Simple Triage Algorithm and Rapid Treatment and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation mass casualty triage methods for sensitivity, specificity, and predictive values

Nursing student's experiences of Role-Play Scenario-Based Disaster Triage (START) training: A qualitative research

BACKGROUND

Disasters can overwhelm healthcare systems, making effective triage a crucial skill for nurses. Role-Play Scenario-Based Disaster Triage Training offers a promising approach to prepare nursing students for these situations. Understanding students' experiences with this training method can inform its development and effectiveness in fostering disaster preparedness. However, little is known about this training experience of nursing students. In particular, by examining the challenges faced by students, the emotional distress they experience and their achievements, it will provide guidance for the development of education programs in a more comprehensive and student-oriented manner.

AIM

The aim of this study is to elucidate the experiences of nursing students regarding Role-Play Scenario-Based Disaster Triage Training.

DESIGN AND METHODS

A qualitative approach was employed to comprehend participating students' experiences. Face-to-face and online semi-structured interviews were conducted with 17 students using an interview guide, and the interactions were recorded for subsequent analysis. Thematic analysis was employed to develop themes.

RESULTS

The study results emphasize the challenges experienced by students during triage training, their gains and the support they need to cope with the challenges they experience. Data were organized around four main themes: "Challenges of the triage process" with subthemes such as "Thinking of the actual earthquake moment" and "Ethical dilemmas"; "Emotional turmoil" with subthemes including "Anxiety" and "Fear and Helplessness"; "Achievements" with subthemes such as "Increase in knowledge and skills" and "The importance of the nurse"; and "Suggestions" with subthemes including "Continuous education" and "Mandatory course".

CONCLUSIONS

The findings of the study provide new insights into the experiences of nursing students during the disaster triage process. The results may contribute to the improvement of future training programs by identifying the challenges and needs faced by nursing students after disaster triage education.

Admission prioritization of heart failure patients with multiple comorbidities

The primary objective of this study was to enhance the operational efficiency of the current healthcare system by proposing a quicker and more effective approach for healthcare providers to deliver services to individuals facing acute heart failure (HF) and concurrent medical conditions. The aim was to support healthcare staff in providing urgent services more efficiently by developing an automated decision-support Patient Prioritization (PP) Tool that utilizes a tailored machine learning (ML) model to prioritize HF patients with chronic heart conditions and concurrent comorbidities during Urgent Care Unit admission. The study applies key ML models to the PhysioNet dataset, encompassing hospital admissions and mortality records of heart failure patients at Zigong Fourth People's Hospital in Sichuan, China, between 2016 and 2019. In addition, the model outcomes for the PhysioNet dataset are compared with the Healthcare Cost and Utilization Project (HCUP) Maryland (MD) State Inpatient Data (SID) for 2014, a secondary dataset containing heart failure patients, to assess the generalizability of results across diverse healthcare settings and patient demographics. The ML models in this project demonstrate efficiencies surpassing 97.8% and specificities exceeding 95% in identifying HF patients at a higher risk and ranking them based on their mortality risk level. Utilizing this machine learning for the PP approach underscores risk assessment, supporting healthcare professionals in managing HF patients more effectively and allocating resources to those in immediate need, whether in hospital or telehealth settings.

Usability evaluation of a glove-type wearable device for efficient biometric collection during triage

To efficiently allocate medical resources at disaster sites, medical workers perform triage to prioritize medical treatments based on the severity of the wounded or sick. In such instances, evaluators often assess the severity status of the wounded or sick quickly, but their measurements are qualitative and rely on experience. Therefore, we developed a wearable device called Medic Hand in this study to extend the functionality of a medical worker's hand so as to measure multiple biometric indicators simultaneously without increasing the number of medical devices to be carried. Medic Hand was developed to quantitatively and efficiently evaluate "perfusion" during triage. Speed is essential during triage at disaster sites, where time and effort are often spared to attach medical devices to patients, so the use of Medic Hand as a biometric measurement device is more efficient for collecting biometric information. For Medic Hand to be handy during disasters, it is essential to understand and improve upon factors that facilitate its public acceptance. To this end, this paper reports on the usability evaluation of Medic Hand through a questionnaire survey of nonmedical workers.

