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Chia JS, Chang C, Lo SC, Yang CH, Yang HY. Healthcare failure mode and effect analysis combined service blueprint - Mitigating mass casualty triage in emergency units: A qualitative study. Int Emerg Nurs 2024; 77:101508. [PMID: 39236663 DOI: 10.1016/j.ienj.2024.101508] [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: 05/22/2023] [Revised: 08/05/2024] [Accepted: 08/17/2024] [Indexed: 09/07/2024]
Abstract
INTRODUCTION The 24-hour operation of medical emergency units involves crucial first-hand information and medical treatments, which could involve potential complications and disputes if not handled with the utmost professionalism. Effective logistical support and timely activation are crucial in mass casualty triage to prevent systematic treatment issues and chaos. OBJECTIVE This study explores the integration of Healthcare Failure Mode and Effect Analysis (HFMEA) with a service blueprint to mitigate medical risks and enhance mass casualty triage efficiency in emergency units. METHOD An expert team analyzed emergency unit standard operating procedure cases using a service blueprint to visually represent mass casualty triage scenarios. The HFMEA identified potential hazards and failure risks in healthcare service delivery during mass casualty triage. RESULTS Fifteen high-risk hazard indexes exceeding the standard score of eight were identified among three main processes and thirty-one potential failure reasons. The initial operational time for mass casualty triage was approximately 104 min, significantly reduced to 34 min after process revision (p = 0.043, <0.05). CONCLUSIONS This study demonstrates effective time management in mass casualty triage, potentially saving up to an hour. Improved operational efficiency allows for focused resuscitation efforts, alleviating concerns about timely patient flow initiation.
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Affiliation(s)
- Jen-Shu Chia
- Ph.D. Program of Management, Chung Hua University, Hsinchu 30012, Taiwan, ROC.
| | - Ching Chang
- Department of Business Administration, Chung Hua University, Hsinchu 30012, Taiwan, ROC.
| | - Shih-Ching Lo
- Department of Business Administration, Chung Hua University, Hsinchu 30012, Taiwan, ROC.
| | - Chen-Hsuan Yang
- Industry-University Education Center Director, Chung Hua University, Hsinchu 30012, Taiwan, ROC.
| | - Hui-Yu Yang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan, ROC; Department of Maritime Patrol, Taiwan Police College, Taipei 11695, Taiwan, ROC.
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Olinga D, Oyania F, Bagonza K, Odakha JA, Balu MC, Mwanje W, Flanery A, Okello A, Musau EM, Kizito PM. Characteristics of paediatric injuries as predictors of 24-hour disposition from the Emergency Department of a teaching hospital in Southwestern Uganda. Afr J Emerg Med 2024; 14:224-230. [PMID: 39262425 PMCID: PMC11388695 DOI: 10.1016/j.afjem.2024.08.001] [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: 04/03/2024] [Revised: 08/04/2024] [Accepted: 08/08/2024] [Indexed: 09/13/2024] Open
Abstract
Background Paediatric injuries are among the leading causes of morbidity and mortality globally, especially in low- and middle-income countries. We aimed to characterize paediatric injuries as predictors of disposition from Mbarara Regional Referral Hospital Emergency Department (ED) Southwestern Uganda. Methods This was a prospective cohort study done from 12th December 2022 to 31st March 2023. We described the characteristics of injuries sustained by children and evaluated the predictors of 24-hour disposition from the ED using logistic regression. Results Of the 160 children followed up, 64.4% were male with a median age of 7 years, brought in with road traffic accidents (RTAs) (40.6%) and falls (35.6%) as the commonest mechanism of injury. Over half of the patients were triaged as yellow (urgent); polytrauma and head injuries were the top injury patterns. The majority (45.6%) of the children were admitted to the inpatient surgical ward. Only 1.9% and 5.0% ended up in intensive care unit (ICU) and died (to mortuary), respectively. The median time to disposition was 8 h and 14% stayed in the ED beyond 24-hours. Patients who needed more intensive initial treatment, including additional medications or interventions, were significantly more likely to be admitted to the ward (AOR= 5.3, 95%CI: 2.0-13.0, p <0.01). Conclusion Paediatric injuries were caused mainly by RTAs and presenting with polytrauma and head injuries. Most patients were disposed of to the inpatient surgical ward within 24 h with severe KTS and initial management being strongest predictors of admission. These findings can be used to tailor quick risk stratification and decision-making tools and improve ED disposition of paediatric injuries in Low- and Middle- income countries.
