The civilian validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to primary major incident triage

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.

Comparative analysis of major incident triage tools in children: a UK population-based analysis

INTRODUCTION

Triage is a key principle in the effective management of major incidents. There is currently a paucity of evidence to guide the triage of children. The aim of this study was to perform a comparative analysis of nine adult and paediatric triage tools, including the novel 'Sheffield Paediatric Triage Tool' (SPTT), assessing their ability in identifying patients needing life-saving interventions (LSIs).

METHODS

A 10-year (2008-2017) retrospective database review of the Trauma Audit Research Network (TARN) Database for paediatric patients (<16 years) was performed. Primary outcome was identification of patients receiving one or more LSIs from a previously defined list. Secondary outcomes included mortality and prediction of Injury Severity Score (ISS) >15. Primary analysis was conducted on patients with complete prehospital physiological data with planned secondary analyses using first recorded data. Performance characteristics were evaluated using sensitivity, specificity, undertriage and overtriage.

RESULTS

15 133 patients met TARN inclusion criteria. 4962 (32.8%) had complete prehospital physiological data and 8255 (54.5%) had complete first recorded physiological data. The majority of patients were male (69.5%), with a median age of 11.9 years. The overwhelming majority of patients (95.4%) sustained blunt trauma, yielding a median ISS of 9 and overall, 875 patients (17.6%) received at least one LSI. The SPTT demonstrated the greatest sensitivity of all triage tools at identifying need for LSI (92.2%) but was associated with the highest rate of overtriage (75.0%). Both the Paediatric Triage Tape (sensitivity 34.1%) and JumpSTART (sensitivity 45.0%) performed less well at identifying LSI. By contrast, the adult Modified Physiological Triage Tool-24 (MPTT-24) triage tool had the second highest sensitivity (80.8%) with tolerable rates of overtriage (70.2%).

CONCLUSION

The SPTT and MPTT-24 outperform existing paediatric triage tools at identifying those patients requiring LSIs. This may necessitate a change in recommended practice. Further work is needed to determine the optimum method of paediatric major incident triage, but consideration should be given to simplifying major incident triage by the use of one generic tool (the MPTT-24) for adults and children.

A translational triage research development tool: standardizing prehospital triage decision-making systems in mass casualty incidents

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.

Relationship between the Injury Severity Score and the need for life-saving interventions in trauma patients in the UK

INTRODUCTION

Major trauma is the third leading cause of avoidable mortality in the UK. Defining which patients require care in a major trauma centre is a critical component of developing, evaluating and enhancing regional major trauma systems. Traditionally, trauma patients have been classified using the Injury Severity Score (ISS), but resource-based criteria have been proposed as an alternative. The aim of this study was to investigate the relationship between ISS and the use of life-saving interventions (LSI).

METHODS

Retrospective cohort study using the Trauma Audit Research Network database for all adult patients (aged ≥18 years) between 2006 and 2014. Patients were categorised as needing an LSI if they received one or more interventions from a previously defined list determined by expert consensus.

RESULTS

193 290 patients met study inclusion criteria: 56.9% male, median age 60.0 years (IQR 41.2-78.8) and median ISS 9 (IQR 9-16). The most common mechanism of injury was falls <2 m (52.1%), followed by road traffic collisions (22.2%). 15.1% received one or more LSIs. The probability of a receiving an LSI increased with increasing ISS, but only a low to moderate correlation was evident (0.334, p<0.001). A clinically significant number of cases (5.3% and 7.6%) received an LSI despite having an ISS ≤8 or <15, respectively.

CONCLUSIONS

A clinically significant number of adult trauma patients requiring LSIs have an ISS below the traditional definition of major trauma. The traditional definition should be reconsidered and either lowered, or an alternative metric should be used.

Major incident triage and the evaluation of the Triage Sort as a secondary triage method

INTRODUCTION

A key principle in the effective management of major incidents is triage, the process of prioritising patients on the basis of their clinical acuity. In many countries including the UK, a two-stage approach to triage is practised, with primary triage at the scene followed by a more detailed assessment using a secondary triage process, the Triage Sort. To date, no studies have analysed the performance of the Triage Sort in the civilian setting. The primary aim of this study was to determine the performance of the Triage Sort at predicting the need for life-saving intervention (LSI).

METHODS

Using the Trauma Audit Research Network (TARN) database for all adult patients (>18 years) between 2006 and 2014, we determined which patients received one or more LSIs using a previously defined list. The first recorded hospital physiology was used to categorise patient priority using the Triage Sort, National Ambulance Resilience Unit (NARU) Sieve and the Modified Physiological Triage Tool-24 (MPTT-24). Performance characteristics were evaluated using sensitivity and specificity with statistical analysis using a McNemar's test.