Comparative Analysis of META and SALT Disaster Triage in an Adult Trauma Population: A Retrospective Observational Study

BACKGROUND

Medical professionals can use mass-casualty triage systems to assist them in prioritizing patients from mass-casualty incidents (MCIs). Correct triaging of victims will increase their chances of survival. Determining the triage system that has the best performance has proven to be a difficult question to answer. The Advanced Prehospital Triage Model (Modelo Extrahospitalario de Triaje Avanzado; META) and Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) algorithms are the most recent triage techniques to be published. The present study aimed to evaluate the META and SALT algorithms' performance and statistical agreement with various standards. The secondary objective was to determine whether these two MCI triage systems predicted patient outcomes, such as mortality, length-of-stay, and intensive care unit (ICU) admission.

METHODS

This retrospective study used patient data from the trauma registry of an American College of Surgeons Level 1 trauma center, from January 1, 2018 through December 31, 2020. The sensitivity, specificity, and statistical agreement of the META and SALT triage systems to various standards (Revised Trauma Score [RTS]/Sort Triage, Injury Severity Score [ISS], and Lerner criteria) when applied using trauma patients. Statistical analysis was used to assess the relationship between each triage category and the secondary outcomes.

RESULTS

A total of 3,097 cases were included in the study. Using Sort triage as the standard, SALT and META showed much higher sensitivity and specificity in the Immediate category than for Delayed (Immediate sensitivity META 91.5%, SALT 94.9%; specificity 60.8%, 72.7% versus Delayed sensitivity 28.9%, 1.3%; specificity 42.4%, 28.9%). With the Lerner criteria, in the Immediate category, META had higher sensitivity (77.1%, SALT 68.6%) but lower specificity (61.1%) than SALT (71.8%). For the Delayed category, SALT showed higher sensitivity (META 61.4%, SALT 72.2%), but lower specificity (META 75.1%, SALT 67.2%). Both systems showed a positive, though modest, correlation with ISS. For SALT and META, triaged Immediate patients tended to have higher mortality and longer ICU and hospital lengths-of-stay.

CONCLUSION

Both META and SALT triage appear to be more accurate with Immediate category patients, as opposed to Delayed category patients. With both systems, patients triaged as Immediate have higher mortality and longer lengths-of-stay when compared to Delayed patients. Further research can help refine MCI triage systems and improve accuracy.

Evaluation of the effectiveness of non-contact respiration rate detection for post-crash care application

The ability of emergency medical services (EMS) personnel to understand the mortality and morbidity risks associated with different injuries is critical for effective motor vehicle collision (MVC) post-crash care. Interwoven with this ability is the practice of accurate and efficient patient triage. Triage allows EMS to gain a better understanding of the physiological and physical status of a patient and their injuries, with the intention of identifying additional resources needed, potential treatment options, and the most appropriate care destination. An interactive, in-vehicle triage system, based on the Simple Triage and Rapid Treatment protocol, under development could lead to improved MVC triage accuracy and efficiency. As a component of that system, this study examines the effectiveness of using non-contact respiration rate detection technologies integrated into a vehicle cabin. The selected technologies included ultrasonic respiration detection, thermal respiration detection, and pressurebased detection which were all compared against data collected from a respiration belt. All technologies were integrated into a 2015 Ford Taurus. Testing took place inside the running vehicle and considered occupant weight, cabin temperature, occupant clothing weight, and environmental sound as experimental factors. Respiration rate was then calculated using a 30-second sliding window where the means and standard deviations were used to compare the accuracy and precision of the sensor systems across the experimental factors. The sensor type, temperature level, and sound level main effects significantly influenced the mean respiration rate. For the standard deviation of respiration rate, significant effects were found for the sensor type, sound level, and clothing weight main effects. Among the tested sensor systems, the pressure sensor was found to best match the accuracy and precision of the respiration belt. Future work should address limitations in the approach used for this proof-of-concept work.

Unmanned aerial vehicle based intelligent triage system in mass-casualty incidents using 5G and artificial intelligence

BACKGROUND

Rapid on-site triage is critical after mass-casualty incidents (MCIs) and other mass injury events. Unmanned aerial vehicles (UAVs) have been used in MCIs to search and rescue wounded individuals, but they mainly depend on the UAV operator's experience. We used UAVs and artificial intelligence (AI) to provide a new technique for the triage of MCIs and more efficient solutions for emergency rescue.

METHODS

This was a preliminary experimental study. We developed an intelligent triage system based on two AI algorithms, namely OpenPose and YOLO. Volunteers were recruited to simulate the MCI scene and triage, combined with UAV and Fifth Generation (5G) Mobile Communication Technology real-time transmission technique, to achieve triage in the simulated MCI scene.

