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Wisnesky UD, Kirkland SW, Rowe BH, Campbell S, Franc JM. A Qualitative Assessment of Studies Evaluating the Classification Accuracy of Personnel Using START in Disaster Triage: A Scoping Review. Front Public Health 2022; 10:676704. [PMID: 35284379 PMCID: PMC8907512 DOI: 10.3389/fpubh.2022.676704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 01/31/2022] [Indexed: 11/18/2022] Open
Abstract
Background Mass casualty incidents (MCIs) can occur as a consequence of a wide variety of events and often require overwhelming prehospital and emergency support and coordinated emergency response. A variety of disaster triage systems have been developed to assist health care providers in making difficult choices with regards to prioritization of victim treatment. The simple triage and rapid treatment (START) triage system is one of the most widely used triage algorithms; however, the research literature addressing real-world or simulation studies documenting the classification accuracy of personnel using START is lacking. Aims and Objectives To explore the existing literature related to the current state of knowledge about studies assessing the classification accuracy of the START triage system. Design Scoping review based on Arksey and O'Malley's methodological framework and narrative synthesis based on methods described by Popay and colleagues were performed. Results The literature search identified 1,820 citations, of which 32 studies met the inclusion criteria. Thirty were peer-reviewed articles and 28 published in the last 10 years (i.e., 2010 and onward). Primary research studies originated in 13 countries and included 3,706 participants conducting triaging assessments involving 2,950 victims. Included studies consisted of five randomized controlled trials, 17 non-randomized controlled studies, eight descriptive studies, and two mixed-method studies. Simulation techniques, mode of delivery, contextual features, and participants' required skills varied among studies. Overall, there was no consistent reporting of outcomes across studies and results were heterogeneous. Data were extracted from the included studies and categorized into two themes: (1) typology of simulations and (2) START system in MCIs simulations. Each theme contains sub-themes regarding the development of simulation employing START as a system for improving individuals' preparedness. These include types of simulation training, settings, and technologies. Other sub-themes include outcome measures and reference standards. Conclusion This review demonstrates a variety of factors impacting the development and implementation of simulation to assess characteristics of the START system. To further improve simulation-based assessment of triage systems, we recommend the use of reporting guidelines specifically designed for health care simulation research. In particular, reporting of reference standards and test characteristics need to improve in future studies.
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Affiliation(s)
- Uirá Duarte Wisnesky
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Scott W. Kirkland
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Sandra Campbell
- J.W. Scott Health Sciences Library, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey Michael Franc
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Jeffrey Michael Franc
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METASTART: A Systematic Review and Meta-Analysis of the Diagnostic Accuracy of the Simple Triage and Rapid Treatment (START) Algorithm for Disaster Triage. Prehosp Disaster Med 2021; 37:106-116. [PMID: 34915954 DOI: 10.1017/s1049023x2100131x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The goal of disaster triage at both the prehospital and in-hospital level is to maximize resources and optimize patient outcomes. Of the disaster-specific triage methods developed to guide health care providers, the Simple Triage and Rapid Treatment (START) algorithm has become the most popular system world-wide. Despite its appeal and global application, the accuracy and effectiveness of the START protocol is not well-known. OBJECTIVES The purpose of this meta-analysis was two-fold: (1) to estimate overall accuracy, under-triage, and over-triage of the START method when used by providers across a variety of backgrounds; and (2) to obtain specific accuracy for each of the four START categories: red, yellow, green, and black. METHODS A systematic review and meta-analysis was conducted that searched Medline (OVID), Embase (OVID), Global Health (OVID), CINAHL (EBSCO), Compendex (Engineering Village), SCOPUS, ProQuest Dissertations and Theses Global, Cochrane Library, and PROSPERO. The results were expanded by hand searching of journals, reference lists, and the grey literature. The search was executed in March 2020. The review considered the participants, interventions, context, and outcome (PICO) framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Accuracy outcomes are presented as means with 95% confidence intervals (CI) as calculated using the binomial method. Pooled meta-analyses of accuracy outcomes using fixed and random effects models were calculated and the heterogeneity was assessed using the Q statistic. RESULTS Thirty-two studies were included in the review, most of which utilized a non-randomized study design (84%). Proportion of victims correctly triaged using START ranged from 0.27 to 0.99 with an overall triage accuracy of 0.73 (95% CI, 0.67 to 0.78). Proportion of over-triage was 0.14 (95% CI, 0.11 to 0.17) while the proportion of under-triage was 0.10 (95% CI, 0.072 to 0.14). There was significant heterogeneity of the studies for all outcomes (P < .0001). CONCLUSION This meta-analysis suggests that START is not accurate enough to serve as a reliable disaster triage tool. Although the accuracy of START may be similar to other models of disaster triage, development of a more accurate triage method should be urgently pursued.
