BACHELOR OF SCIENCE IN NURSING:

NCMB 418: CARE OF THE CLIENT WITH LIFE-

THREATENING CONDITIONS, ACUTELY ILL / MULTI-
ORGAN PROBLEMS, HIGH ACUITY AND EMERGENCY
SITUATION
COURSE MODULE COURSE UNIT WEEK
3 15 17
Nursing Care of Clients in Emergency Situations 2: Triage, Severity Indices, and Other Emergencies

✓ Read course and unit objectives

✓ Read study guide prior to class attendance
✓ Read required learning resources; refer to unit
terminologies for jargons
✓ Proactively participate in classroom discussions
✓ Participate in weekly discussion board (Canvas)
✓ Answer and submit course unit tasks on time

At the end of the end of this unit, the students are expected to:

1. Recognize and examine the client with life-threatening conditions, acutely ill/ multi-organ
problems, high acuity and emergency through triage and severity indices.
2. Determine a client’s the health status/ competence through triage and severity indices and/or
expected outcomes of nurse –client working relationship.
3. Record client’s responses / nursing care services rendered and processes / outcomes of the
nurse client working relationship.
4. Ensure completeness, integrity, safety, accessibility, and security of information.
5. Adhere to protocols of confidentiality in safekeeping and releasing of records and other
information.
6. Evaluate the client’s health status / competence through triage and severity indices and/or
expected outcomes of nurse-client working relationship.
 Burns, S. M., & Delgado, S. A. (2019). AACN essentials of critical care nursing. New York:
McGraw-Hill Education.

Crouch, R., Charters, A., Dawood, M., & Bennett, P. (2017). Oxford handbook of emergency
nursing. Oxford, United Kingdom: Oxford University Press.

A serious medical emergency is stressful and traumatic, and it is

important to receive quality care when needed most as this could
mean the difference between life and death. Healthcare
professionals have the skills and equipment necessary to
resuscitate, diagnose and treat most emergencies. The initial
assessment process is referred to as triage.

Triage – derived from old French word “trier” which means “to sort” and known as the process of
determining the priority of patients' treatments based on the severity of their condition.
− A process for sorting injured people into groups based on their need for or likely benefit from
immediate medical treatment; an ongoing process done many times
− Used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical
resources must be allocated
− Focus: To do as little as possible for the greatest number in the shortest period of time (Famorca,
2013); 75-85% of fatalities occur within first 20 minutes

NOTE: Before performing a triage

✓ Evaluate every situation before acting; perform quick incident scene survey
✓ Determine scene hazards
✓ Use appropriate PPE
✓ Remain in appropriate zone

Casualty – a person severely affected by an event or situation, victim

o Multiple – number of victims is < 100
o Mass – number of victims is > 100; MCI (Mass Causality Incident) is an event that exceeds the
health care capabilities of the response
o Direct Victim – an individual who is immediately affected by the event
o Indirect Victim – may be a family member or friend of the victim or a first responder
o Displaced – those who have to evacuate their home, school or business as a result of the disaster
o Refugees – a group of people who have fled their home or even their country as a result of
famine, drought, natural disaster, war or civil unrest

Triage Methods
1. M.A.S.S. – Move, Assess, Sort, Send
− Starts the process by clearing the ‘walking wounded’ using verbal instructions
2. S.A.L.T. – Sort, Assess. Life-threatening intervention(s), Treat and Transport
3. S.T.A.R.T. – Simple Triage and Rapid Treatment (Jump START for Pediatrics)
− Rapid approach to triaging large numbers of causalities
− To assess the victims / patients and their injuries
− Fast, easy to use and to remember (RPM = 30-2-Can Do)
− Allows the best for the most patients with the least amount of resources

Figure 1. The START Algorithm

Source: WHO, 2020

Triage Tagging: (MET-TAG)
1. Black = expectant (deceased)
2. Red = immediate – client needs immediate treatment within the hour but has a chance of
survival
3. Yellow = delayed – client not in immediate danger; treatment may be delayed for an hour
4. Green = minor - “walking wounded”

