Health sector readiness for patient tracking in disaster: A literature review on concepts and patterns

Abstract

Background: One of the main concerns for patient safety in disaster is continuous patient trace from disaster scene to a care center, including victims' identification, data register at the scene, records of the initial medical assessment, real-time alerts regarding patients' situation, and update location of them. This process is called patient tracking which promotes their safety and reduces number of victims and secondary problems caused by disaster. The aim of this study was to review the literature and evidence of patient tracking in disasters. Materials and Methods: This was a review study which was performed through databases, journals, and available electronic resources in the case of a contract with the Ministry of Health. Inclusion criteria included the resources regarding the concepts, considerations, and components of patient tracking and related patterns for tracking the patients who were injured in disasters. Data were collected through taking notes, were analyzed by content analysis, and were presented in two categories. Results: The review and evaluation of the results obtained were classified into two areas: The findings of the research showed that 40% of references were pertained to patient tracking concepts, considerations, and components, and the rest of them were related to the implementation of the tracking system and patterns in the exercises and rarely at disasters. Conclusions: Identification and tracking of natural disaster's victims is a vital role to collect important information and facilitate communication in a timely manner which helps to address patients' medical needs, reduce duplication activities for them. Also classification and distribution of this information among health officials and institutions is a national necessity. This important issue facilitates to do preparedness plans for disaster response and to reduce people losses in the community. This important issue facilitates to do preparedness plans for disaster response and to reduce people losses in the community.

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© 2016 International Journal of Health System and Disaster Management | Published by Wolters Kluwer - Medknow
Health sector readiness for patient
tracking in disaster: A literature review
on concepts and patterns
Nahid Tavakoli, Mohammad H Yarmohammadian1, Reza Safdari2, Mahmoud Keyvanara3
Health Management in Disaster, Health Management and Economics Research Center, Isfahan University of Medical Sciences,
Isfahan, Iran, 1Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran,
2Department of Health Information Management, Tehran University of Medical Sciences, Tehran, Iran, 3Social Determinants
of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
Abstract
Background: One of the main concerns for patient safety in disaster is continuous patient trace from disaster scene to a care center, including
victims’ identification, data register at the scene, records of the initial medical assessment, real‑time alerts regarding patients’ situation, and update
location of them. This process is called patient tracking which promotes their safety and reduces number of victims and secondary problems
caused by disaster. The aim of this study was to review the literature and evidence of patient tracking in disasters. Materials and Methods: This
was a review study which was performed through databases, journals, and available electronic resources in the case of a contract with the Ministry
of Health. Inclusion criteria included the resources regarding the concepts, considerations, and components of patient tracking and related
patterns for tracking the patients who were injured in disasters. Data were collected through taking notes, were analyzed by content analysis, and
were presented in two categories. Results: The review and evaluation of the results obtained were classified into two areas: The findings of the
research showed that 40% of references were pertained to patient tracking concepts, considerations, and components, and the rest of them were
related to the implementation of the tracking system and patterns in the exercises and rarely at disasters. Conclusions: Identification and tracking
of natural disaster's victims is a vital role to collect important information and facilitate communication in a timely manner which helps to address
patients' medical needs, reduce duplication activities for them. Also classification and distribution of this information among health officials and
institutions is a national necessity. This important issue facilitates to do preparedness plans for disaster response and to reduce people losses in
the community. This important issue facilitates to do preparedness plans for disaster response and to reduce people losses in the community.
Key words: Concepts and patterns, disaster, healthcare preparation, literature review, patient tracking
Address for correspondence:
Prof. Mohammad H Yarmohammadian,
Health Management and Economics Research Center, Isfahan
University of Medical Sciences, Hezarjerib Street, Isfahan, Iran.
E‑mail: yarmohamadian@mng.mui.ac.ir
Introduction
During the past 20 years, a lot of countries have been
experienced a signicant number of natural catastrophic
disasters which have had global effects on nature and
societies.[1‑3] In 2014, natural disasters had devastating
effects on the human society. Three hundred and
twenty‑four natural disasters caused the death of more
than 7823 individuals, 140.7 million injured individuals,
and 99.2 billion dollars financial damages. Asia has
experienced the highest number of disasters (44.4%) and
naturally has had the highest number of victims (69.5%).[4]
During the past three decades until 2010, natural disasters
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DOI:
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How to cite this article: Tavakoli N, Yarmohammadian MH,
Safdari R, Keyvanara M. Health sector readiness for patient tracking
in disaster: A literature review on concepts and patterns. Int J Health
Syst Disaster Manage 2016;4:75-81.