RESULTS

Seven postures were designed and recognized to achieve brief but meaningful triage in MCIs. Eight volunteers participated in the MCI simulation scenario. The results of simulation scenarios showed that the proposed method was feasible in tasks of triage for MCIs.

CONCLUSION

The proposed technique may provide an alternative technique for the triage of MCIs and is an innovative method in emergency rescue.

Accuracy of prehospital triage systems for mass casualty incidents in trauma register studies - A systematic review and meta-analysis of diagnostic test accuracy studies

BACKGROUND

Prioritising patients in mass casualty incidents (MCI) can be extremely difficult. Therefore, triage systems are important in every emergency medical service. This study reviews the accuracy of primary triage systems for MCI in trauma register studies.

METHODS

We registered a protocol at PROSPERO ID: CRD42018115438. We searched MEDLINE, EMBASE, Central, Web of Science, Scopus, Clinical Trials, Google Scholar, and reference lists for eligible studies. We included studies that both examined a primary triage system for MCI in trauma registers and provided sensitivity and specificity for critically injured vs non-critically injured as results. We excluded studies that used paediatric, chemical, biological, radiological or nuclear MCIs populations or triage systems. Finally, we calculated intra-study relative sensitivity, specificity and diagnostic odds ratio for each triage system.

RESULTS

Triage Sieve (TS) significantly underperformed in relative diagnostic odds ratio (DOR) when compared to START and CareFlight (CF) (START vs TS: 19.85 vs 13.23 (p<0.0001)│CF vs TS: 23.72 vs 12.83 (p<0.0001)). There was no significant difference in DOR between TS and Military Sieve (MS) (p<0.710). Compared to START, MS and CF TS had significantly higher relative specificity (START vs TS: 93.6% vs 96.1% (p=0.047)│CF vs TS: 96% vs 95.3% (p=0.0006)│MS vs TS: 94% vs 88.3% (p=0.0002)) and lower relative sensitivity (START vs TS: 57.8% vs 34.8% (p<0.0001)│CF vs TS: 53.9% vs 34.7% (p<0.0001)│MS vs TS: 51.9% vs 35.2% p<0.0001)). CF had significantly better relative DOR than START (CF vs START: 23.56 vs 27.79 (p=0.043)). MS had significantly better relative sensitivity than CF and START (MS vs CF: 49.5% vs 38.7% (p<0.0001)│MS vs START: 49.4% vs 43.9% (p=0.01)). In contrast, CF had significantly better relative specificity than MS (MS vs CF: 91.3% vs 93.3% (p<0.0001)). The remaining comparisons did not yield any significant differences.

CONCLUSION

As the included studies were at risk of bias and had heterogenic characteristics, our results should be interpreted with caution. Nonetheless, our results point towards inferior accuracy of Triage Sieve compared to START and CareFlight, and less firmly point towards superior accuracy of Military Sieve compared to START, CareFlight and Triage Sieve.

Sensitivity and Specificity of Spanish Prehospital Advanced Triage Method (META)

INTRODUCTION

Mass-casualty incident (MCI) triage systems aim to provide the best possible health care to the greatest number of affected people with the available resources in the context of a mass-casualty event. The Spanish Prehospital Advanced Triage Method (Modelo Extrahospitalario de Triaje Avanzado; META) was designed to improved patient sorting in MCIs.

OBJECTIVE

The aim of this study was to estimate and compare sensitivity and specificity of META and the Manchester Triage System (MTS) in MCIs by retrospectively applying both triage algorithms to real MCI patients from the Emergency and Disaster Research Unit (Unidad de Investigación en Emergencia y Desastres; UIED) MCI database.

METHOD

This was a comparative study of two triage methods using sensitivity and specificity with the Revised Trauma Score (RTS) as the gold standard. A total of 134 MCI patients from the UIED database were included. An MCI in Asturias is defined as an incident that involves four or more victims that require ambulance mobilization.

RESULTS

Patients mean age was 39.85 years (95% CI, 35.9-43.8) with an age range from one to 88 years old. In total, 54.4% of the patients were female. The most common types of MCI involved were fires (51.0%), followed by road traffic accident (43.3%) and street fight (3.7%). For MTS, the overall sensitivity was 30.6% (95% CI, 22.9-39.1) and specificity was 66.0% (95% CI, 60.0-71.7). For META triage algorithm, the overall sensitivity was 79.9% (95% CI, 72.1-86.3) and specificity was 89.9% (95% CI, 85.7-93.3).