ID-ME: Immediate = red

Delayed = yellow
Minimal = green
Expectant = black

Emergency Severity Rating Systems

➢ Emergency department triage has several functions:
1. Identification of patients who should not wait to be seen, and
2. Prioritization of incoming patients
➢ Accomplished by determining the patient’s illness/injury severity or acuity (the degree to which
the patient’s condition is life- or limb-threatening and whether immediate treatment is needed to
alleviate symptoms)
➢ Means of scoring an individual’s severity of condition and analyzes outcomes of trends in hospital
stay and hospital rates
➢ 2-5-level triaging
❖ 2- level = sick / not sick
❖ 3-level = Emergent/Urgent/Non-urgent
❖ 4-level = life-threatening/Emergent/Urgent/Non-urgent
❖ 5-level = most acute/Emergent/Urgent/Non-urgent /least acute
Emergency Severity Index (ESI)
❖ A – intubated, pulseless, apneic, unresponsive = unstable
❖ B – high risk situation (confused, lethargic, or disoriented; in severe pain or distress) =
threatened = stable in less than 60 minutes
❖ C – number of resources needed = could be delayed
❖ D – danger zone = reclassify based on vital signs

Figure 2. ESI Triage Algorithm

Quick Assessment Components

A. For Adults (AMPLE) B. For Pediatric Clients (CIAMPEDS)
✓ Allergies ✓ Chief complaint
✓ Medication(s) taken ✓ Immunizations
✓ Past medical history ✓ Allergies
✓ Last mealtime ✓ Medication(s) taken
✓ Event/environment ✓ Past medical history
✓ Event/environment
✓ Diet and diapers
✓ Signs and symptoms (include onset)

Figure 3. MCI Management System

Source: WHO, 2020

OTHER EMERGENCIES:
I. Heat Stroke – an acute medical emergency caused by failure of the heat-regulating mechanisms
of the body; can also cause death
- body’s temperature rises rapidly, the sweating mechanism fails, and the body is
unable to cool down (CDC, n.d.)
- Usually occurs during extended heat waves (especially when they are
accompanied by high humidity)
- People at risk: those not acclimatized to heat, elderly and very young people,
those unable to care for themselves, those with chronic and debilitating diseases,
and those taking certain medications (e.g. major tranquilizers, anticholinergics,
diuretics, beta-adrenergic blocking agents)
- Exertional heat results because of inadequate heat loss
Assessment:
− Heat stroke causes thermal injury at the cellular level, resulting in widespread damage to the
heart, liver, kidney, and blood coagulation.
− profound central nervous system (CNS) dysfunction (manifested by confusion, delirium, bizarre
behavior, coma);
− elevated body temperature (40.6°C [105°F] or higher); hot, dry skin; and usually anhidrosis
(absence of sweating), tachypnea, hypotension, and tachycardia.

Management
− Primary goal: to reduce the high temperature as quickly as possible because mortality is directly
related to the duration of hyperthermia
− Simultaneous treatment focuses on stabilizing oxygenation using the ABCs of basic life support.
− Remove patient’s clothing and reduce the core (internal) temperature to 39°C (102°F) as rapidly
as possible
− One or more of the following methods may be used as directed:
✓ Cool sheets and towels or continuous sponging with cool water
✓ Ice applied to the neck, groin, chest, and axillae while spraying with tepid water
✓ Cooling blankets
✓ Iced saline lavage of the stomach or colon if the temperature does not decrease
✓ Immersion of the patient in a cold-water bath (if possible)
- During cooling, the patient is massaged to promote circulation and maintain cutaneous
vasodilation. An electric fan is positioned so that it blows on the patient to augment heat
dissipation by convection and evaporation. The patient’s temperature is constantly monitored
with a thermistor placed in the rectum, bladder, or esophagus to evaluate core temperature.

IMPORTANT! Caution is used in managing heat stroke patients to avoid hypothermia

and to prevent hyperthermia, which may recur spontaneously within 3 to 4 hours.