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Khorram-Manesh A, Nordling J, Carlström E, Goniewicz K, Faccincani R, Burkle FM. A translational triage research development tool: standardizing prehospital triage decision-making systems in mass casualty incidents. Scand J Trauma Resusc Emerg Med 2021; 29:119. [PMID: 34404443 PMCID: PMC8369703 DOI: 10.1186/s13049-021-00932-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background There is no global consensus on the use of prehospital triage system in mass casualty incidents. The purpose of this study was to evaluate the most commonly used pre-existing prehospital triage systems for the possibility of creating one universal translational triage tool. Methods The Rapid Evidence Review consisted of (1) a systematic literature review (2) merging and content analysis of the studies focusing on similarities and differences between systems and (3) development of a universal system. Results There were 17 triage systems described in 31 eligible articles out of 797 identified initially. Seven of the systems met the predesignated criteria and were selected for further analysis. The criteria from the final seven systems were compiled, translated and counted for in means of 1/7’s. As a product, a universal system was created of the majority criteria. Conclusions This study does not create a new triage system itself but rather identifies the possibility to convert various prehospital triage systems into one by using a triage translational tool. Future research should examine the tool and its different decision-making steps either by using simulations or by experts’ evaluation to ensure its feasibility in terms of speed, continuity, simplicity, sensitivity and specificity, before final evaluation at prehospital level. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00932-z.
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Affiliation(s)
- Amir Khorram-Manesh
- Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 413 45, Gothenburg, Sweden. .,Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden. .,Department of Research and Development, Armed Forces Center for Defense Medicine, 426 76, Västra Frölunda, Gothenburg, Sweden.
| | - Johan Nordling
- Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 413 45, Gothenburg, Sweden
| | - Eric Carlström
- Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden.,Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden.,USN School of Business, University of South-Eastern Norway, 3616, Kongsberg, Norway
| | - Krzysztof Goniewicz
- Department of Aviation Security, Military University of Aviation, 08-521, Dęblin, Poland
| | - Roberto Faccincani
- Emergency Department, Humanitas Mater Domini, 210 53, Castellanza, Italy
| | - Frederick M Burkle
- T.H. Chan School of Public Health, Harvard Humanitarian Initiative, Harvard University, Boston, MA, 02115, USA
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Hughes AM, Sonesh SC, Mason RE, Gregory ME, Marttos A, Schulman CI, Salas E. Trauma, Teams, and Telemedicine: Evaluating Telemedicine and Teamwork in a Mass Casualty Simulation. Mil Med 2021; 186:e811-e818. [PMID: 33216935 DOI: 10.1093/milmed/usaa434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/05/2020] [Accepted: 10/06/2020] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Mass casualty events (MASCAL) are on the rise globally. Although natural disasters are often unavoidable, the preparation to respond to unique patient demands in MASCAL can be improved. Utilizing telemedicine can allow for a better response to such disasters by providing access to a virtual team member with necessary specialized expertise. The purpose of this study was to examine the positive and/or negative impacts of telemedicine on teamwork in teams responding to MASCAL events. METHODS We introduced a telemedical device (DiMobile Care) to Forward Surgical Teams during a MASCAL simulated training event. We assessed teamwork-related attitudes, behaviors, and cognitions during the MASCAL scenario through pre-post surveys and observations of use. Analyses compare users and nonusers of telemedicine and pre-post training differences in teamwork. RESULTS We received 50 complete responses to our surveys. Overall, clinicians have positive reactions toward the potential benefits of telemedicine; further, participants report a significant decrease in psychological safety after training, with users rating psychological safety as significantly higher than non-telemedicine users. Neither training nor telemedicine use produced significant changes in cognitive and behavioral-based teamwork. Nonetheless, participants reported perceiving that telemedicine improved leadership and adaptive care plans. CONCLUSIONS Telemedicine shows promise in connecting Forward Surgical Teams with nuanced surgical expertise without harming quality of care metrics (i.e., teamwork). However, we advise future iterations of DiMobile Care and other telemedical devices to consider contextual features of information flow to ensure favorable use by teams in time-intensive, high-stakes environments, such as MASCAL.