CONCLUSION

The META triage algorithm is a reliable triage system; thus, it can be recommended to be used in an MCI.

Simple triage and rapid treatment protocol for emergency department mass casualty incident victim triage

OBJECTIVE

Triage plays an essential role in emergency medical care. It is crucial to adopt appropriate triage in a mass casualty incident (MCI) when resources are limited. The simple triage and rapid treatment (START) protocol is commonly used worldwide; however, the effectiveness of the START protocol for emergency department (ED) triage is unclear. This study aimed to examine the accuracy of START for the ED triage of victims following a MCI.

METHODS

We retrospectively reviewed the records of victims who presented to our ED during a MCI response after a train crash. The ED nurses applied the START protocol upon patient arrival, and we used a consensus-based standard to determine the outcome-based categories of these same patients. We compared the START protocol and outcome-based categories. In addition, the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of START in terms of predicting surgery and ED disposition were determined.

RESULTS

This study enrolled 47 patients (predominantly women, 68.1%; median age: 39.0years). Most victims were triaged into the START minor category (61.7%) and discharged from the ED (68.1%). Twenty-nine patients had matched START and outcome-based categories, whereas 2 patients were over-triaged and 16 patients were under-triaged. Additionally, the START system had acceptable AUC and sensitivities for predicting surgery and ED disposition (AUC/sensitivity/specificity for surgery: 0.850/100%/69.1%; AUC/sensitivity/specificity for admission: 0.917/93.3%/87.5%; AUC/sensitivity/specificity for intensive care unit (ICU)/ED death: 0.994/100%/97.8%).

CONCLUSIONS

This study demonstrated poor agreement between START categories, as determined in the ED, and the consensus-based standard categories. However, the START protocol was acceptable in terms of identifying emergent patients (100% sensitivity for the immediate and deceased categories) and predicting ED disposition (surgery, admission, and ICU/ED mortality). Although START is not perfect, our findings suggest that it could be used for the ED triage of trauma-related MCI victims.

Developing a Context-Bound Model for Hospital Triage in Disasters and Mass Casualty Incidents in the Health System of Iran

OBJECTIVE

The aim of this study was to develop a context-bound model of hospital triage in disasters and mass casualty incidents in the health system of Iran.

METHODS

This study was done using a sequential mixed method. Data were analyzed using Expert Choice software program.

RESULTS

In the qualitative phase, 27 specialists were interviewed. Walking and purposeful movement, airway and respiration, circulatory status, and mental indices were included in the finalized model. In the quantitative phase, 21 participants responded to a questionnaire for weighting and ranking the final indices based on 3 competing options, including clinical importance of the index, lack of complexity and simplicity in implementation, and speed of implementation. The index of walking and purposeful movements weighing 0.300 and ranking 1, airway and respiration weighing 0.276 and ranking 2, blood circulatory status weighing 0.245 and ranking 3, and finally mental status weighing 0.179 and ranking 4 were obtained.

CONCLUSIONS

This is the first attempt to design and develop a new context-bound model of hospital triage in disasters and mass casualties in Iran. The development of new triage models is a dynamic and continuous process, and changes will be applied to them, in case further developments and improvements are required.

Determination of START triage skill and knowledge levels of Prehospital Emergency Medical Staff: A cross sectional study

BACKGROUND

Emergency medical staff working in pre-hospital (PH-staff) may encounter mass casualty incident (MCI) events. In these events these medical personnel should perform triage. The objective of this study is to determine the skill and knowledge levels of PH-staff about Simple Triage and Rapid Treatment (START) triage.

METHODS

With this cross-sectional, observational study we analyzed data from 127 PH-staff. Data was collected with the survey tool (response rate = 74.7%). Kruskal-Wallis H Test, Mann-Whitney U Test, and Spearman's Correlation analyzes were used in the data analysis by means of SPSS Software.

RESULTS

Of the participants, 63% were men, the median age was 24 years, 88 PH-staff (69.3%) intervened in MCI events, and 37 PH-staff (29.1%) applied START triage. The skill score was 60% and the knowledge score was 72.5%. There was a weak positive correlation between knowledge and skill scores (r = 0.337, p < 0.01). The knowledge level of the emergency medical technicians (EMTs) and paramedics was higher than those from the other professions.

CONCLUSIONS

The triage knowledge and skill levels of the PH-staff were not low contrary to the expectations. The triage knowledge and skill levels of professions that did not have pre-hospital training such as paramedics and EMTs were low.

