first responders to gather patients vital signs, injuries, and triage status in a prompt and accurate way, and enables first responders to wirelessly communicate vital health information throughout the entire care continuum. The architecture infrastructure for the portable device is called Triage and Casualty Informatics Technology (TACIT) and can expedite triage, transport and treatment procedures within an MCI. TACIT was developed by integrating handheld devices, wireless networks, global positioning system (GPS), digital cameras, and bar code scanners with customized triage software. Two MCI initial field trials verified that the TACIT software, battery life, data accuracy, and wireless transmission met the emergency response system requirements. Initial field trials also demonstrated robustness of operation, reduced triage collection time and improved collection accuracy. The TACIT system could work as an efficient prehospital response tool and platform.

INTRODUCTION

C

ATASTROPHIC CASUALTY SITUATIONS seldom occur; however, the tendency for them to occur is on the rise. Multivictim mass casualty incidents (MCIs) can easily strain resources of emergency medical systems (EMS) and local hospitals over the course of a year. It is with this idea that we plan and train for deployment of effective casualty response. The important lessons from the September 11 terrorist attacks

show that a regional system of collecting and sharing key information, before, during, and after an emergency, must be implemented.1 Furthermore, public health agencies and the emergency response community must work together to respond to any future incidents and focus on surveillance and preparedness for MCI events.2 One critical requirement in a MCI response is to gather timely and accurate patient information in order to sort the victims for treat-

1Medical Informatics and Technology Applications Consortium, Department of Surgery and 2Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia.

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INTEGRATION OF INFORMATION TECHNOLOGY

ment. The report on the Pentagon attack from September 11 illustrated that there was little information relayed from the scene to the hospitals about patient flow for the first few hours.3 The lack of medical patient information from first responders at the incident site frustrated efforts by regional hospitals to plan ahead. Patients are typically evaluated and stabilized at the scene by trained prehospital personnel, then triaged and transported to appropriate hospitals with proper resources.4 Integration of information gathering technologies can improve current MCI systems for optimal application to respond to unpredictable volume and character of casualties. Collecting patient information digitally at the disaster site and transmitting cumulative trends of victims to the field command center with further relay of information to regional hospital in real-time can serve as a venue for improving the MCI response system. The unpredictable magnitudes of patients and escalating operating cost in responding to incidents bring multiple challenges for emergency medical services and prehospital care practices. For example, there were 374,730 emergency vehicle dispatches reported in Illinois in 1997.5 Of those, 77 percent were reported as emergency response to a scene and 46 percent from the scene as an emergency. Preliminary studies show that quality documentation and data collection system play a critical role to assure the success of a response plan.6,7 Emerging technologies have been developed to assist in gathering data from large volume of prehospital patients such as the systems developed using Personal Digital Assistants (PDAs) to collect military medical records or to evaluate users perceived ease of use.8–10 To supplement communication in relaying archived information, wireless networks have been developed to transmit the information. For example, a mobile telemedicine system based on third-generation (3G) wireless networks was studied to provide data acquisition from numerous instruments and harmonious transmission to healthcare providers.11 However, MCI events proved vulnerable communications such as cellular services were adversely affected due to spikes in usage at critical times.12,13 Further research demonstrated feasibility of redundant wireless com-

munication technology using Low Earth Orbiting Satellites (LEOS) for real-time surveillance of data throughput when cellular transmission frequencies are compromised.14 Moreover, the Capital Wireless Integrated Network (CapWIN) was developed to provide an integrated and scaleable first responder data wireless communication and information sharing network covering 40 jurisdictions in the Washington DC Metropolitan area.15,16 The architecture entitled TACIT was developed in this study to integrate existing wireless handheld devices with customized software, and database archiving capability to register, track and characterize patients during MCIs. The purpose of this study was to evaluate a portable and efficient tool to accumulate casualty information rapidly by first responders in a MCI event. TACIT allows documentation of casualty vital signs, character of injuries, and triage status in a prompt and accurate way, as well as enables first responders to wirelessly communicate vital health information throughout the entire care continuum.

MATERIALS AND METHODS The TACIT system was constructed using personal digital assistants (PDAs) entitled TACIT units and a personal computer (PC) as a base station, as shown in Figure 1. The TACIT workstation installed in a Mobile Command Vehicle receives and transmits the information between the TACIT unit and the Central Command Center. A PDA, the iPAQ Pocket PC H5550 (Hewlett-Packard, Palo Alto, CA) with 128 Mb RAM and 400 MHz Xscale Processor, was chosen as the hardware platform for the TACIT unit. The TACIT unit was proposed to be the portable device used by first responders. The embedded operating system of the H5550 PDA is Microsoft Windows® Pocket PC 2003 Premium Edition (Redmond, WA). The TACIT unit integrates Bluetooth® and WiFi/WLAN 802.11b capability for wireless communication. Wireless capabilities of the TACIT unit allow communication with the TACIT workstation and thus synchronize the patient database. An addition made to the workstation was to install an Aironet 350 Wireless Bridge (Cisco Systems,

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ZHAO ET AL.

