BACKGROUND:Emergency care (EC) systems provide an integrated platform for addressing urgent healthcare needs. It has been estimated that time-sensitive conditions comprise approximately half of the total burden of disease in low- and middle-income countries (LMICs), but data from the Pacific region are limited. This study sought to determine the burden of 'emergency medical diseases' (EMDs) in the Melanesian countries of Fiji, Papua New Guinea, Solomon Islands, and Vanuatu. METHODS:Morbidity and mortality data for Fiji, Papua New Guinea, Solomon Islands, and Vanuatu were sourced from the Institute for Health Metrics and Evaluation's Global Burden of Disease Project database (2019 dataset). Diseases were categorised into EMDs and non-EMDs based on previously published definitions, namely, whether their assessment or management is time-sensitive or not. Descriptive statistics were used to summarise the burden of EMDs, with disability-adjusted life years (DALYs) used as the primary measure of morbidity. FINDINGS:EMDs account for 43%-60% of mortality and 37%-52% of morbidity in Fiji, Papua New Guinea, Solomon Islands, and Vanuatu. The five most prevalent EMDs in these countries (ischaemic heart disease, stroke, injuries, lower respiratory tract infections, and diarrhoeal illnesses) cause 37%-60% of all deaths. INTERPRETATION:Approximately half of all pre-pandemic mortality and morbidity in Melanesia is attributable to EMDs. This is consistent with previously reported literature for LMICs and confirms the need for resilient EC systems in the Pacific.

Emergency and critical care services are essential to universal health coverage. World Health Assembly (WHA) Resolution 76.2, adopted in 2023, outlined the importance of integrated emergency, critical and operative care systems in strengthening primary healthcare capabilities. Recent research has determined that system strengthening and partnership-based approaches to healthcare capacity development have the potential to achieve greater equity and sustainability. The Regional Emergency and Critical Care Systems Strengthening Initiative (RECSI) is an Australian Government funded programme under the Partnerships for a Healthy Region (PHR) initiative. It aims to enhance acute care capacity and healthcare system resilience across the Pacific and Timor Leste. RECSI is led by a consortium of acute care organisations and provides a vehicle for progressing WHA 76.2. The programme focuses on four thematic areas: workforce capacity and training, systems and processes, data and research, and leadership and governance. As part of RECSI's inception, a structured programme logic was developed, which describes programme activities and outputs, and how they contribute to defined intermediate and end-of-programme outcomes. RECSI's monitoring, evaluation and learning (MEL) plan, which supplements the programme logic, incorporates sustainability indicators that are focused on monitoring the impact of mechanisms designed to enable ongoing benefits from programme outcomes. Utilising a partner-led and context-specific programme design, RECSI represents a rigorous approach to acute care system strengthening. This strategy aims to build genuine partnerships to leverage skills, knowledge and opportunity across the Pacific and Timor-Leste.

Triage is widely regarded as a core emergency care function, as reflected in the World Health Organization (WHO) Emergency care systems framework and in recent World Health Assembly resolutions. In this article, we explore the evidence supporting triage in low-resource settings, with a focus on the Interagency Integrated Triage Tool. Following its release by WHO in the early stages of the coronavirus disease pandemic, the tool has been implemented across a range of low- and middle-income countries. We report evidence regarding its acceptability and performance from Papua New Guinea in the WHO Western Pacific Region. Data from four single-centre studies suggest that the tool can be reliably and efficiently applied by health workers, and its predictive validity is within the performance range of other triage instruments. The system is highly regarded by emergency care clinicians, and can be implemented with limited digital or in-person training. Although triage has intuitive and widely acknowledged value, recent research has identified a lack of high-quality evidence supporting an association between triage implementation and improved clinical outcomes. Evidence from several pre-post intervention studies suggests that the introduction of triage can reduce waiting times and mortality, but these data may have been subject to confounding and publication bias. Further research is required to establish the performance characteristics of the Interagency Integrated Triage Tool in other countries and contexts, and more rigorously examine the impact of triage implementation on quality of care.