Digital versus analogue record systems for mass casualty incidents at sea-Results from an exploratory study

Objective

Mis-triage may have serious consequences for patients in mass casualty incidents (MCI) at sea. The purpose of this study was to assess outcome, reliability and validity of an analogue and a digital recording system for triage of a MCI at sea.

Methods

The study based on a triage exercise conducted with a cross-over-design. Forty-eight volunteers were presented a fictional MCI with 50 cases. The volunteers were randomly assigned to start with the analogue (Group A, starting with the analogue followed by the digital system) or digital system (Group B, starting with the digital followed by the analogue system). Triage score distribution and agreement between the triage methods and a predefined standard were reported. Reliability was analysed using Cronbach’s Alpha and Cohen’s Kappa. Validity was measured through sensitivity, specificity and predictive value. Treatment, period and carry-over-effects were analysed using a linear mixed-effects model.

Results

The number of patients triaged (total: n = 3545) with the analogue system (n = 1914; 79.75%) was significantly higher (p = 0.001) than with the digital system (n = 1631; 67.96%). A trend towards a higher percentage of correct triages with the digital system was observed (p = 0.282). Ratio of under-triage was significantly smaller with the digital system (p = 0.001). Validity measured with Cronbach’s Alpha and Cohen’s Kappa was higher with the digital system. So was sensitivity (category; green: 80.67%, yellow: 73.24%, red: 83.54%; analogue: green: 93.28%, yellow: 82.36%, red: 94.04%) and specificity of the digital system (green: 78.07%, yellow: 63.75%, red: 66.25%; analogue: green: 85.50%, yellow: 79.88%, red: 91.50%). Comparing the predictive values and accuracy, the digital system showed higher scores than the analogue system. No significant patterns of carry-over-effects were observed.

Conclusions

Significant differences were found for the number of triages comparing the analogue and digital recording system. The digital system has a slightly higher reliability and validity than the analogue triage system.

Comparison between simple triage and rapid treatment and Taiwan Triage and Acuity Scale for the emergency department triage of victims following an earthquake-related mass casualty incident: a retrospective cohort study

BACKGROUND

Triage plays a crucial role in the emergency department (ED) management of mass casualty incidents (MCIs) when resources are limited. This study aimed to compare the performance of simple triage and rapid treatment (START) with that of the Taiwan Triage and Acuity Scale (TTAS) for the ED triage of victims following an earthquake-related MCI.

METHODS

We retrospectively reviewed the records of victims presenting at our ED with earthquake-related injuries within 24 h of a large-scale earthquake. TTAS was initially used at our ED for this event, and START was performed by retrospectively reviewing the patient records in a blinded manner. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of START and TTAS were determined for predicting ED discharge.

RESULTS

We enrolled 105 patients (predominantly women, 60.0%; median age, 45.0 years) in this study; most of them presented with traumatic injuries and were initially triaged as TTAS level III (78.1%), followed by TTAS level II (11.4%). Although the majority of the victims (81.0%) were discharged, four deaths occurred. A moderate agreement in differentiating emergency from nonemergency patients was observed between START and TTAS. Furthermore, both the triage systems showed similar predictions for ED disposition (START AUC/sensitivity/specificity: 0.709/82.35%/55.00%; TTAS AUC/sensitivity/specificity: 0.709/90.59%/45.00%).

CONCLUSIONS

The present study demonstrated that START and TTAS have similar triage accuracy and ability to predict ED disposition. Our findings demonstrate that START may be used as an alternative to TTAS for the ED triage of victims following earthquake-related MCIs.

The Principles of Triage in Emergencies and Disasters: A Systematic Review

INTRODUCTION

The use of triage systems is one of the most important measures in response to mass-casualty incidents (MCIs) caused by emergencies and disasters. In these systems, certain principles and criteria must be considered that can be achieved with a lack of resources. Accordingly, the present study was conducted as a systematic review to explore the principles of triage systems in emergencies and disasters world-wide.

METHODS

The present study was conducted as a systematic review of the principles of triage in emergencies and disasters. All papers published from 2000 through 2019 were extracted from the Web of Science, PubMed, Scopus, Cochrane Library, and Google Scholar databases. The search for the articles was conducted by two trained researchers independently.