San Jose, CA) with a high-gain antenna to increase both the effective strength of the outgoing signals and the receiving sensitivity for incoming signals. The TACIT unit integrates several devices to allow comprehensive data capture regarding the casualties at site of incident (Fig. 1). Peripherals integrated to the TACIT unit include a bar code scanner, GPS receiver, digital camera, and a mobile headset. Use of the mobile headset provides hands-free execution of software initiation with audio commands using Bluetooth wireless link. A finger stylus capa-

FIG. 1.

bility allows the first responder to enter characters, navigate screens, and manipulate the touch screen of the TACIT unit when it is attached to the wrist of the first responder wearing a hazmat suit, as illustrated in Figure 2. A key element of the TACIT unit is the TACIT triage software. The TACIT triage software archives all information including location, patient records, timestamps and treatments into a local Pocket Microsoft Access database. The first step in documenting a casualty using TACIT is to assign the patient a unique identification in the database. Patient

Information integration in the Triage and Casualty Informatics Technology (TACIT).

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FIG. 2. Triage and Casualty Informatics Technology (TACIT) information input with a finger stylus.

identification is achieved by using the InHand Scan™ Card (Socket Communications, Newark, CA) installed in the extension pack of TACIT unit. The TACIT triage software communicates via barcode scanner to detect the scanner status and operate the laser scanning. The first responder attaches a Virginia Commonwealth government-issued triage tag to the patient and the barcode built into the tag is scanned by TACIT as a patient identification during the initial disaster scenario, transportation and hospital, shown in Figure 3. Following identification, the location of the casualty is documented using the GPS coordi-

Admin Info Patient Number: Date:

nates. The HP GPS iPAQ navigation system (HP, Palo Alto, CA) was integrated into the TACIT unit for geographic identification. Using Bluetooth communication TACIT software captures the latitude and longitude values from the GPS receiver, and enters them in the TACIT triage forms and database, as shown in Figure 3. Then the origin of the patient can be coordinated by Regional Command Center for overall epidemiological assessment. In addition, the TACIT unit was equipped with one lightweight Photosmart Mobile Camera (HP), which has 1.3 megapixel resolution. It is possible to capture still images, video clips and audio of subjects as well as surrounding area into the TACIT Triage software. First Responders can also record audio notes wirelessly using Bluetooth Headset HS820 (Motorola, Schaumburg, IL). The photos and audio clips are stored in specific folders within the TACIT unit while they are linked to the database. Customized triage software was programmed with Microsoft Visual C#.Net and Visual Basic.Net Embedded. Detailed casualty information can be quickly and conveniently input into the TACIT forms by first responders using the software graphic interfaces such as check boxes, radio boxes, and drop lists. For example, the first responder can

Injury

3:52

Patient Number:

131701 Time:

03/31/05

Location:

GPS

Latitude:

37.54033N

4:10 131701 Penetrating

15:32

Blunt Trauma Lasceration

Address

Fracture Amputation Burn

Longitude: 77.432198W

Scene Information

Other

Scene Picture

Area

Close Clear GPS Scan FIG. 3.

Capture patient ID (GPS).

Chief Complaint

Close Clear Scan FIG. 4.

Capture of chief complaints.

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FIG. 5.

Triage codes in the TACIT unit.

draw the corresponding chief complaints on the anatomic figures on the screen and use different colors to identify different injures as illustrated in Figure 4. Evaluations during the sequential triage and hospital stages can be input to the TACIT triage form with attached timestamps. The TACIT system uses the standard triage color codes to represent the patient status as presented in Figure 5. Vital signs, such as blood pressure, pulse, and respiration could be easily entered into the patient triage form as presented in Figure 6. Furthermore, the TACIT unit software also provides capacity to record any initial treatments, as well as transportation routes and destination facilities. A communication software module based on transmission control protocol (TCP)/Internet protocol (IP) and Microsoft ActiveSync always runs in the background to synchronize the local database and files within the TACIT unit to the TACIT workstation through 802.11b wireless connection. In the case of no wireless connection, the TACIT triage software will keep the local backup and search available wireless links. Once the TACIT unit approaches in the range of the TACIT WLAN, the communication module will resume synchronization. An option for manual synchronization is also

available for immediate data transmission. As a result, first responders may temporarily break from the communication continuum of the Mobile Command Vehicle without losing information. Complete and fast-index reference databases are helpful during MCIs so that first responders can quickly identify the type of biologic or chemical attacks and find out the prescribed method for response. The TACIT unit was outfitted with a 5MCC (Skyscape, Hudson, MA) to provide the first responders with the latest information on bio-terror agents including anthrax, smallpox, and bacterial pathogens. The reference databases are updated weekly to ensure the latest agents and drugs information. The TACIT workstation software at the Mobile Command Vehicle monitors multiple TACIT units and retrieves all the patient information into a central relational database. TACIT workstation software also provides management functions for triage cases. All the triage information could be displayed on the workstation interface. The triage cases can be sorted or searched by triage ID, patient name, triage status, and collection time. The software can automatically produce complete triage re-