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Affiliation(s)
- Daniel Olinga
- Mbarara University of Science and Technology, Faculty of Medicine, Emergency medicine Department, Uganda
- Mbarara Regional Referral Hospital, Uganda
| | - Felix Oyania
- Mbarara University of Science and Technology, Faculty of Medicine, Surgery Department, Uganda
- Mbarara Regional Referral Hospital, Uganda
| | - Kenneth Bagonza
- Mbarara University of Science and Technology, Faculty of Medicine, Emergency medicine Department, Uganda
- Mbarara Regional Referral Hospital, Uganda
- Seed Global Health, Uganda
| | - Justine Athieno Odakha
- Mbarara University of Science and Technology, Faculty of Medicine, Emergency medicine Department, Uganda
- Mbarara Regional Referral Hospital, Uganda
| | - Mabiala Constant Balu
- Mbarara University of Science and Technology, Faculty of Medicine, Emergency medicine Department, Uganda
- Mbarara Regional Referral Hospital, Uganda
| | | | - Andrew Flanery
- Mbarara University of Science and Technology, Faculty of Medicine, Emergency medicine Department, Uganda
- Mbarara Regional Referral Hospital, Uganda
- Seed Global Health, Uganda
| | - Ambrose Okello
- Mbarara University of Science and Technology, Faculty of Medicine, Emergency medicine Department, Uganda
- Mbarara Regional Referral Hospital, Uganda
| | - Evelyn Mwende Musau
- Mbarara University of Science and Technology, Faculty of Medicine, Emergency medicine Department, Uganda
- Mbarara Regional Referral Hospital, Uganda
| | - Prisca Mary Kizito
- Mbarara University of Science and Technology, Faculty of Medicine, Emergency medicine Department, Uganda
- Mbarara Regional Referral Hospital, Uganda
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Shrestha GS, Battaglini D, Sodhi K, Schultz MJ. Medical Triage: Ethical Implications and Management Strategies. Anesthesiol Clin 2024; 42:457-472. [PMID: 39054020 DOI: 10.1016/j.anclin.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Natural or man-made medical disasters have repeatedly affected human communities. The impact on health care resources may vary depending on the magnitude of each crisis, catastrophe or pandemic, and the resources available. Medical triage protocols serve as invaluable tools to address clinical needs, particularly when resources, including supplies, equipment, and personnel, are limited. Although resources should be allocated to maximize the benefit, resource allocations need to be ethically sound. Existing triage protocols have inherent limitations.
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Affiliation(s)
- Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
| | - Denise Battaglini
- Department of Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, the Netherlands; Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK; Division of Cardiothoracic and Vascular Anesthesia & Critical Care Medicine, Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
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Lamine H, Markou-Pappas N, Ragazzoni L, Caviglia M. Key performance indicators and benchmarks in MCI prehospital response using technological tools: a qualitative study assessing the perception of practitioners and tool developers. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02627-3. [PMID: 39172151 DOI: 10.1007/s00068-024-02627-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 07/26/2024] [Indexed: 08/23/2024]
Abstract
PURPOSE The aim of this study is to investigate the opinions and perspectives of The Novel Integrated Toolkit for Enhanced Prehospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE) end-users and tool developers regarding Key Performance Indicators (KPIs) and benchmarks that assess the prehospital response to Mass Casualty Incidents (MCIs) enhanced by the NIT-MR. METHODS A qualitative study employing focus group discussions was conducted to collect opinions and perspectives of end-users and tool developers regarding KPIs and benchmarks in MCI response using the NIT-MR. The criteria considered for the selection and distribution of participants within the groups was the nature of their involvement within the NIGHTINGALE project and their familiarity with the tools to be discussed. RESULTS Thirty-one participants from different countries were included. Four themes emerged during data analysis which are: definition/explanation is the personal understanding of participants of the term KPI, process of KPI development and relationship with User Requirements is the decision process for assigning KPIs to user requirements, benchmarking is the mental process of associating a benchmark to a KPI or for developing a benchmark, and technical/medical gap is the gap of understanding between each sides' fields. CONCLUSION This study emphasized the need for a structured approach to using KPIs and bridging the gap between technological and medical worlds, taking the NIGHTINGALE project, funded by the European Union, which aims to develop a technological toolkit for first responders in mass casualty incidents as an example. These insights are crucial for enhancing disaster response.
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Affiliation(s)
- Hamdi Lamine
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and GlobalHealth, Università del Piemonte Orientale IT, Vercelli, Italy.