II. Near-Drowning
- Survival for at least 24 hours after submersion into liquid (usually water)
- One of the leading causes of unintentional death in children < 14 years
old (WHO, 2020)
- Most common consequence = hypoxemia

Risk Factors:
- Age and gender (males)
- Access to water (flood, travelling on water, tourists unfamiliar with local water risks and features,
diving injuries)
- Alcohol ingestion (near or in water), inability to swim, hypothermia, exhaustion
- Medical conditions (i.e. epilepsy)

Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid
(fresh or salt water) and the volume aspirated. Fresh water aspiration results in a loss of
lung surfactant. Saltwater aspiration leads to pulmonary edema from the osmotic effects
of the salt within the lung.

Management
- Goal: successful resuscitation with full neurologic recovery has occurred (possible due to
decrease in metabolic demands or the diving reflex)
- Maintain cerebral perfusion and adequate oxygenation / prevention of hypoxia
- Primary problems post-resuscitation: hypoxia and acidosis (require immediate intervention in the
ED)
- Immediate CPR (greatest influence on survival)
- Ensure an adequate airway and respiration, thus improving ventilation (to correct respiratory
acidosis) and oxygenation.
1. ABGs – to determine the type of ventilatory support needed
2. ET intubation with positive pressure ventilation (with PEEP) – to improve oxygenation,
prevents aspiration, and corrects intrapulmonary shunting and ventilation (perfusion
abnormalities caused by aspiration of water)
3. Rectal probe – to determine the degree of hypothermia
4. Rewarming procedures (eg, extracorporeal warming, warmed peritoneal dialysis, inhalation
of warm aerosolized oxygen, torso warming) – started during resuscitation and determined
by the severity and duration of hypothermia and available resources
5. Intravascular volume expansion and inotropic agents – to manage hypotension and impaired
tissue perfusion
6. ECG monitoring – dysrhythmias frequently occur
7. Indwelling urinary catheter – to measure urine output
8. NGT – to decompress the stomach and to prevent gastric-content aspiration

Complications:
1. Hypoxic or ischemic cerebral injury
2. ARDS, pulmonary damage secondary to aspiration
3. Cardiac arrest

III. Poisoning
Poison is any substance when ingested, inhaled, absorbed, applied to the skin, or
produced within the body in relatively small amounts, injures the body by its chemical
action. Poisoning from inhalation and ingestion of toxic materials, both intentional and
unintentional, constitutes a major health hazard and an emergency situation.

Emergency treatment is initiated with the following goals:

➢ To remove or inactivate the poison before it is absorbed
➢ To provide supportive care in maintaining vital organ systems
➢ To administer a specific antidote to neutralize a specific poison
➢ To implement treatment that hastens the elimination of the absorbed poison
A. Injected Poisons:
1. Stinging Insects – victims may have an extreme sensitivity to the venoms of the
Hymenoptera (bees, hornets, yellow jackets, fire ants, and wasps). Venom allergy is
thought to be an IgE-mediated reaction, and it constitutes an acute emergency. Although
stings in any area of the body can trigger anaphylaxis, stings of the head and neck are
especially serious.

Clinical manifestations
➢ generalized urticaria; itching
➢ malaise
➢ anxiety due to laryngeal edema to severe bronchospasm, shock, and death.

Generally, the shorter the time between the sting and the onset of severe
symptoms, the worse the prognosis.

Management
a. stinger removal if the bite is from a bee (venom is associated with sacs around the
barb of the stinger itself)
b. Wound care with soap and water is sufficient for stings (scratching is avoided as this
results to histamine response)
c. Ice application – reduces swelling and venom absorption.
d. Oral antihistamine and analgesic – to decrease the itching and pain
e. Epinephrine
− in the case of an anaphylactic or severe allergic response
− epinephrine (aqueous) is injected SC
− injection site is massaged to hasten absorption.
f. Monitor for signs and symptoms of anaphylactic reaction and treated as necessary
g. Desensitization therapy for people who have had systemic or significant local
reactions.
h. Patient and family education is an important measure in preventing exposure to
stinging insects.

2. Snake Bites
Snakes bite either to capture prey or for self-defense. But since there
are so many different types of snakes — including both venomous and non-
venomous — not every snake bite is created equal (CDC, n.d.).

Different species carry different types of venom. Categories include:

a. Cytotoxins: Cause swelling and tissue damage wherever you’ve been bitten.
b. Haemorrhagins: Disrupt the blood vessels.
c. Anti-clotting agents: Prevent the blood from clotting.
d. Neurotoxins: Cause paralysis or other damage to the nervous system.
e. Myotoxins: Break down muscles.