RESULTS

The classification and prioritization of the injured people, the speed, and the accuracy of the performance were considered as the main principles of triage. In certain circumstances, including chemical, biological, radiation, and nuclear (CBRN) incidents, certain principles must be considered in addition to the principles of the triage based on traumatic events. Usually in triage systems, the classification of the injured people is done using color labeling. The short duration of the triage and its accuracy are important for the survival of the injured individuals. The optimal use of available resources to protect the lives of more casualties is one of the important principles of triage systems and does not conflict with equity in health.

CONCLUSION

The design of the principles of triage in triage systems is based on scientific studies and theories in which attempts have been made to correctly classify the injured people with the maximum correctness and in the least amount of time to maintain the survival of the injured people and to achieve the most desirable level of health. It is suggested that all countries adopt a suitable and context-bond model of triage in accordance with all these principles, or to propose a new model for the triage of injured patients, particularly for hospitals in emergencies and disasters.

Multiple victims incident simulation: training professionals and university teaching

OBJECTIVE

to describe the teaching strategy based on the Multiple Victims Incident (MVI) simulation, discussing and evaluating the performance of the students involved in the initial care of trauma victims.

METHODS

a cross-sectional, and quantitative study was performed. A realistic MVI simulation involving students, and professionals from nursery and medical schools, as well as a prehospital care team was performed.

RESULTS

it was possible to notice that the classification according to the START method (Simple Triage and Rapid Treatment) was correct in 94.1% of the time from the analysis of 17 preestablished checklists. Following the primary evaluation with the ABCDE mnemonic, all steps were performed correctly in 70%. However, there was only supply of oxygen in high flow in 64.7% of the examination. The search for visible and hidden bleeding was performed in 70.6% of the examination. The neurological evaluation with the Glasgow coma scale and pupillary evaluation occurred in 70.6% of the victims. The victims exposure was performed in 70.6% of the examination.

CONCLUSION

a simulated environment allows the consolidation and improvement of professional skills, especially when we are talking about a poorly trained area during the undergraduate program, such as the MVI. Early training and teamwork encourage clinical thinking, integration and communication, essential abilities when facing chaotic situations.

Chinese expert consensus on the treatment of modern combat-related spinal injuries

The battlefield treatments of spinal and spinal cord injury vary from civilian settings. However, there is no unified battlefield treatment guidelines for spine trauma in PLA. An expert consensus is reached, based on spine trauma epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since the specialized treatment for spine trauma are no significant difference between civilian settings and modern war, the first aid, emergency treatment and early treatment of spine trauma are introduced separately in three levels in this consensus. In Level I facilities, the fast and accurate evaluation of spine trauma followed by fixation and stabilization are recommended during the first-aid stage. Re-evaluation, further treatment for possible hemorrhagic shock, dyspnea and infection are recommended at Level II facilities. At Level III facilities, it is recommended to strengthen the intensive care and the prevention of urinary system and lung infection for the wounded with severe spinal injury, however, spinal surgery is not recommended in a battlefield hospital. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach

BACKGROUND:

Injuries caused by emergencies and accidents are increasing in the world. To prioritise patients to provide them with proper services and to optimally use the resources and facilities of the medical centres during accidents, the use of triage systems, which are one of the key principles of accident management, seems essential.

AIM:

This study is an attempt to identify available triage systems and compare the differences and similarities of the standards of these systems during emergencies and disasters through a review study.

METHODS:

This study was conducted through a review of the triage systems used in emergencies and disasters throughout the world. Accordingly, all articles published between 1990 and 2018 in both English and Persian journals were searched based on several keywords including Triage, Disaster, Mass Casualty Incidents, in the Medlib, Scopus, Web of Science, PubMed, Cochrane Library, Science Direct, Google scholar, Irandoc, Magiran, Iranmedex, and SID databases in isolation and in combination using both and/ or conjunctions.

RESULTS:

Based on the search done in these databases, twenty different systems were identified in the primary adult triage field including START, Homebush triage Standard, Sieve, CareFlight, STM, Military, CESIRA Protocol, MASS, Revers, CBRN Triage, Burn Triage, META Triage, Mass Gathering Triage, SwiFT Triage, MPTT, TEWS Triage, Medical Triage, SALT, mSTART and ASAV. There were two primary triage systems including Jump START and PTT for children, and also two secondary triage systems encompassing SAVE and Sort identified in this respect. ESI and CRAMS were two other cases distinguished for hospital triage systems.