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Tavakoli, et al.: Healthcare preparation for patient tracking
76 International Journal of Health System and Disaster Management | Vol. 4 | Issue 3 | Jul-Sep 2016
in Iran annually caused the death of 3000 individuals
and affecting 1.5 million individuals. In such a country
enjoying such frequent natural disasters, informing,
preparing, and managing disasters are signicant points
in the public health.[5,6] Due to these disasters, disaster
planning based on few experiences and assumptions
is changing into evidence‑based planning.[7] Therefore,
paying attention to the issue of health management in
natural disasters in Iran and organizing the information
and communication situation for rescuing victims, as well
as doing comprehensive research on disasters in Iran,
result in preparedness and more appropriate responses
in cases of occurrence of such events.[8,9] These studies
require the existence of data and documented information
about public health such as number of patients who have
been cured, their release states, and types of diseases and
injuries which have been cured after disasters in order that
different reports needed for studies of disaster management
in Iran, and particularly, epidemiological studies should be
provided.[10] Insufciency in tracking casualties of Katrina
Disaster in the USA was identied as a weakness in the
planning of local and national preparedness for handling
the event.[11] After Bam Earthquake, Rathore stated that
due to the insufciency of patients’ information, their
management and effective assessment of their states were
difcult.[12] Marres declared that facing great disasters
needs a coordinated response of different organizations,
but establishing coordination among organizations and
geographically dispersed locations is a complicated
process. One of the biggest challenges in such conditions
is patient tracking. Mostly, there are no data about the
number of victims, their conditions, their places, and their
transfer.[13]
If we imagine a scenario of earthquakes, a large number
of injured or dead individuals which are beyond the
capacity of the emergency answering system are at scenes.
Hospitals do not receive information about the number of
patients whom they are to admit. Incident commanders at
scenes have no appropriate information about the cases
such as how many patients are transferred to different
hospitals?, whether hospitals have capacity for admitting
new victims?, how many vehicles of emergency medical
services are at hand?, and where are their exact locations
at each time? The emergency personnel has no idea of
destinations of patients and the injured people who are
removed from the scene. Members of families cannot
call each other due to the insufciency of telephone and
mobile lines. Medical centers which admit victims are
overcrowded and cannot make communications with
patients’ families at least in the primary hours. It may
also be need to transfer patients to medical centers in
other cities or countries if disasters are large enough.[14]
Therefore, plans for preparedness against disasters should
move toward a standard global system for labeling,
identifying, and tracking victims.[15] In the recent decade,
most patient tracking systems designed in different
countries and reported in different articles are at different
levels of development and they are not completely
implemented. However, all have the common aim of
positioning patients, tracking their medical conditions,
returning them to the conditions before disasters, and
joining them to their family members.[16] This study aimed
to perform a literature review on concepts and patterns of
patient tracking in disasters.
Materials and Methods
This literature review study was conducted in nine databases
which were available electronic resources in the case of a
contract with the Ministry of Health in February 2016 using
the search strategy which is showed in Table 1.
All articles published between 2003 and 2015 were screened
and read in full text. Relevant references were assessed
to meet the study’s inclusion criteria and included in the
review and they were divided into two categories. From
the 78 references extracted, 34 documents were excluded
because they were not relevant for the aim of this study.
Data were collected through taking notes. Finally, data were
analyzed by content analysis.
Results
The ndings of the research showed that 40% of references
pertained to patient tracking concepts, considerations, and
components (Part A), and the rest of them (Part B) were
related to the implementation of the tracking system and
patterns in the exercises and rarely at disasters.