Background: Pain is one of the most common causes for presentation to the emergency department (ED). Although previous research has identified factors influencing time to analgesia (TTA), impact of isolation, an infection control measure for selected communicable diseases, has not been investigated. Aim: To determine the association between isolation precautions and TTA for patients presenting to the ED with pain. Method: A retrospective cohort study included adult patients with pain requiring analgesia and a Australasian Triage Scale category of 2 or 3 that presented to two metropolitan EDs, located in Melbourne, Australia, between 1 January 2021-31 March 2021. Patients were identified using a Health Registry for Emergency Care. The primary outcome was the proportion of eligible patients that received analgesia within 30 min of their ED arrival. Secondary outcomes included TTA and ED disposition. The primary exposure variable was placement in isolation precautions in the ED. Ethical approval was granted by the Alfred Health Ethics Committee (Reference no: 783/20) and the study conforms with the Australian National statement on ethical conduct in human research. Results: During the study period, 2786 eligible patients were identified. There were no differences in baseline characteristics between exposure groups. Among 541 isolated patients, 3.3% (n = 18) received analgesia within 30 min of ED arrival, compared with 8.0% (n = 180) of the 2245 patients who did not require isolation precautions (odds ratio 0.39, 95% confidence interval 0.24-0.65, p < 0.001). The median TTA was 164 min for patients requiring isolation and 106 min for those that did not (p < 0.001). Conclusion: Among patients presenting to the ED with acute pain, placement in isolation precautions was associated with prolonged TTA. Further research is required to determine specific factors to mitigate delays to analgesia, including for isolated patients.

Background: The Interagency Integrated Triage Tool (IITT) is a three-tier triage instrument recommended by the World Health Organization, but only the pilot version of the tool has been comprehensively assessed for its validity and reliability. This study sought to evaluate the performance of the IITT in a resource-constrained emergency department (ED) during the COVID-19 pandemic. Methods: This prospective observational study was conducted at ANGAU Memorial Provincial Hospital in Lae, Papua New Guinea. The study period commenced approximately six weeks after introduction of the IITT, coinciding with a major COVID-19 wave. The primary outcome was sensitivity for the detection of time-critical illness, defined by eight pre-specified conditions. Secondary outcomes included the relationship between triage category and disposition. Inter-rater reliability was assessed using Cohen's Kappa. Results: There were 759 eligible presentations during the study period. Thirty patients (4.0%) were diagnosed with one of the eight pre-specified time-critical conditions and 21 were categorised as red or yellow, equating to a sensitivity of 70.0% (95%CI 50.6-85.3). There was a clear association between triage category and disposition, with 22 of 53 red patients (41.5%), 72 of 260 yellow patients (27.7%) and 22 of 452 green patients (4.9%) admitted (p = <0.01). Negative predictive values for admission and death were 95.1% (95%CI 92.7-96.9) and 99.3% (95%CI 98.1-99.9) respectively. Among a sample of 106 patients, inter-rater reliability was excellent (kappa = 0.83) and the median triage assessment time was 94 seconds [IQR 57-160]. Conclusion: In this single-centre study, the IITT's sensitivity for the detection of time-critical illness was comparable to previous evaluations of the tool and within the performance range reported for other triage instruments. There was a clear relationship between triage category and disposition, suggesting the tool can predict ED outcomes. Health service pressures related to COVID-19 may have influenced the findings. (c) 2023 The Author(s). Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).

According to the World Health Organization’s (WHO) Emergency Care Systems Framework, triage is an essential function of emergency departments (EDs). This practice innovation article describes four strategies that have been used to support implementation of the WHO-endorsed Interagency Integrated Triage Tool (IITT) in the Pacific region, namely needs assessment, digital learning, public communications and electronic data management. Using a case study from Vila Central Hospital in Vanuatu, a Pacific Small Island Developing State, we reflect on lessons learned from IITT implementation in a resource-limited ED. In particular, we describe the value of a bespoke needs assessment tool for documenting triage and patient flow requirements; the challenges and opportunities presented by digital learning; the benefits of locally designed, public-facing communications materials; and the feasibility and impact of a low-cost electronic data registry system. Our experience of using these tools in Vanuatu and across the Pacific region will be of interest to other resource-limited EDs seeking to improve their triage practice and performance. Although the resources and strategies presented in this article are focussed on the IITT, the principles are equally relevant to other triage systems.