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Affiliation(s)
- Ashley M Hughes
- Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, IL 60612, USA.,Center of Innovations in Chronic, Complex Healthcare (CINCCH), Edward Hines JR VA Medical Center, Hines, IL 60540, USA
| | | | - Rachel E Mason
- Centers for Biobehavioral Health and Innovation in Pediatric Practice, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH 43215, USA
| | - Megan E Gregory
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH 43210, USA.,Center for the Advancement of Team Science, Analytics and Systems Thinking in Health Services and Implementation Science Research (CATALYST), The Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - Antonio Marttos
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33101, USA
| | - Carl I Schulman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33101, USA
| | - Eduardo Salas
- Center of Innovations in Chronic, Complex Healthcare (CINCCH), Edward Hines JR VA Medical Center, Hines, IL 60540, USA.,Department of Psychological Sciences, Rice University, TX 77005, USA
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Aslan R, Şahinöz S, Şahinöz T. Determination of START triage skill and knowledge levels of Prehospital Emergency Medical Staff: A cross sectional study. Int Emerg Nurs 2021; 56:101004. [PMID: 33957489 DOI: 10.1016/j.ienj.2021.101004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 02/28/2021] [Accepted: 03/12/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Ramazan Aslan
- Department of Emergency and Disaster Management, Faculty of Health Sciences, Gümüşhane University, Gümüşhane, Turkey.
| | - Saime Şahinöz
- Department of Public Health, Faculty of Medicine, Ordu University, Ordu, Turkey
| | - Turgut Şahinöz
- Department of Healthc Management, Faculty of Health Sciences, Ordu University, Ordu, Turkey
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Hartman EN, Daines B, Seto C, Shimshoni D, Feldman ME, LaBrunda M. Sort, Assess, Life-Saving Intervention, Triage With Drone Assistance in Mass Casualty Simulation: Analysis of Educational Efficacy. Cureus 2020; 12:e10572. [PMID: 33110714 PMCID: PMC7577607 DOI: 10.7759/cureus.10572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction Mass casualty incident (MCI) simulation and triage are educational methods used to provide high fidelity training to first response teams. Simulation and triage need to be as effective as possible to train professionals for true emergencies involving mass casualty. Although MCI simulation and triage have been used in the pre-professional setting (i.e. medical school, nursing school, etc.), more data is required regarding quality improvement of these simulations. This study focuses on quality improvement of MCI simulation and triage in the pre-professional training. In order to evaluate simulation quality to optimize future triage simulations, this study had three specific aims: (1) assess participant accuracy of triage after training in Sort, Assess, Life-Saving Interventions, Triage/Transport (SALT); (2) evaluate the role of stress and confidence in participants of triage simulation; (3) determine trainees’ perception of unmanned aerial vehicles (drones) in the setting of mass casualty simulation. Methods A total of 44 attendees of the University of Central Florida (UCF) College of Medicine Global Health Conference participated in this study across three groups. Each group was provided a 15-minute lecture on SALT protocol. After the training, the participants continued to a 30-minute simulation in which they were asked to accurately triage up to 46 patient-actors. Each participants’ triage designations were compared to the previously assigned designations of each patient-actor. Pre- and post-simulation surveys were collected and analyzed using Statistical Package for the Social Sciences (SPSS) (IBM Corp., Chicago, IL). All other data were analyzed using descriptive statistics. Results Qualitative and Likert data for the simulation were collected from 44 participants. Given a total of 1,113 triage scores (average of 25.29 triage designations per person), there was data to support that novice learners in this study tended to under-triage using the SALT protocol after 15-minute SALT training, with an overall accuracy of 52.43%. Survey data showed that confidence in mass casualty triage improved post-simulation, improving from median 3/10 to 5/10. Most participants were unaware of the use of unmanned aerial vehicles in MCI but most had positive opinions of their usefulness in MCI after the simulation, with a median score of 8/10. Conclusions Participant accuracy of triage after undergoing a 15-minute training in SALT triage was 52.43%, with a non-statistically significant tendency to under-triage. This accuracy level is consistent with other studies of SALT triage in MCI, but the tendency to undertriage requires further study for validation. Stress levels during the simulation were significantly elevated, while post-simulation confidence increased significantly from pre-simulation. The perception of drone utility in MCI was favorable among participants in this study, indicating drones may be useful for first response teams in future mass casualty simulations.
