Emergency and critical care medicine demands rapid and accurate assessment to ensure timely and effective interventions. Visual diagnosis, the process of identifying medical conditions through observation and visual cues, plays a pivotal role in this high-stakes environment. In emergency and critical care settings, where time is often of the essence, the ability to quickly and accurately diagnose conditions visually can significantly improve patient outcomes. Recognizing the crucial nature of standardized practices in this field, a recent study employed a rigorous methodology to define essential elements of emergency and critical care. This article delves into the methods used to establish expert consensus on these vital practices, highlighting the importance of visual diagnostic skills within this framework.
The Critical Need for Standardized Emergency and Critical Care Protocols
The landscape of emergency and critical care is complex and varied, often requiring clinicians to make critical decisions under pressure. To ensure consistent and high-quality care across different settings, especially in resource-limited environments, the establishment of essential emergency and critical care (EECC) protocols is paramount. These protocols serve as a foundation for healthcare systems to deliver effective and timely interventions for critically ill patients. However, defining what constitutes “essential” in this broad field requires careful consideration and expert input.
To address this challenge, a groundbreaking study outlined in the original article, utilized a three-phase approach to achieve consensus among global clinical experts on EECC treatments and actions. This methodology, centered around a modified Delphi technique, aimed to create a user-friendly and feasible package of clinical processes, along with a list of hospital readiness requirements. The study’s process is visually summarized in Figure 1, which illustrates the systematic approach taken to define EECC.
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Figure 1: Visual representation of the three-phase study methodology employed to define Essential Emergency and Critical Care (EECC) Treatment and Actions (T&A).
Phase I: Delphi Method for Consensus Building
The first phase of the study employed a modified Delphi process, a structured communication technique that relies on a panel of experts to reach consensus on a specific topic. This method was particularly well-suited for defining EECC because it allows for anonymous contributions, iterative feedback, and the incorporation of diverse perspectives from a large group of experts. The Delphi process unfolded over three rounds, conducted online in November and December 2020.
Experts were carefully selected to ensure a broad representation of clinical experience, particularly those with substantial experience in low- and middle-income countries. The panel included professionals from various specialties such as paediatrics, obstetrics, medicine, surgery, intensive care, anaesthesia, and emergency care. Doctors, nurses, and other health professionals from diverse geographical locations and genders were invited to participate, ensuring a balanced and comprehensive perspective. Potential participants were identified through stakeholder mapping, literature reviews, researcher networks, and snowball sampling to reach under-represented groups. An open invitation was also extended through professional networks and social media, resulting in 895 experts being invited and providing informed consent.
The core element of the Delphi process was the evaluation of specific treatments and actions (T&A) relevant to EECC. These T&A were categorized into identification of critical illness, general care of critical illness, and diagnosis-specific care for critically ill patients, notably including COVID-19. Crucially, the criteria for inclusion of a T&A were effectiveness, feasibility, and universality (for general critical illness care) or relevance (for COVID-19 specific care). The initial list of potential T&A was derived from existing clinical guidelines and tools from related specialties, as well as the WHO/International Committee of the Red Cross’s Basic Emergency Care guidelines. This draft list was further refined by specialist reviewers with expertise across various medical fields.
In each Delphi round, experts rated their agreement on the inclusion of each T&A using a 4-point Likert scale. Consensus was defined as over 90% agreement (‘agree’ or ‘strongly agree’), excluding ‘don’t know’ responses. Experts could also provide free-text comments, which were analyzed to refine the wording of T&A and propose new ones. New T&A meeting the EECC criteria were reviewed and included in subsequent rounds. T&A that did not reach consensus were reassessed in subsequent rounds, with visual feedback provided on the distribution of previous responses to inform expert opinions. Subgroup analysis was also conducted to identify potential differences in opinions based on factors like experience in low-income countries, professional background (doctor vs. non-doctor), and experience in emergency or intensive care.
Phase II: Refining and Organizing Clinical Processes
Following the Delphi process, the T&A that achieved consensus underwent a refinement phase. This involved minor adjustments to wording to ensure consistency and clarity. More importantly, the individual T&A were reassembled into coherent clinical processes. This step aimed to enhance the user-friendliness and feasibility of the EECC package for practical implementation within healthcare systems and quality improvement initiatives. The goal was to create a logical and easily understandable set of clinical processes that could be readily adopted in diverse healthcare settings. Specialist reviewers, involved in Phase I, iteratively contributed to this process, ensuring the relevance of the refined clinical processes across all acute medical specialties. The final package was organized into processes for identification, general care, and specific treatments, creating a structured and practical framework for EECC.
Phase III: Defining Hospital Readiness Requirements
The final phase focused on establishing the necessary hospital readiness requirements for the successful implementation of the defined clinical processes. A preliminary list of requirements was developed drawing upon existing WHO tools, guidelines from related specialties, facility preparedness checklists, and the collective experience of the study team. This list was then iteratively reviewed and refined by the specialist reviewers. They contributed by validating suggested items, adding relevant requirements from their respective specialties, and proposing modifications to ensure comprehensiveness and practicality. Through consultation with health economists and procurement experts, the final list of hospital readiness requirements was agreed upon and categorized into eight key areas: equipment, consumables, drugs, human resources, training, routines, guidelines, and infrastructure. This structured list provides a practical guide for hospitals aiming to strengthen their capacity to deliver essential emergency and critical care.
Conclusion: Towards Standardized and Effective Emergency and Critical Care
The study’s rigorous three-phase methodology successfully established expert consensus on essential treatments and actions for emergency and critical care. By utilizing the Delphi method, the researchers effectively incorporated diverse perspectives from a global panel of experts, ensuring the relevance and feasibility of the defined EECC protocols. The resulting package of clinical processes and hospital readiness requirements offers a valuable framework for standardizing and improving emergency and critical care delivery, particularly in resource-constrained settings. While visual diagnosis is implicitly embedded within the broader context of patient assessment and identification of critical illness, further research and resource development in visual diagnostic aids, such as readily accessible PDF guides and training materials, could significantly enhance the practical application of these essential emergency and critical care protocols, leading to improved patient outcomes worldwide.