4:14

Treatment Patient Number: Date 03/31/05 03/31/05 Date:

131701

Time

Pulse

Blood Pressure

16:11 16:26

94 91

100/150 95/148

Time: 16:14

03/31/05

Blood Pressure: Pulse: 89

93/142

Respirations: 35

Add Delete

Level of Consciousness Light Coma

Vitals

Treatment

Comments

Close Clear Scan FIG. 6. Treatment interface in the Triage and Casualty Informatics Technology (TACIT) unit.

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RESULTS

FIG. 7. Sample of the Triage and Casualty Informatics Technology (TACIT) triage report. Note: the names and vital signs are fictitious for research purposes.

ports according to Virginia Commonwealth government-issued triage tag format, as illustrated in Figure 7. The TACIT unit security is protected by user password and biometric fingerprint reader. The first responder can only access the TACIT unit with the correct user password or fingerprint. The wireless data transmission is encrypted by Wired Equivalent Privacy (WEP) 128-bit security protocol to guarantee that no data are intercepted by unauthorized clients. The information is stored into a secure Microsoft Access database in the TACIT workstation, to which only trusted users have designated degrees of access. In the TACIT system, the VitalSense® devices (Mini Mitter, Bend, OR) were integrated to monitor the first responder’s physiological data, which can be transmitted up to 1,000 feet between the first responder and the TACIT workstation in real-time. The monitored data can be logged and reviewed on the TACIT workstation.

Two simulated emergency scenarios were conducted using the TACIT system to test its performance. An MCI drill, which simulated a scenario representing a dangerous chemical gas spill from a storage container during a class, was carried out at Virginia Tech (VT), Blacksburg, Virginia. A total of 24 trainees in the Virginia Tech Rescue Squad (VTRS) attended a 1-hour TACIT training class before the drill. There were 36 students playing the role of casualty victims in that classroom and most were assigned to be affected. Four first responders from VTRS arrived at the disaster site, and the TACIT system was deployed as the patient identification mechanism during triage screening and the platform for transmission of patient information to a central database in a TACIT workstation. The entire MCI exercise took 11/2 hours. The first responders triaged all 36 victims with the TACIT units in the disaster site, as illustrated in Figure 8. Standard paper-based triage screening was also used to triage 36 victims in order to compare to the TACIT system. The TACIT workstation was located in the VT ambulance truck during the drill. The GPS signals were not received because the classroom and rescue areas were in a lecture hall. GPS signal strength was adequate outside the building. However, collecting GPS information from outside the building did provide enough geo-

FIG. 8. Mass casualty incident (MCI) drill using the Triage and Casualty Informatics Technology (TACIT) at Virginia Tech.

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spatial information to the Command Center in identifying the location of the disaster event. In-person interviews with first responders after the simulated exercise provided feedback. All first responders in the drill verified that TACIT system was very helpful to gather data in an efficient and accurate fashion. The wireless communication between the TACIT unit and workstation was not continuous because of the distance between user and emergency vehicle outside the building. However, patient triage information within the TACIT unit database was synchronized to the TACIT workstation when the drill was finished. Surveying first responders, 100% preferred using TACIT unit to the paper-based triage collection. They felt comfortable with the PDA-based TACIT unit as the triage collection tool because of its portability and user-friendly interface. The second drill was conducted in a residential area in Richmond, Virginia, to simulate a dirty bomb attack in that area. Ten patient scenarios were evaluated and documented using the TACIT units. The vital signs from the first responders were also collected using the VitalSense in order to track their health status. The first responders heart rates, skin temperatures and body activities (physical motion) were wirelessly transmitted to the TACIT workstation. The 802.11b wireless connection was stable and synchronized entire data from the TACIT units to the workstation in real-time. First responder voice clips were recorded using Bluetooth headset to store short descriptions of the disaster. In both drills, the battery life for the TACIT unit was measured. The TACIT unit lasted over 3.5 hours without charging when the TACIT unit worked on data gathering and communicating. The TACIT unit can last more than 72 hours in a standby mode when neither data collection nor transmission was performed. The Bluetooth GPS receiver provided eight hours of continuous operation and the Bluetooth headset can last up to six hours of continuous talk. The battery test verified that the TACIT unit could provide qualified working time for the first responders in both drills. The average triage data collection time for each case was approximately 3.4 minutes, including basic patient information, vital signs, chief complains, and transportation. The col-