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Operation continued care: A large mass-casualty, full-scale exercise as a test of regional preparedness. Surgery 2019; 166:587-592. [PMID: 31447104 DOI: 10.1016/j.surg.2019.05.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/02/2019] [Accepted: 05/15/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Our regional trauma organization, which comprises 7 trauma centers, 30 acute care hospitals and free-standing emergency departments, and 42 emergency medical services agencies, conducted possibly the largest mass-casualty drill to date, totaling 445 victims at 3 sites involving 11 hospitals and 25 agencies and organizations. METHODS The drill was preceded by a tabletop exercise 4 months beforehand called Operation Continued Care Full-Scale Exercise, which consisted of simulated terrorist events at 3 sites to wound 445 moulaged patients. Four law enforcement and 5 fire and emergency medical services departments and 16 supporting organizations and agencies were involved in transporting patients to 11 different hospitals. The 7 objectives for the event addressed coordinating emergency operations, sustaining adequate communications, updating regional bed status, processing resource requests, triaging patients, tracking patients, and patient identification. RESULTS Of the 445 transported patients, 270 (60%) were entered correctly into the state patient tracking system; 68 (25.2%) upgrades and 34 (12.6%) downgrades from scene triage categories were noted. Multiple opportunities for improvement were identified, with major weaknesses noted in communication and coordination from event sites to the regional trauma organizations and hospitals. CONCLUSION The size and complexity of the drill provided experience and knowledge to facilitate future disaster preparedness and highlighted weaknesses in communication and coordination. Large, multijurisdictional, multiagency exercises provide opportunities to stress, evaluate, and improve regional disaster preparedness.
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McKee CH, Heffernan RW, Willenbring BD, Schwartz RB, Liu JM, Colella MR, Lerner EB. Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population. PREHOSP EMERG CARE 2019; 24:515-524. [PMID: 31287350 DOI: 10.1080/10903127.2019.1641579] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To use a previously published criterion standard to compare the accuracy of 4 different mass casualty triage systems (Sort, Assess, Lifesaving Interventions, Treatment/Transport [SALT], Simple Triage and Rapid Treatment [START], Triage Sieve, and CareFlight) when used in an emergency department-based adult population. Methods: We performed a prospective, observational study of a convenience sample of adults aged 18 years or older presenting to a single tertiary care hospital emergency department. A co-investigator with prior emergency medical services (EMS) experience observed each subject's initial triage in the emergency department and recorded all data points necessary to assign a triage category using each of the 4 mass casualty triage systems being studied. Subjects' medical records were reviewed after their discharge from the hospital to assign the "correct" triage category using the criterion standard. The 4 mass casualty triage system assignments were then compared to the "correct" assignment. Descriptive statistics were used to compare accuracy and over- and under-triage rates for each triage system. Results: A total of 125 subjects were included in the study. Of those, 53% were male and 59% were transported by private vehicle. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (52%; 95% CI 43-60) compared to START (36%; 95% CI 28-44), CareFlight (36%; 95% CI 28-44), and TriageSieve (37%; 95% CI 28-45). SALT also had the lowest under-triage rate (26%; 95% CI 19-34) compared to START (57%; 95% CI 48-66), CareFlight (58%; 95% CI 49-66), and TriageSieve (58%; 95% CI 49-66). SALT had the highest over-triage rate (22%; 95% CI 14-29) compared to START (7%; 95% CI 3-12), CareFlight (6%; 95% CI 2-11) and TriageSieve (6%; 95% CI 2-11). Conclusion: We found that SALT triage most often correctly triaged adult emergency department patients when compared to a previously published criterion standard. While there are no target under- and over-triage rates that have been published for mass casualty triage, all 4 systems had relatively high rates of under-triage.