CONCLUSION:

There are divergent triage systems in the world, but there is no general and universal agreement on how patients and injured people should be triaged. Accordingly, these systems may be designed based on such criteria as vital signs, patient’s major problems, or the resources and facilities needed to respond to patients’ needs. To date, no triage system has been known as superior, specifically about the patients’ clinical outcomes, improvement of the scene management or allocation of the resources compared to other systems. Thus, it is recommended that different countries such as Iran design their triage model for emergencies and disasters by their native conditions, resources and relief forces.

Introduction of a mass burn casualty triage system in a hospital during a powder explosion disaster: a retrospective cohort study

Background

The triage system used during an actual mass burn casualty (MBC) incident is a major focus of concern. This study introduces a MBC triage system that was used by a burn center during an actual MBC incident following a powder explosion in New Taipei City, Taiwan.

Methods

This study retrospectively analyzed data from patients who were sent to the study hospital during a MBC incident. The patient list was retrieved from a national online management system. A MBC triage system was developed at the study hospital using the following modifiers: consciousness, breathing, and burn size. Medical records were retrieved from electronic records for analysis. Patient outcomes consisted of emergency department (ED) disposition and intervention.

Results

The patient population was predominantly female (56.3%), with an average age of 24.9 years. Mean burn sizes relative to the TBSA of triage level I, II, and III patients were 57.9%, 40.5%, and 8.7%, respectively. ICU length of stay differed markedly according to triage level (mean days for levels I vs II vs III: 57.9 vs 39.9 vs 2.5 days; p < 0.001). Triage system levels I and II indicate ICU admission with a sensitivity of 93.9% (95%CI 80.4-98.3%) and a specificity of 86.7% (62.1-96.3%).Overall, 3 (6.3%) patients were under-triaged. Two (4.2%) patients were over-triaged. Sixteen (48.5%) and 21 (63.6%) patients of triage levels I and II received endotracheal intubation and central venous catheterization, respectively. Sorting of the study population with simple triage and rapid treatment (START) showed great sensitivity (100.0%) but poor specificity (53.3%). The Taiwan Triage and Acuity Scale (TTAS) presented 87.9% sensitivity and 93.9% specificity.

Conclusions

The current MBC triage algorithm served as a good indicator of ED disposition but might have raised excessive immediate attention and had the potential to exhaust the available resources. These findings add to our knowledge of the MBC triage system and should help future researchers in adjusting the triage criteria to fit actual disasters.

START versus SALT Triage: Which is Preferred by the 21st Century Health Care Student?

IntroductionWhile the art and science of disaster triage continue to evolve, the education of the US health care student in matters pertaining to disaster preparedness and response remains stifled. Unfortunately, these students will be assuming major decision-making responsibilities regarding catastrophes that will be complicated by climate change, nuclear threats, global terrorism, and pandemics. Meanwhile, Sort, Assess, Life-Saving Interventions, Treatment, and/or Transport (SALT) triage is being advocated over the globally popular Simple Triage and Rapid Treatment (START) algorithm for multiple reasons: (1) it's an all-hazard approach; (2) it has four medical interventions; and (3) it has an additional triage color for victims with non-survivable injuries.Hypothesis/ProblemAs present-day threats become more ominous and health care education emphasizes the needs of vulnerable populations and palliative care, the authors hypothesize that, when given a choice, health care students will prefer SALT triage.

METHODS

A convenience sample of 218 interprofessional, disaster-naïve health care students received just-in-time, unbiased education on both START and SALT triage systems. Students then completed a survey asking them to decide which triage system they believe would be most effective in their community.

RESULTS

A total of 123 health care students (56.4%) preferred SALT while 95 (43.6%) preferred START; however, only the physician assistant students showed a statistically significantly preference (28 versus six, respectively; P=.042). Interestingly, there was also a statistically significant difference in preference by gender (Chi-square=5.02; P=.025) of the observed distribution versus expected distribution in SALT and START. The females preferred SALT (61.0%) while the males preferred START (55.9%).Among those who preferred START, START being easier to learn was the most important reason cited. Among those who preferred SALT, the most important reason cited was that the number of patient triage categories seemed more logical, comprehensible, and consistent with traditional medical care.

CONCLUSION

While SALT's preference among females and physician assistant students was based on the addition of medical interventions and the provision of palliative care, START's preference was related to expediency. Based on this research, incorporating disaster concepts into US health care students' curricula encourages thoughtful consideration among the future health care leaders about the most effective approach to triage care. It is critical that further research be completed to determine, without reservation, which triage system will not only save the most lives but provide the most humane care to victims.Fink BN, Rega PP, Sexton ME, Wishner C. START versus SALT triage: which is preferred by the 21st century health care student? Prehosp Disaster Med. 2018;33(4):381-386.