Issues of patient tracking concepts,
considerations, and components
Patient tracking
In emergency medicine, the concept of tracking has
different meanings. One of its meaning refers to tracking
patients’ physical location, and the other refers to
the advancement in patients’ treatment and tracking
their medical needs while providing emergency
services.[17] Tracking the injured people in disasters
refers to identifying and registering names of the injured,
recording their information and medical conditions,
prioritizing schedules for evacuation of them from scenes
in accordance with the color of triages, and tracking and
positioning them from scenes to reaching medical centers
and then up to the end of the treatment course and their
discharging states.[18]
Table 1: Search strategy details
Search characteristics Related information
Search engines and
databases
Springer, Emerald, ProQuest, ScienceDirect,
Google Scholar, PubMed, Scientic
Information Database, IranMedex, Magiran
Time Before 2016
Search strategy #1 and #2
Keywords Patient tracking system, patient
identication, disaster(s), emergency
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Importance of patient tracking
Accurate, accessible, and timely information about
patients, their conditions and injuries, services provided
for them at the scene, and their nal discharging states
for the success and organization of general responses to
disasters are highly vital. The incident commander should
access to timely information about casualties and patients’
needs regarding the resources at hand such as physicians
at the scene, deployment places of ambulances, and the
capacity of hospitals so that he/she can develop necessary
coordination. Real‑time data for determining patients’
appropriate destinations are vital depending on the type
of their injuries and the capacity of hospitals.[19]
Objectives of patient tracking
Due to the primary effect of disaster, patients’ relatives tend
to know that where their family members are being cured?
In most disasters, patients may be transferred to different
locations. In addition, patients may themselves directly and
without prehospital emergency intervention refer to medical
centers and hospitals or they may be referred to hospitals
by their relatives. The primary aim of patient tracking is to
identify patients’ identities and locations in all moments and
inform their relatives and supervisors about their medical
conditions at real time. The signicance of this issue is no less
than the process of caring patients and their drug treatment.[20]
Tracking stages in emergencies and disasters
The tracking process starts with patients’ triage; at the
same time, when patients are prioritized by triage ofcers
and their assistants, they are identied with an observable
label and grouped with similar patients in a geographical
area. Tracking starts with registering their documents
which enter healthcare systems with the emphasis on this
issue that registering data can be done only to the extent
that treatment conditions allow. When documentation tags
were used for patients, the number previously assigned
to this tag is the rst identication of patients’ identities.
Technological development for tracking triaged victims
eliminates problems of the paper system and helps track
patients up to reaching nal destinations. By scanning
each patient’s unique wristband in each place (accident
scene, scene‑care center, emergency room, hospital wards,
operating rooms, and Intensive Care Unit), the system can
track him and identify the latest location of that patient.
Adding a Wi‑Fi network compatible with a barcode
reader device at the point of collecting patients which can
be uploaded to the network provides the possibility of
tracking, dispatches, and updates paths for all hospitals.
This process helps hospitals guide patients’ family members
to the latest patients’ locations.[21]
Patient tracking system
It includes the three terminologies of locating, tracking,
and organizing.
• Locating: It is a system which provides allowed users
the ability to determine the current and update location
of patients and their medical conditions
• Tracking: It is a system which provides allowed users
the determination of the current and previous locations
as well as medical conditions of patients
• Organizing: It refers to a process in which efforts are
exerted to ensure that patients or evacuated individuals
have been transferred by appropriate vehicles to a place
having human forces, equipment, and other facilities
for curing them.[16]
Dimensions of the patient tracking system
Patient tracking system can be explained in three
dimensions: Functional, data, and technological.
The functional domain includes functions expected to
be fullled in the system. In this domain, important
questions about the function of the patient tracking
system are presented. Some of these questions are as
follows:
• Who should enter the tracking system?
• Where data should be entered?
• Who is responsible for recording data?
The content domain includes main elements of data and
their other elements. In this domain, two important parts
are referred to:
• Main elements of data which should be completed as
far as possible
• Other elements of data which are better to be
completed; however, due to particular conditions of
events, it is not mandatory and they can be added to
the database later.
The technological domain includes different types of
information technology (IT) required in the system.
In spite of the lack of standardization, there are some
common cases for the patient tracking system with
facilitated technological platforms. Planners should
consider four domains related to technology:
a. Patient identication technologies
b. Information and communication technologies (ICTs)
for collecting and recording data
c. Main application.