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Organizational Description and Emergency Preparedness of Nationally Registered First Responders. Prehosp Disaster Med 2017. [DOI: 10.1017/s1049023x00064955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction: This study intended to describe the types of organizations and communities in which Nationally Registered First Responders (NRFR) perform their duties. Also, it aimed to estimate the number of NRFR who received disaster preparedness training. It was hypothesized that NRFR participation in disaster preparedness training was related to the types of organizations and communities in which they performed their duties.Methods: The NRFR re-registering in 2006 were asked to report the organization type and community size in which they work. They also were asked to report the amount and content of preparedness training received during the last 24 months. Multivariable logistic regression modeling was utilized to describe the relationship between NRFR organizational characteristics and the receipt of disaster preparedness training.Results: The analysis included 872 (59%) individuals who completed the survey and reported working for one or more emergency medical services (EMS) organizations. The majority of NRFR performed work in rural areas (75%) and more NRFR reported working for fire departments (61%) than for any other organization type. In all categories of service type, participants who reported working in urban areas had higher odds of receiving disaster preparedness training than those working in rural areas. Additionally, regardless of community size, individuals working in fire departments were more likely to receive disaster preparedness training.Conclusions: This study indicated that the majority of NRFR perform EMS duties for fire departments and work in rural communities. In this sample of NRFR, more than one-quarter did not receive disaster preparedness training within a 24-month period. Finally, a statistical model was constructed that indicated a relationship between service type, community size, and the participation in disaster preparedness training.
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Abstract
BACKGROUND Mass-casualty incidents (MCIs) present a unique challenge with regards to triage as patient volume often outweighs the number of available Emergency Medical Services (EMS) providers. A possible strategy to optimize existing triage systems includes the use of other first responder groups, namely fire and police, to decrease the triage time during MCIs, allowing for more rapid initiation of life-saving treatment and prioritization of patient transport. Hypothesis First-year primary care paramedic (PCP), fire, and police trainees can apply with similar accuracy an internationally recognized MCI triage tool, Sort, Assess, Life-saving interventions, Treatment/transport (SALT), immediately following a brief training session, and again three months later. METHODS All students enrolled in the PCP, fire, and police foundation programs at two community colleges were invited to participate in a 30-minute didactic session on SALT. Immediately following this session, a 17-item, paper-based test was administered to assess the students' ability to understand and apply SALT. Three months later, the same test was given to assess knowledge retention. RESULTS Of the 464 trainees who completed the initial test, 364 (78.4%) completed the three month follow-up test. Initial test scores were higher (P<.05) for PCPs (87.0%) compared to fire (80.2%) and police (68.0%) trainees. The mean test score for all respondents was higher following the initial didactic session compared to the three month follow-up test (75% vs 64.7%; Δ 10.3%; 95% CI, 8.0%-12.6%). Three month test scores for PCPs (75.4%) were similar to fire (71.4%) students (Δ 4.0%; 95% CI, -2.1% to 10.1%). Both PCP and fire trainees significantly outperformed police (57.8%) trainees. Over-triage errors were the most common, followed by under-triage and then critical errors, for both the initial and follow-up tests. CONCLUSIONS Amongst first responder trainees, PCPs were able to apply the SALT triage tool with the most accuracy, followed by fire, then police. Over-triage was the most frequent error, while critical errors were rare.
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Arcos González P, Castro Delgado R, Cuartas Alvarez T, Garijo Gonzalo G, Martinez Monzon C, Pelaez Corres N, Rodriguez Soler A, Turegano Fuentes F. The development and features of the Spanish prehospital advanced triage method (META) for mass casualty incidents. Scand J Trauma Resusc Emerg Med 2016; 24:63. [PMID: 27130042 PMCID: PMC4850631 DOI: 10.1186/s13049-016-0255-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/22/2016] [Indexed: 11/10/2022] Open
Abstract
This text describes the process of development of the new Spanish Prehospital Advanced Triage Method (META) and explain its main features and contribution to prehospital triage systems in mass casualty incidents. The triage META is based in the Advanced Trauma Life Support (ATLS) protocols, patient’s anatomical injuries and mechanism of injury. It is a triage method with four stages including early identification of patients with severe trauma that would benefit from a rapid evacuation to a surgical facility and introduces a new patient flow by-passing the advanced medical post to improve evacuation. The stages of triage META are: I) Stabilization triage that classifies patients according to severity to set priorities for initial emergency treatment; II) Identifying patients requiring urgent surgical treatment, this is done at the same time than stage I and creates a new flow of patients with high priority for evacuation; III) Implementation of Advanced Trauma Life Support protocols to patients previously classified according to stablished priority; and IV) Evacuation triage, stablishing evacuation priorities in case of lacks of appropriate transport resources. The triage META is to be applied only by prehospital providers with advanced knowledge and training in advanced trauma life support care and has been designed to be implemented as prehospital procedure in mass casualty incidents (MCI).