Management: There is no one specific protocol for treatment of snake bites.

a. Initial first aid at the site of the snake
- have the victim lie down
 - Remove constrictive items such as rings
- Providing warmth, clean the wound, and
cover with a light sterile dressing,
- Immobilize the injured body part below the
level of the heart (ice or a tourniquet is not
applied)
b. Initial evaluation in the ED is performed quickly
and includes information about the following:
- Whether the snake was venomous or
nonvenomous (if the snake is dead/killed, it
should be transported to the ED with the
patient for identification)
- Where and when the bite occurred and the
circumstances of the bite
- Sequence of events, signs and symptoms
(fang punctures, pain, edema, and erythema
of the bite and nearby tissues)
- Severity of poisonous effects
- Vital signs
- Circumference of the bitten extremity or area
at several points; the circumference of the
extremity that was bitten is compared with
the circumference of the opposite extremity
- Laboratory data (complete blood count, urinalysis, and clotting studies)
- Close observation for at least 6 hours – patient is never left unattended
- Medications:
a. Corticosteroids are not used during the acute stage – contraindicated in the first 6-
8 hours after the bite (may depress antibody production and hinder the action of
antivenin
b. Parenteral fluids may be used to treat hypotension
c. Vasopressors are used to treat hypotension (their use should be short-term)
d. Antivenin (antitoxin) administration
1) Most effective if administered within 12 hours after the snake bite. (Children may
require more antivenin than adults because their smaller bodies are more
susceptible to toxic effects of venom.)
2) A skin or eye test should be performed before the initial dose to detect allergy
to the antivenin.
3) Before administering antivenin and every 15 minutes thereafter, the
circumference of the affected part is measured proximally.
4) Premedicate with diphenhydramine and cimetidine (decreases the allergic
response to antivenin)
5) Antivenin is administered as an intravenous infusion whenever possible,
although intramuscular administration can be used.
6) The antivenin is diluted in 500 to 1000 mL of normal saline solution; the fluid
volume may be reduced for children.
7) The infusion is started slowly, and the rate is increased after 10 minutes if there
is no reaction.
8) The total dose should be infused during the first 4 to 6 hours after poisoning.
 9) The initial dose is repeated until symptoms decrease. After the symptoms
decrease, the circumference of the affected part should be measured every 30
to 60 minutes for the next 48 hours to detect symptoms of compartment
syndrome (swelling, loss of pulse, increased pain, and paresthesia).
10) The most common cause of allergic reaction to the antivenin is its too-rapid
infusion, although about 3% of patients with neg active skin test results develop
reactions not related to infusion rate.
11) Reactions may consist of a feeling of fullness in the face, urticaria, pruritus,
malaise, and apprehension. These symptoms may be followed by tachycardia,
shortness of breath, hypotension, and shock.
12) Intravenous diphenhydramine (Benadryl)
13) Vasopressors are used for patients in shock
14) Resuscitation equipment must be on standby while antivenin is infusing.

B. Ingested (Swallowed) Poisons

Corrosive poisons include alkaline and acid agents that can cause tissue destruction
after coming in contact with mucous membranes
1. Alkaline agents: Iye, drain cleaners, toilet bowl cleaners, bleach, non-phosphate
detergents, oven cleaners, and button-shaped batteries
2. Acid products – toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, battery
acid.

Signs and symptoms

▪ pain or burning sensations
▪ evidence of redness or burn in the mouth or throat
▪ pain on swallowing or an inability to swallow
▪ vomiting, or drooling; age and weight of the patient
▪ pertinent health history
▪ signs of shock (may result from the cardio depressant action of the substance ingested,
from venous pooling in lower extremities, or from reduced circulating blood volume
resulting from increased capillary permeability