ZHAO ET AL.

lection time varied depending on the patient physical situation and response possibilities. However, compared with the paper-based collection, which used 5 minutes per case, the responders spent less time on triage data collection in the two drills. In addition, barcode scanning did improve the collection accuracy and promptness without writing down the incorrect patient IDs. The test results showed the average patient record size, including two chief complaint figures, one scenery and one patient photo ranged from 130–140 kilobits (Kb) depending on how much the patient information was collected. The average collection time for first responder ranged from 2 to 5 minutes. As a result, the 802.11b wireless networks, which work at 11 megabits per second (Mbps), can grant enough bandwidth to transmit all the records. The comparison between the database and files in the TACIT units and TACIT workstation confirmed that there was no data loss or data corruption in the total 50 patient records collected in the two drills.

DISCUSSION Current practices in responding to MCI do not provide mechanisms to fully document large volumes of casualties in detail. At best, casualty information is outlined on a paper based triage tag which is tied by a string to a particular region of the patient. Paper-based triage collection only can record some basic patient information and the MCI environmental and patient images cannot be gathered or are very limited. To achieve the multimedia collection, the TACIT system harnessed the latest technologies for patient imaging, GPS locating, bar-code scanning, and voice recording to facilitate accurate information gathering electronically in an MCI response. With transmission of the complete information regarding patterns of casualties using real-time WIFI communication, commanders could acknowledge and understand the real disease situation and make the right decision in timely manner. By using VitalSense and GPS, the commanders in the center could also know the first responder status. This is relevant to secure that responders are not exposed to some inductive

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agent hampering the response process. Both laboratory-run tests and field drills demonstrated the TACIT as the successful implementation of interoperability infrastructure by seamlessly integrating various information gathering devices, wireless networks and PDA units enabling first responders to collect and exchange information. The TACIT system utilized the capabilities of software and hardware automation so that first responders can spend less time on triage gathering. The TACIT unit triage software activates the digital camera, scanner and GPS receiver hardware automatically, controls all these devices and collects the multimedia information in simple user interfaces. The TACIT unit software interfaces also completely implemented combo boxes, dropdown lists, automatic date/time fill fields, and graphic drawing fields so that information input is convenient and time saving. As a result, the average collection time was reduced although more information was collected. In addition, information gathering accuracy was also greatly enhanced, since there were less human factor mistakes. The typical errors caused by the unrecognized handwriting, contaminated triage tag in paper-based triage collection were eliminated. During the early stages of MCI, photos attached to patient records would be significant information to diagnose and consult the nature of an injury or the magnitude of physical force injury when conducting emergency rescues.17,18 The cumulative database of all the patients triaged during the golden hour of response to an MCI can be easily transmitted to the TACIT workstation in the background. In comparison, the traditional MCI response relies on radio systems such as Very High Frequency (VHF), Ultra-High Frequency (UHF), and 800 MHz, which transmits only two-way voice. Furthermore, the GPS information could be also transmitted to the Mobile Command Vehicle and Regional Command Center, which will allow the command center to determine the exact MCI location. This also allows the command center analysts to create “hot-zone” maps and make critical decisions for public safety. The TACIT information communication from the Mobile Command Vehicle to the Local Command Center or Regional Command Center via

satellite connection or radio connection is under development. Training the first responders in MCI responses can be a challenge because of geography as well as time consuming and complex operation procedures. The TACIT system provides the standard procedures which help trainees to easily understand and operate. The trainees can follow step-by-step instructions to accomplish the triage data gathering without confusion of the complicate description from the traditional manual. The TACIT system has a mobile training platform, which contains comprehensive medical references for MCI. It gives the first responder instant instructions and knowledge whenever and wherever they are. The training courses are also easily staged and instructed because the TACIT software can be presented on any projectors or PC monitors using the software as SOTI Pocket Controller (SOTI Inc, Ontario, Canada). The trainees or trainer can control the TACIT software from the computer keyboard or mouse. The success of TACIT design, training and deployment will help regional emergency services to improve preparation and response for disasters and bioterrorism emergencies. The TACIT system is designed for firefighters and other emergency personnel—using mobile devices—to transmit patient information rapidly from the casualty site to a central database accessible over the wireless networks. Local, state and Department of Homeland Security officials may use the gathered information to determine trends in the event of a biologic event or chemical attack. Such trends in casualties are also critical to understand epidemiology of exposure by residents within communities.

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Address reprint requests to: Ronald C. Merrell, M.D. Medical Informatics and Technology Applications Consortium Department of Surgery Virginia Commonwealth University Box 980480 Richmond, VA 23298 E-mail: [email protected]