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Affiliation(s)
- Pedro Arcos González
- Unit for Research in Emergency and Disaster, Department of Medicine, Universidad de Oviedo, Oviedo, Spain
| | - Rafael Castro Delgado
- Unit for Research in Emergency and Disaster, Department of Medicine, Universidad de Oviedo, Oviedo, Spain. .,SAMU-Asturias, Oviedo, Spain.
| | - Tatiana Cuartas Alvarez
- Unit for Research in Emergency and Disaster, Department of Medicine, Universidad de Oviedo, Oviedo, Spain.,SAMU-Asturias, Oviedo, Spain
| | | | | | | | - Alberto Rodriguez Soler
- School of Nursing Nuestra Señora de La Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
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Fukumoto Y, Inoue Y, Takeuchi Y, Hoshino T, Nakamura Y, Ishikawa K, Morikawa M, Suginaka H, Sueyoshi K, Sumi Y, Matsuda S, Okamoto K, Tanaka H. Utility of blood lactate level in triage. Acute Med Surg 2016; 3:101-106. [PMID: 29123760 PMCID: PMC5667377 DOI: 10.1002/ams2.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/05/2015] [Indexed: 11/11/2022] Open
Abstract
Aim Simple Triage and Rapid Treatment (START) is commonly used at disaster scenes. The Canadian Emergency Department Triage and Acuity Scale (CTAS) is used in urban and rural emergency departments (ED). However, triage is not always accurate or appropriate. The blood lactate level (BLL) is a major biomarker of physical status. We measured BLL using the Lactate Pro-1710 Test Meter in all patients transported to our ED and assessed their correlation with the triage level determined using START and the CTAS. Methods This retrospective study included 510 patients admitted to our ED between January 2011 and July 2012 whose BLL was measured. The patients were classified into triage divisions (green, yellow, red, and black) according to vital signs and chief complaints, and correlations among BLL, triage level, and prognosis were assessed in all groups. Results Of the total, 62 patients had cardiopulmonary arrest (CPA), 262 had internal pathologies, and 186 had external pathologies. Significant correlations were observed between BLL and both START and CTAS triage. Also BLL was significantly higher in severe patients categorized with START and CTAS (P < 0.0001), especially in the death group when the patients were divided into two groups according to prognosis (P < 0.0001). Two patients categorized yellow with START died during the hospitalization, however BLL of these two patients were high on admission at the ED. Conclusion BLL could be used to correct the triage level, and decide the priority of treatment and transportation even within the same triage level, thereby avoiding under-triage.
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Affiliation(s)
- Yuichi Fukumoto
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Yoshiaki Inoue
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Yuji Takeuchi
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Tetsuya Hoshino
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Yuki Nakamura
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Kohei Ishikawa
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Miki Morikawa
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Hiroshi Suginaka
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Koichiro Sueyoshi
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Yuka Sumi
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Shigeru Matsuda
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Ken Okamoto
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine Urayasu Hospital Juntendo University Urayasu Japan
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Abstract
INTRODUCTION During mass-casualty incidents (MCIs), patient volume often overwhelms available Emergency Medical Services (EMS) personnel. First responders are expected to triage, treat, and transport patients in a timely fashion. If other responders could triage accurately, prehospital EMS resources could be focused more directly on patients that require immediate medical attention and transport. HYPOTHESIS Triage accuracy, error patterns, and time to triage completion are similar between second-year primary care paramedic (PCP) and fire science (FS) students participating in a simulated MCI using the Sort, Assess, Life-saving interventions, Treatment/Transport (SALT) triage algorithm. METHODS All students in the second-year PCP program and FS program at two separate community colleges were invited to participate in this study. Immediately following a 30-minute didactic session on SALT, participants were given a standardized briefing and asked to triage an eight-victim, mock MCI using SALT. The scenario consisted of a four-car motor vehicle collision with each victim portrayed by volunteer actors given appropriate moulage and symptom coaching for their pattern of injury. The total number and acuity of victims were unknown to participants prior to arrival to the mock scenario. RESULTS Thirty-eight PCP and 29 FS students completed the simulation. Overall triage accuracy was 79.9% for PCP and 72.0% for FS (∆ 7.9%; 95% CI, 1.2-14.7) students. No significant difference was found between the groups regarding types of triage errors. Over-triage, under-triage, and critical errors occurred in 10.2%, 7.6%, and 2.3% of PCP triage assignments, respectively. Fire science students had a similar pattern with 15.2% over-triaged, 8.7% under-triaged, and 4.3% critical errors. The median [IQR] time to triage completion for PCPs and FSs were 142.1 [52.6] seconds and 159.0 [40.5] seconds, respectively (P=.19; Mann-Whitney Test). CONCLUSIONS Primary care paramedics performed MCI triage more accurately than FS students after brief SALT training, but no difference was found regarding types of error or time to triage completion. The clinical importance of this difference in triage accuracy likely is minimal, suggesting that fire services personnel could be considered for MCI triage depending on the availability of prehospital medical resources and appropriate training.