This application includes three sections: Database, number
of observable and web‑based user interfaces in different
locations, and Internet network for making connections
among those who revise data.[7,22]
A patient tracking system should have the following
capabilities:
• Tracking patients from their entrance to the healthcare
system up to their discharges
• Identifying users of the system who have appropriate
permissions to access the electronic system
• Accessing patient tracking mass data from the
prehospital emergency and hospitals
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• Observing rules and regulations concerning patient
condentiality
• Integrating by the national patient tracking system.[23]
Requirements for developing the patient tracking system
Extensive discussions with incident management personnel
have caused that it is felt that functional requirements
needed for improving situational awareness can be
classied into ve groups:
• Performance: The system should ensure that vital
information collected at the scene is transferred rapidly
and accurately to the personnel who receive patients
• Registration and documentation: The system should
ensure that all patients and rescuers have been
registered and identied
• Accountability: The system should ensure that patients,
personnel, and equipment are continuously counted
• Integration: The system should integrate all information
related to the situational and decision‑making
management into a unit plan
• Support: The system should have contingency
capabilities in cases of occurring deficits in the system
or in the network.[24]
The data set required for the patient tracking system
At the same time, when victims are transferred from
hot zones to triage and treatment units, information
started to be produced. This information includes triage,
physical evaluation, and conducted treatment provided
at the scene.[25] The minimum elements of primary data
include patients’ unique numbers, names, gender, dates
of birth, health conditions, location identier, identiers
of arriving or leaving locations, and dates of arriving or
leaving locations. In addition, more elements of data such
as transportation, specic medical needs, decontamination
states, particular security needs, IDs for joining members
of a family to each other, attached les such as medical
les and images, particular communication needs, and
disposition from the healthcare system are required.[16]
The patient tracking systems and patterns
implemented in the exercises and disasters
Electronic triage
Zhao conducted a study with the aim of assessing a portable
tool for the use of rescuers in documenting victims’ triages
in high loss incidents. This tool provides the rescuers this
possibility to collect patients’ vital signs, injuries, and
triage states immediately and appropriately and then send
wirelessly the patients’ vital signs for continuing their
treatment. Architectural infrastructures for this manual
tool are called triage and casualty informatics technology
and can facilitate triage measures, transportation, and
treatment in a mass casualty incident (MCI). This system
was developed and executed by integrating handle
equipment such as wireless networks, global positioning
system (GPS), digital cameras, and bar code scanners with
software localized triage. This system was conrmed in two
trial tests at the scene and the results indicated that it had
realized software, battery life, accuracy of data, wireless
transfer of data, and needs of the emergency response
system. Furthermore, the performance power, reduction in
the triage period, and improvement in the accuracy of data
collection were indicated using this system.[26]
Gao conducted a study entitled, “A next generation
electronic triage to aid mass casualty emergency medical
response,” in which the integrated computer system of
triage can be used in emergency services in such a way
that it can easily facilitate tracking victims by making
patients’ triage documentations electronic and supporting
triage assessment by decision support systems. This study
was conducted with the cooperation of three prehospital
emergency groups in the Washington metropolitan
area where the triage system of the next generation was
developed for improving the efficiency of emergency
responses.[27]
The Advanced Health and Disaster Aid Network has
developed electronic triage strips which identify patients’
geographical locations automatically everywhere both
indoors and outdoors. When patients are marked with
electronic triage strips, they are tracked automatically
without any need for other entries on the part of medical
personnel involved in servicing via the software tracking
system. These strips which are founded on smart hardware
grounds are small, lightweight, easy to use, and cost‑effective,
and their application is easy in high loss events. After each
MCI, emergency response services require that all patients
be registered. In this system, registering all patients at the
scene is conducted electronically and automatically. The
emergency personnel, accordingly, instead to waiting for
the subsidence of incidents, can track real time all patients.[28]
Online and wireless tracking system
an online victim tracking and tracing system (VITTS) can be
designed and executed based on a wireless network with
routers in ambulances and online and direct guidance of
registering victims and their triage data via barcode cards.
The system was tested for its feasibility and applicability
during an incident maneuver. The results indicated that the
establishment of a local radio network from mobile canons
and routers and the connection based on the general packet
radio service with a central database work appropriately.