Background Triage implementation in resource-limited emergency departments (EDs) has traditionally relied on intensive in-person training. This study sought to evaluate the impact of a novel digital-based learning strategy focused on the Interagency Integrated Triage Tool, a three-tier triage instrument recommended by the World Health Organization.Methods A mixed methods study utilising pre-post intervention methods was conducted in two EDs in Papua New Guinea. The primary outcome was the mean change in knowledge before and after completion of a voluntary, multimodal training program, primarily delivered through a digital learning platform accessible via smartphone. Secondary outcomes included the change in confidence to perform selected clinical tasks, and acceptability of the learning methods.Findings Among 136 eligible ED staff, 91 (66.9%) completed the digital learning program. The mean knowledge score on the post-training exam was 87.5% (SD 10.4), a mean increase of 12.9% (95% CI 10.7-15.1%, p < 0.0001) from the pre-training exam. There were statistically significant improvements in confidence for 13 of 15 clinical tasks, including undertaking a triage assessment and identifying an unwell patient. In an evaluation survey, 100% of 30 respondents agreed or strongly agreed the online learning platform was easy to access, use and navigate, and that the digital teaching methods were appropriate for their learning needs. In qualitative feedback, respondents reported that limited internet access and a lack of dedicated training time were barriers to participation. Interpretation The use of digital learning to support triage implementation in resource-limited EDs is feasible and effective when accompanied by in-person mentoring. Adequate internet access is an essential pre-requisite. Health 2023;33: Published February https://doi.org/10. 1016/j.lanwpc.2023. 100683

INTRODUCTION:Triage is widely regarded as an essential function of emergency care (EC) systems, especially in resource-limited settings. Through a systematic search and review of the literature, we investigated the effect of triage implementation on clinical outcomes and process measures in low- and middle-income country (LMIC) emergency departments (EDs). METHODS:Structured searches were conducted using MEDLINE, CENTRAL, EMBASE, CINAHL, and Global Health. Eligible articles identified through screening and full-text review underwent risk-of-bias assessment using the Newcastle-Ottawa Scale. The quality of evidence for each effect measure was summarized using GRADE. RESULTS:Among 10,394 articles identified through the search strategy, 58 underwent full-text review and 16 were included in the final synthesis. All utilized pre-/postintervention methods and a majority were single center. Effect measures included mortality, waiting time, length of stay, admission rate, and patient satisfaction. Of these, ED mortality and time to clinician assessment were evaluated most frequently. The majority of studies using these outcomes identified a positive effect, namely a reduction in deaths and waiting time among patients presenting for EC. The quality of the evidence was moderate for these measures but low or very low for all other outcomes and process indicators. CONCLUSIONS:There is moderate quality of evidence supporting an association between the introduction of triage and a reduction in deaths and waiting time. Although the available data support the value of triage in LMIC EDs, the risk of confounding and publication bias is significant. Future studies will benefit from more rigorous research methods.

Triage aims to identify and prioritize patients with time-sensitive health care needs.This process is particularly important when demand for emergency care exceeds the available resources. A small number of triage instruments have been purpose designed for low-and middle-income countries.Most recently,the World Health Organization,in collaboration with the International Committee of the Red Cross and Médecins Sans Frontières,has released the Inter-agency Integrated Triage Tool(IITT).Despite endorsement by leading global health agencies,little has been published regarding the IITT's validity and reliability. Although triage is widely regarded as a critical tool for organizing emergency care services,many instruments have demonstrated subop-timal sensitivity for the detection of time-critical illness.There is a pressing need therefore to assess the performance of the IITT relative to other systems.Recent efforts to implement and evaluate the tool in the Western Pacific region will provide valuable insights into its validity,reliability and acceptability.

Background:Emergency care (EC) addresses the needs of patients with acute illness and injury, and has fulfilled a critical function during the COVID-19 pandemic. 'Processes' (e.g. triage) and 'data' (e.g. surveillance) have been nominated as essential building blocks for EC systems. This qualitative research sought to explore the impact of the pandemic on EC clinicians across the Pacific region, including the contribution of EC building blocks to effective responses.Methods:The study was conducted in three phases, with data obtained from online support forums, key informant interviews and focus group discussions. There were 116 participants from more than 14 Pacific Island Countries and Territories. A phenomenological approach was adopted, incorporating inductive and deductive methods. The deductive thematic analysis utilised previously identified building blocks for Pacific EC. This paper summarises findings for the building blocks of 'processes' and 'data'.Findings:Establishing triage and screening capacity, aimed at assessing urgency and transmission risk respectively, were priorities for EC clinicians. Enablers included support from senior hospital leaders, previous disaster experience and consistent guidelines. The introduction of efficient patient flow processes, such as streaming, proved valuable to emergency departments, and checklists and simulation were useful implementation strategies. Some response measures impacted negatively on non-COVID patients, and proactive approaches were required to maintain 'business as usual'. The pandemic also highlighted the value of surveillance and performance data.Interpretation:Developing effective processes for triage, screening and streaming, among other areas, was critical to an effective EC response. Beyond the pandemic, strengthening processes and data management capacity will build resilience in EC systems.Funding:Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Low-and middle-income countries (LMICs) across the Pacific region have been severely impacted by the COVID-19 pandemic, and emergency care (EC) clinicians have been on the frontline of response efforts. Their responsibilities have extended from triage and clinical management of patients with COVID-19 to health system leadership and coordination. This has exposed EC clinicians to a range of ethical and operational challenges. This paper describes the context and methodology of a rapid, collaborative, qualitative research project that explored the experiences of EC clinicians in Pacific LMICs during the COVID-19 pandemic. The study was conducted in three phases, with data obtained from online regional EC support forums, key informant interviews and focus group discussions. A phenomenological approach was adopted, incorporating a hybrid inductive and deductive thematic analysis. Research findings, reported in other manuscripts in this collection, will inform multi-sectoral efforts to improve health system preparedness for future public health emergencies. Copyright Crown Copyright (c) 2022 Published by Elsevier Ltd.