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Timbie JW, Ringel JS, Fox DS, Pillemer F, Waxman DA, Moore M, Hansen CK, Knebel AR, Ricciardi R, Kellermann AL. Systematic review of strategies to manage and allocate scarce resources during mass casualty events. Ann Emerg Med 2013; 61:677-689.e101. [PMID: 23522610 PMCID: PMC6997611 DOI: 10.1016/j.annemergmed.2013.02.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 01/30/2013] [Accepted: 02/04/2013] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVE Efficient management and allocation of scarce medical resources can improve outcomes for victims of mass casualty events. However, the effectiveness of specific strategies has never been systematically reviewed. We analyze published evidence on strategies to optimize the management and allocation of scarce resources across a wide range of mass casualty event contexts and study designs. METHODS Our literature search included MEDLINE, Scopus, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, and the Cochrane Database of Systematic Reviews, from 1990 through late 2011. We also searched the gray literature, using the New York Academy of Medicine's Grey Literature Report and key Web sites. We included both English- and foreign-language articles. We included studies that evaluated strategies used in actual mass casualty events or tested through drills, exercises, or computer simulations. We excluded studies that lacked a comparison group or did not report quantitative outcomes. Data extraction, quality assessment, and strength of evidence ratings were conducted by a single researcher and reviewed by a second; discrepancies were reconciled by the 2 reviewers. Because of heterogeneity in outcome measures, we qualitatively synthesized findings within categories of strategies. RESULTS From 5,716 potentially relevant citations, 74 studies met inclusion criteria. Strategies included reducing demand for health care services (18 studies), optimizing use of existing resources (50), augmenting existing resources (5), implementing crisis standards of care (5), and multiple categories (4). The evidence was sufficient to form conclusions on 2 strategies, although the strength of evidence was rated as low. First, as a strategy to reduce demand for health care services, points of dispensing can be used to efficiently distribute biological countermeasures after a bioterrorism attack or influenza pandemic, and their organization influences speed of distribution. Second, as a strategy to optimize use of existing resources, commonly used field triage systems do not perform consistently during actual mass casualty events. The number of high-quality studies addressing other strategies was insufficient to support conclusions about their effectiveness because of differences in study context, comparison groups, and outcome measures. Our literature search may have missed key resource management and allocation strategies because of their extreme heterogeneity. Interrater reliability was not assessed for quality assessments or strength of evidence ratings. Publication bias is likely, given the large number of studies reporting positive findings. CONCLUSION The current evidence base is inadequate to inform providers and policymakers about the most effective strategies for managing or allocating scarce resources during mass casualty events. Consensus on methodological standards that encompass a range of study designs is needed to guide future research and strengthen the evidence base. Evidentiary standards should be developed to promote consensus interpretations of the evidence supporting individual strategies.
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Catlett CL, Jenkins JL, Millin MG. Role of emergency medical services in disaster response: resource document for the National Association of EMS Physicians position statement. PREHOSP EMERG CARE 2011; 15:420-5. [PMID: 21480774 DOI: 10.3109/10903127.2011.561401] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The National Association of EMS Physicians (NAEMSP) advocates for a strong emergency medical services (EMS) role in all phases of disaster management--preparedness, response, and recovery. Emergency medical services administrators and medical directors should play a leadership role in preparedness activities such as training and education, development of performance metrics, establishment of memoranda of understanding (MOUs), and planning for licensure and liability issues. During both the planning and response phases, EMS leadership should advocate for participation in unified command, modified scope of practice appropriate for providers and the event, and expanded roles in community and federal response efforts. To enhance recovery, EMS leadership should strongly advocate for national recognition for EMS efforts and further research into strategies that foster healthy coping techniques and resiliency in the EMS workforce. This resource document will outline the basis for the corresponding NAEMSP position statement on the role of EMS in disaster management.