Expert consensus on the evaluation and diagnosis of combat injuries of the Chinese People's Liberation Army

The accurate assessment and diagnosis of combat injuries are the basis for triage and treatment of combat casualties. A consensus on the assessment and diagnosis of combat injuries was made and discussed at the second annual meeting of the Professional Committee on Disaster Medicine of the Chinese People's Liberation Army (PLA). In this consensus agreement, the massive hemorrhage, airway, respiration, circulation and hypothermia (MARCH) algorithm, which is a simple triage and rapid treatment and field triage score, was recommended to assess combat casualties during the first-aid stage, whereas the abbreviated scoring method for combat casualty and the MARCH algorithm were recommended to assess combat casualties in level II facilities. In level III facilities, combined measures, including a history inquiry, thorough physical examination, laboratory examination, X-ray, and ultrasound examination, were recommended for the diagnosis of combat casualties. In addition, corresponding methods were recommended for the recognition of casualties needing massive transfusions, assessment of firearm wounds, evaluation of mangled extremities, and assessment of injury severity in this consensus.

Developing a Mass Casualty Surge Capacity Protocol for Emergency Medical Services to Use for Patient Distribution

OBJECTIVES

Metropolitan areas must be prepared to manage large numbers of casualties related to a major incident. Most US cities do not have adequate trauma center capacity to manage large-scale mass casualty incidents (MCIs). Creating surge capacity requires the distribution of casualties to hospitals that are not designated as trauma centers. Our objectives were to extrapolate MCI response research into operational objectives for MCI distribution plan development; formulate a patient distribution model based on research, hospital capacities, and resource availability; and design and disseminate a casualty distribution tool for use by emergency medical services (EMS) personnel to distribute patients to the appropriate level of care.

METHODS

Working with hospitals within the region, we refined emergency department surge capacity for MCIs and developed a prepopulated tool for EMS providers to use to distribute higher-acuity casualties to trauma centers and lower-acuity casualties to nontrauma hospitals. A mechanism to remove a hospital from the list of available resources, if it is overwhelmed with patients who self-transport to the location, also was put into place.

RESULTS

The number of critically injured survivors from an MCI has proven to be consistent, averaging 7% to 10%. Moving critically injured patients to level 1 trauma centers can result in a 25% reduction in mortality, when compared with care at nontrauma hospitals. US cities face major gaps in the surge capacity needed to manage an MCI. Sixty percent of "walking wounded" casualties self-transport to the closest hospital(s) to the incident.

CONCLUSIONS

Directing critically ill patients to designated trauma centers has the potential to reduce mortality associated with the event. When applied to MCI responses, damage-control principles reduce resource utilization and optimize surge capacity. A universal system for mass casualty triage was identified and incorporated into the region's EMS. Flagship regional coordinating hospitals were designated to coordinate the logistics of the disaster response of both trauma-designated and undesignated hospitals. Finally, a distribution tool was created to direct the flow of critically injured patients to trauma centers and redirect patients with lesser injuries to centers without trauma designation. The tool was distributed to local EMS personnel and validated in a series of tabletop and functional drills. These efforts demonstrate that a regional response to MCIs can be implemented in metropolitan areas under-resourced for trauma care.

Difference in First Aid Activity During Mass Casualty Training Based on Having Taken an Educational Course

BACKGROUND

The Japanese Association for Disaster Medicine developed a mass casualty life support (MCLS) course to improve cooperation among medical practitioners during a disaster, which is essential for reducing the rates of preventable disaster death. We investigated whether there was difference in first aid activity among members of the ambulance service during mass casualty training based on having taken the MCLS course.

METHODS

Mass casualty training was held at the fire department of Numazu City. Twenty-one ambulance service parties participated in this training. They first evaluated the mass casualty situation, performed the appropriate services at the scene during the initial period, and then provided START triage for mock wounded patients. Throughout the training, 5 examiners evaluated their performance.

RESULTS

Regarding the difference in first aid activity based on MCLS course attendance among the ambulance service members, the cooperative management (scored on a scale of 1 to 5) among the members who had taken the MCLS course was significantly better than that among those who had not taken the course (median [interquartile range]: 5 [0.5] vs. 4 [1.75], P<0.05).

CONCLUSION

Attending an MCLS course may help to improve outcomes in the face of an actual mass casualty incident. (Disaster Med Public Health Preparedness. 2018;12:437-440).