RESULTS

127 233patients (58.1%) had complete data and were included: 55.6% men, aged 61.4 (IQR 43.1-80.0 years), ISS 9 (IQR 9-16), with 24 791 (19.5%) receiving at least one LSI (priority 1). The Triage Sort demonstrated the lowest accuracy of all triage tools at identifying the need for LSI (sensitivity 15.7% (95% CI 15.2 to 16.2) correlating with the highest rate of under-triage (84.3% (95% CI 83.8 to 84.8), but it had the greatest specificity (98.7% (95% CI 98.6 to 98.8).

CONCLUSION

Within a civilian trauma registry population, the Triage Sort demonstrated the poorest performance at identifying patients in need of LSI. Its use as a secondary triage tool should be reviewed, with an urgent need for further research to determine the optimum method of secondary triage.

Major incident simulation in Rwanda: A report of two exercises

INTRODUCTION

Healthcare systems must be equipped to handle major incidents. Few have been described in the African setting, including in Rwanda. The purpose of this case report was to describe and discuss two major incident simulations in Rwanda with different challenges.

CASE REPORT

We report two recent major incident exercises conducted in Rwanda, in 2017. The exercises exemplify two different types of multiple casualty incidents requiring the deployment of extra-ordinary resources, one due to the location of the incident (off-shore), and the other due to the large volume of casualties. Both exercises required extensive multi-agency planning and training beforehand, as part of an increasing awareness of the need for preparedness for these types of incidents.

CONCLUSION

The exercises demonstrated the need for a standardised, physiological method of triage based on clinical needs; this is in order to maximise the number of lives saved. Triage training should be an integral part of further major incident exercises, which should be conducted regularly.

Triage and the Modified Physiological Triage Tool-24 (MPTT-24)

Major incidents occur on a regular basis. So far in 2017, England has witnessed five terrorism-related major incidents, resulting in approximately 40 fatalities and 400 injured. Triage is a key principle in the effective management of a major incident and involves prioritising patients on the basis of their clinical acuity. This paper describes the limitations associated with existing methods of primary major incident triage and the process of developing a new and improved triage tool-the Modified Physiological Triage Tool-24 (MPTT-24). Whilst the MPTT-24 is likely to be the optimum physiological method for primary major incident triage, it needs to be accompanied by an appropriate secondary triage process. The existing UK military and civilian secondary triage tool, the Triage Sort, is described, which offers little advantage over primary methods for identifying patients who require life-saving intervention. Further research is required to identify the optimum method of secondary triage.

Major incident triage and the implementation of a new triage tool, the MPTT-24

Introduction

The Modified Physiological Triage Tool (MPTT) is a recently developed primary triage tool and in comparison with existing tools demonstrates the greatest sensitivity at predicting need for life-saving intervention (LSI) within both military and civilian populations. To improve its applicability, we proposed to increase the upper respiratory rate (RR) threshold to 24 breaths per minute (bpm) to produce the MPTT-24. Our aim was to conduct a feasibility analysis of the proposed MPTT-24, comparing its performance with the existing UK Military Sieve.

Method

A retrospective review of the Joint Theatre Trauma Registry (JTTR) and Trauma Audit Research Network (TARN) databases was performed for all adult (>18 years) patients presenting between 2006–2013 (JTTR) and 2014 (TARN). Patients were defined as priority one (P1) if they received one or more LSIs. Using first recorded hospital RR in isolation, sensitivity and specificity of the ≥24 bpm threshold was compared with the existing threshold (≥22 bpm) at predicting P1 status. Patients were then categorised as P1 or not-P1 by the MPTT, MPTT-24 and the UK Military Sieve.

Results

The MPTT and MPTT-24 outperformed existing UK methods of triage with a statistically significant (p<0.001) increase in sensitivity of between 25.5% and 29.5%. In both populations, the MPTT-24 demonstrated an absolute reduction in sensitivity with an increase in specificity when compared with the MPTT. A statistically significant difference was observed between the MPTT and MPTT-24 in the way they categorised TARN and JTTR cases as P1 (p<0.001).

Conclusions

When compared with the existing MPTT, the MPTT-24 allows for a more rapid triage assessment. Both continue to outperform existing methods of primary major incident triage and within the military setting, the slight increase in undertriage is offset by a reduction in overtriage. We recommend that the MPTT-24 be considered as a replacement to the existing UK Military Sieve.