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Affiliation(s)
- Christina L Catlett
- Johns Hopkins Office of Critical Event Preparedness and Response and Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21209, USA.
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Triaje in situ extrahospitalario. Semergen 2011. [DOI: 10.1016/j.semerg.2010.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Characteristics and triage of a maritime disaster: an accidental passenger ship collision in Korea. Eur J Emerg Med 2009; 17:177-80. [PMID: 19704375 DOI: 10.1097/mej.0b013e328330f452] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to analyze the characteristics of and responses to a maritime disaster, by reviewing the events surrounding the accidental collision of a high-speed passenger ship in South Korea. Of the 215 boarded passengers on a high-speed passenger ship sailing from Fukuoka to Busan, we retrospectively examined information of 114 victims of the ship's collision with a whale on 12 April 2007. We referenced reports from the on-site disaster medical assistance team members; recorded notifications to the Busan 1339 Emergency Medical Information Centre, from the scene of the accident and data from the ship's insurer. The 114 victims were transported to 20 different hospitals. Many patients were transported to nearby local hospitals from the scene of the accident; other patients were transported to more distant hospitals. Eighty-five patients were transported to hospitals through mobile emergency support units, whereas the other patients were transported directly by fire officers from the 119 Fire Officer Centre. One patient died in the transport. In conclusion, our national emergency medical service and disaster response system each suffer from many problems - especially a lack of cooperation among related departments and insufficient communication therein. The onboard planning and practice of a disaster plan is required, and a reliable information system between the scene of a maritime disaster and our emergency medical service system should be developed.
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Vincent DS, Burgess L, Berg BW, Connolly KK. Teaching Mass Casualty Triage Skills Using Iterative Multimanikin Simulations. PREHOSP EMERG CARE 2009; 13:241-6. [DOI: 10.1080/10903120802706088] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kahn CA, Schultz CH, Miller KT, Anderson CL. Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med 2009; 54:424-30, 430.e1. [PMID: 19195739 DOI: 10.1016/j.annemergmed.2008.12.035] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2008] [Revised: 12/05/2008] [Accepted: 12/19/2008] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE The mass casualty triage system known as simple triage and rapid treatment (START) has been widely used in the United States since the 1980s. However, no outcomes assessment has been conducted after a disaster to determine whether assigned triage levels match patients' actual clinical status. Researchers hypothesize that START achieves at least 90% sensitivity and specificity for each triage level and ensures that the most critical patients are transported first to area hospitals. METHODS The performance of START was evaluated at a train crash disaster in 2003. Patient field triage categories and scene times were obtained from county reports. Patient medical records were then reviewed at all receiving hospitals. Victim arrival times were obtained and correct triage categories determined a priori using a combination of the modified Baxt criteria and hospital admission. Field and outcomes-based triage categories were compared, defining the appropriateness of each triage assignment. RESULTS Investigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventy-nine patients were overtriaged, 3 were undertriaged, and 66 patients' outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% confidence interval [CI] 16% to 100%) and green was 89.3% specific (95% CI 72% to 98%). The Obuchowski statistic was 0.81, meaning that victims from a higher-acuity outcome group had an 81% chance of assignment to a higher-acuity triage category. The median arrival time for red patients was more than 1 hour earlier than the other patients. CONCLUSION This analysis demonstrates poor agreement between triage levels assigned by START at a train crash and a priori outcomes criteria for each level. START ensured acceptable levels of undertriage (100% red sensitivity and 89% green specificity) but incorporated a substantial amount of overtriage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.
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Affiliation(s)
- Christopher A Kahn
- Department of Emergency Medicine, University of California, Irvine, Orange, CA 92868, USA.
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Claudius I, Behar S, Ballow S, Wood R, Stevenson K, Blake N, Upperman JS. Disaster Drill Exercise Documentation and Management: Are We Drilling to Standard? J Emerg Nurs 2008; 34:504-8. [DOI: 10.1016/j.jen.2008.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Accepted: 03/24/2008] [Indexed: 10/21/2022]
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Affiliation(s)
- David J Barillo
- U.S. Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas 78234, USA
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