The COVID-19 pandemic continues to test health systems resilience worldwide. Low- and middle-income country (LMIC) health care systems have considerable experience in disasters and disease outbreaks. Lessons from the preparedness and responses to COVID-19 in LMICs may be valuable to other countries.This policy paper synthesises findings from a multiphase qualitative research project, conducted during the pandemic to document experiences of Pacific Island Country and Territory (PICT) frontline clinicians and emergency care (EC) stakeholders. Thematic analysis and synthesis of enablers related to each of the Pacific EC systems building blocks identified key factors contributing to strengthened EC systems.Effective health system responses to the COVID-19 pandemic occurred when frontline clinicians and 'decision makers' collaborated with respect and open communication, overcoming healthcare workers' fear and discontent. PICT EC clinicians demonstrated natural leadership and strengthened local EC systems, supporting essential healthcare. Despite resource limitations, PICT cultural strengths of relational connection and innovation ensured health system resilience. COVID-19 significantly disrupted services, with long-tail impacts on non-communicable disease and other health burdens.Lessons learned in responding to COVID-19 can be applied to ongoing health system strengthening initiatives. Optimal systems improvement and sustainability requires EC leaders' involvement in current decision-making as well as future planning. Search strategy and selection criteria:Search strategy and selection criteria We searched PubMed, Google Scholar, Ovid, WHO resources, Pacific and grey literature using search terms 'emergency care', 'acute/critical care', 'health care workers', 'emergency care systems/health systems', 'health system building blocks', 'COVID-19', 'pandemic/surge event/disease outbreaks' 'Low- and Middle-Income Countries', 'Pacific Islands/region' and related terms. Only English-language articles were included. Funding:Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Copyright of the original work on which this publication is based belongs to WHO. The authors have been given permission to publish this manuscript. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of WHO. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant. RM is supported by a National Health and Medical Research Council (NHMRC) Postgraduate Scholarship and a Monash Graduate Excellence Scholarship. GOR is supported by a NHMRC Early Career Research Fellowship. CEB is supported by a University of Queensland Development Research Fellowship. None of these funders played any role in study design, results analysis or manuscript preparation.

BackgroundThis study explores emergency care (EC) and other frontline healthcare worker (HCW) experiences responding to the COVID-19 pandemic in the Pacific region. The crisis has reinforced the crucial role well-trained, resourced, and supported EC providers play in supporting vital health systems and services in all global regions not only during ‘business as usual’ periods, but in times of tremendous stress and surge.MethodsQualitative data were collected from EC providers and relevant stakeholders in three research phases in 2020 and 2021. Data on the World Health Organization's (WHO) Human Resources Building Block, adapted for the Pacific EC context, was thematically analysed. Key findings were further analysed to identify enablers and barriers to effective EC pandemic management.Findings116 participants from across the Pacific region participated in this study. Five themes emerged: (1) EC providers performed multiple pandemic roles; (2) Importance of authorities’ valuing frontline HCWs; (3) HCW mental health and exhaustion; (4) HCW tension managing stigma, personal/professional expectations, and chronic health needs; and (5) Building health and human resource capacity.InterpretationThis study significantly contributes to the limited scientific literature on HCW experiences responding to COVID-19 across the Pacific. Recommendations arising out of this research align with consensus priorities and standards that were identified pre-pandemic by health stakeholders across the Pacific for enhancing EC system development. With limited HCWs available for many Pacific nations, it is imperative the dignity and welfare of local HCWs is genuinely prioritised.FundingEpidemic Ethics/WHO, Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, International Development Fund Grant.