Management:
Measures are instituted to remove the toxin or decrease its absorption.
➢ Measures are instituted to stabilize cardiovascular and other body functions (treatment of
shock)
➢ Control of the airway, ventilation, and oxygenation are essential.
➢ ECG, vital signs, and neurologic status are monitored closely for changes.
➢ An indwelling urinary catheter is inserted to monitor renal function.
➢ Blood specimens are obtained to test for concentration of drug or poison.
➢ Efforts are initiated to determine what substance was taken (including amount and time
since ingestion)
➢ Water or milk to drink for dilution is given (for those who have ingested corrosive poisons);
however, dilution is not attempted if the patient has acute airway edema or obstruction or
if there is clinical evidence of esophageal, gastric, or intestinal burn or perforation.
➢ Gastric emptying procedures may be used as prescribed:
o Syrup of ipecac to induce vomiting in the alert patient
 o Gastric lavage for the obtunded patient Gastric aspirate is saved and sent to the
laboratory for testing (toxicology screens)
o Activated charcoal administration if poison is one that is absorbed by charcoal
o Cathartic, when appropriate

IMPORTANT! Vomiting is never induced after ingestion of caustic substances (acid

or alkaline) or petroleum distillates.

FOOD POISONING – a sudden illness that occurs after ingestion of contaminated food or
drink. Botulism is a serious form of food poisoning that requires continual surveillance.

Management
➢ Key – determining the source and type of food poisoning (if possible, the suspected food
should be brought to the medical facility and a history obtained from the patient or family)
➢ Specimen for examination: Food, gastric contents (i.e. vomitus), serum, feces
➢ Monitoring: RR, BP, LOC, CVP (if indicated), muscular activity, fluid & electrolyte balance
➢ Antiemetic – administered parenterally as prescribed, if the patient cannot tolerate fluids
or medications by mouth
➢ Mild nausea – take sips of weak tea, carbonated drinks, or tap water
➢ After nausea and vomiting subside, clear liquids are usually prescribed 12 to 24 hours
➢ Diet progressed to a low-residue, bland diet

C. Inhaled Poisons
1. CARBON MONOXIDE POISONING
- may occur as a result of industrial or household incidents or attempted suicide
- implicated in more deaths than any other toxin except alcohol
- exerts its toxic effect by binding to circulating hemoglobin and thereby reducing the
oxygen-carrying capacity of the blood.
- Carboxyhemoglobin (carbon monoxide–bound hemoglobin) absorbs carbon
monoxide 200 times more readily than it absorbs oxygen and does not transport
oxygen.

Clinical Manifestations:
1. Appears intoxicated (from cerebral hypoxia)
2. Headache, dizziness, confusion
3. muscular weakness
4. palpitation
5. coma
6. Skin color - pink or cherry-red to cyanotic and pale (but may not be always reliable)

Pulse oximetry is not valid, because the hemoglobin is well saturated. It is not
saturated with oxygen, but the pulse oximeter reads the saturation as such and
presents the false impression that the patient is well oxygenated and in no danger.

Management
▪ Exposure to carbon monoxide requires immediate treatment.
▪ Goals: to reverse cerebral and myocardial hypoxia and to hasten elimination of carbon
monoxide.
▪ Whenever a patient inhales a poison, the following general measures apply:
 o Expose to fresh air immediately (i.e. open all doors and windows)
o Loosen all tight clothing
o Initiate CPR if required
o Prevent chilling – wrap the patient in blankets
o Keep the patient as quiet as possible
o Do not give alcohol in any form
o Carboxyhemoglobin levels are analyzed on arrival at the ED and before treatment with
oxygen if possible
o Oxygenation:
- 100% oxygen is administered at atmospheric or hyperbaric pressures to reverse
hypoxia and accelerate the elimination of carbon monoxide
- Oxygen is administered until the carboxyhemoglobin level is less than 5%.
o The patient is monitored continuously.
o Psychoses, spastic paralysis, ataxia, visual disturbances, and deterioration of mental
status and behavior may persist after resuscitation and may be symptoms of
permanent brain damage.

D. Skin Contamination / Poisoning (CHEMICAL BURNS)

Exposure to chemicals are challenging because of the large number of offending
agents with diverse actions and metabolic effects. The severity of a chemical burn is
determined by the mechanism of action, the penetrating strength and concentration, and the
amount and duration of exposure of the skin to the chemical.