The VITTS provides correct storage of data, timely access
to data and investigation of the number of victims, their
injury severity, and accommodation. The results of the
study indicated that this system provides the grounds for
registering victims near the incident scene. Using different
online and wireless connections by a diverse range of chains
in releasing events increases interaction capabilities and
makes patient tracking possible.[29] Gao conducted a study
on monitoring vital signs and patient tracking via wireless
networks. Patients at the scene can enjoy technologies which
constantly monitor their vital signs and track their locations
until their admission in hospitals. A system was developed
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International Journal of Health System and Disaster Management | Vol. 4 | Issue 3 | Jul-Sep 2016
for real‑time patient monitoring which can provide the
integration of vital signs sensors, location sensors, electronic
patient records, and web gateway technology. This system
facilitates the relationship between service providers at the
disaster scene, medical specialists in hospitals, and specialist
at hand for getting consultations from remote institutes.
In large events, when medical teams quickly triage a large
number of victims, they do not have time for responding
alerts until all patients are discharged from the triage scene.
This system can prioritize those patients who have been
triaged and are waiting for ambulances. This system was
performed in Suburban Hospital and the Johns Hopkins
Pediatric Trauma Center.[30]
Patient tracking system
Dobson conducted a research on the tracking systems in the
pediatric emergency department with the aim of enhancing
the understanding of how to use electronic tracking
technologies in clinical systems and their effects on the
consequence of patients’ care and safety in a systematic way.
The research resulted in the extraction of ve tracking systems:
Infant monitoring/prevention of abduction, tracking using
barcodes, radio frequency identication (RFID)‑centered
tracking, infrared (IR)‑centered tracking, and mixed
IR‑ and RFID‑centered tracking. Key ndings of the study
emphasized the application of barcodes, RFID, and IR in the
pediatric emergency department for documenting patient
ow, improvement in safety, and increase in the temporal
effectiveness in this department.[2]
In 2006, a study was conducted on the traumatic patient
tracking system using the infrastructure of wireless
monitoring for emergency response. In this study, the
traumatic patient tracking system reports constantly
victims’ locations by tagging them by the rst respondents
and at the same time using a wireless device. This system
not only contributes to prioritizing traumatic patients but
also registers the time of providing healthcare services for
patients. In this system, to track patients’ locations inside
and outside incident scenes, GPS and RFID are used.
Each patient tag uses the Wi‑Fi network (the IEEE 802.11
standard) for communicating with the central server using
each main Wi‑Fi base. A key part of increasing the tolerance
of errors in the terrestrial position and timing system
as a main mobile base which applies different internet
connections for ensuring sending information to the central
server by tags even when local infrastructures is not able
to respond. This template system can be integrated with
equipment for measuring pulse rate and blood pressure as
well as with electrocardiographs. The stability of this system
was tested in a stimulated situation of trauma in an urban
environment on four patients.[31]
The medical evacuation support system for documentation
and the ow of optimal information are in the eld of a
study conducted by Walderhaug for showing the use of new
technologies for obtaining and sharing information in case
of connection among ambulances. Accordingly, the Evac Sys
was used during a military maneuver at the north of Norway
in 2008 and it was assessed in comparison with the paper
system. In this system, emergency technicians use personal
digital assistants for reading personal information and use
soldiers’ electronic tags also called MedTag for medical
conditions of soldiers. This tag has a piece of electronic
memory connected with a personal digital assistant via
an adaptor and can store data as 4 gigabytes. During the
time, when victims are transferred to a healthcare center,
tracking their locations and medical information is possible
via this electronic tag connected to the personal digital
assistant. The architecture of this system is exible and can
be congured for realizing needs of different operational
structures. The study’s results indicated that there was no
technical problem in performing of the system, and users
believed that feasibility and applicability of the system
had vital signicance as compared to the paper system for
obtaining accurate and timely data at the scene.[16]
Hamilton, after investing in the emergency response system
in the USA, Missouri, cooperating with two great web
designing companies, designed a barcode internet‑based
tracking system for reducing confusion at the accident scene
called the emergency patient tracking system (EPTS). The
EPTS is a commutation system used for managing MCI
victims, medical emergency service vehicles, and hospitals.