Objective To assess the feasibility of an ED presenting complaint (PC) tool that categorised all ED PCs into 10 categories. Methods A retrospective analysis of 1445 consecutive patient encounters was conducted. The primary outcome was the frequency of use of the 10 PC categories. Results Of the 1203 patient encounters meeting inclusion criteria, the PC tool was completed by clinicians in 574 (47.7%). When completed, the tool's 10 options were selected for most presentations (72.3%). Conclusion The PC tool captured the majority of presenting complaints in 10 categories. External validation is recommended.

Background:The COVID-19 pandemic highlighted challenges for all health systems worldwide. This research aimed to explore the impact of COVID-19 across the Pacific especially with regards to emergency care (EC) and clinicians' preparations and responses. Methods:A collaboration of Australia and Pacific researchers conducted prospective qualitative research over 18 months of the pandemic. In this three phase study data were gathered from Emergency Clinicians and stakeholders through online support forums, in-depth interviews and focus groups. A phenomenological methodological approach was employed to explore the lived experience of participants. This paper discusses the findings of the study regarding the EC building block of 'Infrastructure and Equipment.' Findings:Pre-existing infrastructure and equipment were not sufficient to help control the pandemic. Adequate space and correct equipment were essential needs for Pacific Island emergency clinicians, with donations, procurement and local ingenuity required for suitable, sustainable supplies and facilities. Adequate personal protective equipment (PPE) conferred a sense of security and increased Health Care Workers willingness to attend to patients. Interpretation:Investing in adequate infrastructure and appropriate equipment is crucial for an effective response to the COVID-19 pandemic. The sustainability of such investments in the Pacific context is paramount for ongoing EC and preparation for future surge responses and disasters. Funding:Phases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Jennifer JAMIESON , Rob MITCHELL , Georgina PHILLIPS , Lai Heng FOONG, Sally MCCARTHY , Clare SKINNER and Simon JUDKINS Department of Emergency Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia, Trauma Service, Royal Hobart Hospital, Hobart, Tasmania, Australia, National Trauma Research Institute, Melbourne, Victoria, Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia, Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia, Emergency Department, St Vincent’s Hospital, Melbourne, Victoria, Australia, Emergency Department, Bankstown Lidcombe Hospital, Sydney, New South Wales, Australia, School of Medicine, The University of New South Wales, Sydney, New South Wales, Australia, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia, International Federation for Emergency Medicine, Melbourne, Victoria, Australia, Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia, Emergency Department, Echuca Health, Echuca, Victoria, Australia, and Emergency Department, Austin Health, Melbourne, Victoria, Australia

Background Universal access to safe, effective emergency care (EC) during the COVID-19 pandemic has illustrated its centrality to healthcare systems. The 'Leadership and Governance' building block provides policy, accountability and stewardship to health systems, and is essential to determining effectiveness of pandemic response. This study aimed to explore the experience of leadership and governance during the COVID-19 pandemic from frontline clini-cians and stakeholders across the Pacific region. Methods Australian and Pacific researchers collaborated to conduct this large, qualitative research project in three phases between March 2020 and July 2021. Data was gathered from 116 Pacific regional participants through online support forums, in-depth interviews and focus groups. A phenomenological approach shaped inductive and deduc-tive data analysis, within a previously identified Pacific EC systems building block framework. Findings Politics profoundly influenced pandemic response effectiveness, even at the clinical coalface. Experienced clinicians spoke authoritatively to decision-makers; focusing on safety, quality and service duty. Rapid adaptability, past surge event experience, team-focus and systems-thinking enabled EC leadership. Transparent communication, collaboration, mutual respect and trust created unity between frontline clinicians and 'top-level' administrators. Pacific cultural assets of relationship-building and community cohesion strengthened responses. Interpretation Effective governance occurs when political, administrative and clinical actors work collaboratively in relationships characterised by trust, transparency, altruism and evidence. Trained, supported EC leadership will enhance frontline service provision, health security preparedness and future Universal Health Coverage goals. Funding Epidemic Ethics/World Health Organization (WHO), Foreign, Commonwealth and Development Office/ Wellcome Grant 214711/Z/18/Z. Co-funding: Australasian College for Emergency Medicine Foundation, Interna-tional Development Fund Grant. Copyright Crown Copyright (c) 2022 Published by Elsevier Ltd. This is an open access article under the CC BY-NC -ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)