Management
1. Identity and characterize chemical agent for future treatment
2. The skin should be drenched immediately with running water from a shower, hose, or
faucet.
3. The skin of health care personnel assisting the patient should be appropriately protected
if the burn is extensive or if the agent is significantly toxic or is still present.
4. Prolonged lavage with generous amounts of tepid water is important.
5. Antimicrobial treatment
6. Debridement
7. Tetanus prophylaxis
8. Plastic surgery for further wound management
9. The patient is instructed to have the affected area reexamined at 24 hours, 72 hours, and
in 7 days because of the risk for underestimating the extent and depth of these types of
injuries.

Triage – the assignment of degrees of urgency to wounds or illnesses to decide the order of
treatment of a large number of patients or casualties

Heat stroke – occurs when the body becomes unable to control its temperature

Near-drowning – the victim is rescued before the point of death or there is temporary survival

Drowning – process of experiencing respiratory impairment from submersion/immersion in liquid

Crouch, R., Charters, A., Dawood, M., & Bennett, P. (2017). Oxford handbook of emergency nursing.
Oxford, United Kingdom: Oxford University Press.

Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis:
Elsevier Mosby.

Study Questions:

There has been an explosion and it is a mass casualty incident. Triage the following clients.
Determine the appropriate color tag and the corresponding ESI category.
1. Levi is a 25-year-old-male. He is able to follow commands but has trouble hearing. His capillary
refill is <2 seconds, radial pulse is nonexistent, can’t move due to a compound left femur fracture,
respirations are >30cpm and he is coughing. What color tag is he and why?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________

2. Mikasa is a 21-year-old-female. She can follow commands but is scared. Her capillary refill is
<2 seconds, has a radial pulse, respirations are < 30cpm with shortness of breath. She has a
sudden onset of chest pain. What color tag is she and why?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________

3. Annie is a 35-year-old-female. She is alert, glossy sheen to exposed skin, capillary refill is <2
seconds, respirations 16cpm, a cut right forearm, minimal bleeding, some white glowing powder
seen on casualty. What color tag is she and why?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________

4. Eren, a 51 year old, installing a ceiling fan assisted by his friend. He was thrown back and his
friend immediately switched off the power and called an ambulance. B2 had a brief period of
loss of consciousness, alert when the ambulance arrived, in and out of consciousness during the
trip to the ED. BP = 150/90mmHg, PR = 88bpm, RR 20cpm, O2 sat = 96% HR = 110bpm, RR =
40cpm, O2 sat = 91%
Tag color = ___________________________ ESI category = ___________
Rationale for color tag and ESI category:
 ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

5. Armin, a 7-year old, an Ilocano speaking child, is brought to the ED in her father’s car. You are
called to assist her to get out of the car. The father tells you she is “very sick” and you noted that
she is able to transfer to a wheelchair with minimal assistance but cringes and cries out when
her hips are moved. According to her father, she fell from her upper double deck bed in their
house. HR = 110bpm, RR = 40cpm, O2 sat = 91%
Tag color = ___________________________ ESI category = ___________
Rationale for color tag and ESI category:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Burns, S. M., & Delgado, S. A. (2019). AACN essentials of critical care

nursing. New York: McGraw-Hill Education.

Crouch, R., Charters, A., Dawood, M., & Bennett, P. (2017). Oxford
handbook of emergency nursing. Oxford, United Kingdom: Oxford
University Press.

Centers for Disease Control and Prevention (CDC) (n.d.).

https://www.cdc.gov/

Emergency Nurses Association. (2019). Sheehy’s Manual of Emergency Care, 7th ed. St. Louis:
Elsevier Mosby.

Famorca, Z, Nies, M., McEwen, M. (2013). Nursing Care of the Community: A comprehensive
text on community and public health nursing in the Philippines. Singapore: Elsevier Pte Ltd

Research Institute for Tropical Medicine (RITM). (2018). First aid for snake bite: What to do when
bitten by a snake. https://ritm.gov.ph/first-aid-for-snake-bite-what-to-do-when-bitten-by-a-
snake/

Schumacher, L., & Chernecky, C. C. (2010). Saunders nursing survival guide: critical care &
emergency nursing. St. Louis, Mo.: Elsevier Saunders.

World Health Organization (WHO). 2020). https://www.who.int