When a disaster occurs, this system activates by the 911
call center of the emergency system announcing disasters.
The disaster news is sent via a system established in a safe
environment. The disaster location is identied on the map.
At the disaster scene, rescuers use a barcoded armband
for each victim. These armbands are identied with labels
previously colored coded, and based on patients’ states,
they are attached to them. After assessing victims’ states and
attaching armbands, rescuers scan them by their personal
data assistants and then transfer victims’ information to
the patient tracking system. This system was assessed in
2002 in a maneuver for participating ve hospitals and
the prehospital emergency. The problem which appeared
after this maneuver was that using armbands and scanners
was disturbing for prehospital emergency personnel and
the burden of these devices prevented them for providing
appropriate services for patients.[32]
Discussion
Investigation on the past studies indicates that valid and
updated information of patients at the time of occurrences
of natural disasters has a vital role in effective response
to disasters and enhancement of patients’ safety quality.
In addition, this information is vital not only for incident
scenes but also for institutes and centers which are far
from scenes and ready to admit patients because hospitals
admitting patients are required to be aware of the number
and medical states of patients who are to be transferred
there for more preparedness and effective responses.[2,17,19,26]
Another important issue to which most studies have
been referred and are very important in the dimension
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80 International Journal of Health System and Disaster Management | Vol. 4 | Issue 3 | Jul-Sep 2016
of humanitarian actions is the necessity of appropriately
informing families for nding their family members after
disasters. They have right to know whether their relatives
are dead or alive, where they are, how they can join their
relatives, etc., A few studies conducted in Iran have
investigated the role of ICT in crisis management and the
role of technology in patient identication using radio
waves.[33‑37] However, regarding infrastructures required
for developing a patient tracking system in disasters, no
study has been conducted in Iran and in the countries of
the Middle East.[6,9,10,35,36] Other studies indicate that in a
few countries such as the USA, some activities have been
conducted in designing the national model of patient
tracking with the emphasis on data infrastructures. In
government reports, challenges and opportunities of this
model have been referred to.[16,18] In addition, a lot of studies
published and presented in conferences and journals
have validated different tracking systems mostly in terms
of technology of data development and in maneuvers.
Generally, some studies investigated information and
management dimensions and other dimensions such as
equipment, facilities, and IT infrastructures in patient
tracking system.[19,20,26‑33] Hence, regarding the fact that
in studies conducted in Iran, there was no literature
indicating the existence of a national system for patient
tracking in disasters; some scientic and key measures seem
necessary for designing and implementing a coordinated
model in terminology of patient tracking in high loss
disasters in Iran so that it can provide the registration of
data at a disaster scene and the possibility of registering
primary medical assessment, alert the emergency team
about patients’ states, register treatment states, and make
connection between prehospitals’ emergency, incident
headquarters, and hospitals for patient identication with
a unique ID employing technologies such as barcodes or
patient identication via radio waves. This system should
have the ability to register and monitor vital signs and
locate patients, track the location of ambulances and their
nal destination, register treatment states, track and locate
patients from incident scenes up to reaching to medical
centers and then up to the end of the treatment period as
well as their discharge states, and regularly document and
update all patients’ information. It also should provide the
possibility of sharing vital information among different
agencies, should make possible the state of patients’
discharge, the state of transferring among treatment
centers and even among cities, and can collect and report
information need by government ofcials. In addition, the
system should provide the possibility of registering data
in different locations (incident scenes, hospitals, etc.) and
update different data in different locations about the same
patients.[7,18,21,38‑40]
Conclusions
Identication and tracking of natural disaster's victims is
a vital role to collect important information and facilitate
communication in a timely manner which helps to address
patients' medical needs, reduce duplication activities for
them. Also classication and distribution of this information
among health officials and institutions is a national
necessity. This important issue facilitates to do preparedness
plans for disaster response and to reduce people losses
in the community. This important issue facilitates to do
preparedness plans for disaster response and to reduce
people losses in the community. Hence, it should provide
grounds for software and physical model of the patient
tracking system to be used in natural disasters in Iran for
locating, tracking, and organizing patients in such incidents
and for enhancing the safety level and reducing casualties
and secondary problems caused by disasters.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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