- Department of Community Health Nursing, College of Nursing, University of Hail, Hail, Saudi Arabia.
| | - Nikolaos Markou-Pappas
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and GlobalHealth, Università del Piemonte Orientale IT, Vercelli, Italy
- Department of Translational Medicine, Università del Piemonte Orientale IT, Vercelli, Italy
| | - Luca Ragazzoni
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and GlobalHealth, Università del Piemonte Orientale IT, Vercelli, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte OrientaleIT, Vercelli, Italy
| | - Marta Caviglia
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and GlobalHealth, Università del Piemonte Orientale IT, Vercelli, Italy
- Department of Translational Medicine, Università del Piemonte Orientale IT, Vercelli, Italy
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Vernon TE, April MD, Fisher AD, Rizzo JA, Long BJ, Schauer SG. An Assessment of Clinical Accuracy of Vital Sign-based Triage Tools Among U.S. and Coalition Forces. Mil Med 2024; 189:e1528-e1536. [PMID: 38285545 DOI: 10.1093/milmed/usad500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Early appropriate allocation of resources for critically injured combat casualties is essential. This is especially important when inundated with an overwhelming number of casualties where limited resources must be efficiently allocated, such as during mass casualty events. There are multiple scoring systems utilized in the prehospital combat setting, including the shock index (SI), modified shock index (MSI), simple triage and rapid treatment (START), revised trauma score (RTS), new trauma score (NTS), Glasgow Coma Scale + age + pressure (GAP), and the mechanism + GAP (MGAP) score. The optimal score for application to the combat trauma population remains unclear. MATERIALS AND METHODS This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry from January 1, 2007 through March 17, 2020. We constructed univariable analyses to determine the area under the receiving operator characteristic (AUROC) for the scoring systems of interest. Our primary outcomes were early death (within 24 hours) or early massive transfusion, as defined by ≥3 units. RESULTS There were 12,268 casualties that met inclusion criteria. There were 168 (1%) who died within the first 24 hours and 2082 (17%) that underwent significant transfusion within the first 24 hours. When assessing the predictive capabilities for death within 24 hours, the AUROCs were 0.72 (SI), 0.69 (MSI), 0.89 (START), 0.90 (RTS), 0.83 (NTS), 0.90 (GAP), and 0.91 (MGAP). The AUROCs for massive transfusion were 0.89 (SI), 0.89 (MSI), 0.82 (START), 0.81 (RTS), 0.83 (NTS), 0.85 (MGAP), and 0.86 (GAP). CONCLUSIONS This study retrospectively applied seven triage tools to a database of 12,268 cases from the Department of Defense Trauma Registry to evaluate their performance in predicting early death or massive transfusion in combat. All scoring systems performed well with an AUROC >0.8 for both outcomes. Although the SI and MSI performed best for predicting massive transfusion (both had an AUROC of 0.89), they ranked last for assessment of mortality within 24 hours, with the other tools performing well. START, RTS, NTS, MGAP and GAP reliably identified early death and need for massive transfusion, with MGAP and GAP performing the best overall. These findings highlight the importance of assessing triage tools to best manage resources and ultimately preserve lives of traumatically wounded warfighters. Further studies are needed to explain the surprising performance discrepancy of the SI and MSI in predicting early death and massive transfusion.
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Affiliation(s)
- Tate E Vernon
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Michael D April
- 14th Field Hospital, Fort Stewart, GA 31314, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87106, USA
| | - Julie A Rizzo
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Brit J Long
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Steven G Schauer
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
- Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO 80045, USA
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Alison L, Shortland N, Herrod-Taylor C, Stevens C, Christiansen P. Medical maximization: The effect of personality on triage decision-making. Soc Sci Med 2024; 352:117006. [PMID: 38850677 DOI: 10.1016/j.socscimed.2024.117006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 06/10/2024]
Abstract
Mass Casualty Incidents (MCIs) rapidly overwhelm the ability of local medical resources to deliver comprehensive and definitive medical care and they have been occurring more frequently in recent decades and affect countries of all socioeconomic backgrounds (Hart et al., 2018). As such, it is important to understand how individuals make such decisions in these events and what factors can hinder or help the process. In this study we focused on the critical role of maximization within MCI triage. Triaging an MCI requires juggling the demand and supply of resources, time, and focus, likely leading to various decisions involving compromise/sacrifice. In a vignette study, hosted on Amazon Mturk (n = 235, Mean age = 38.05, 51.49% self-identified as male), which involved triaging over 100 patients we found that trait differences maximization impacted the willingness to use a "black tag". Furthermore, maximization also impacted how much information an individual needed about the patient before being willing to use a black tag. Overall, this research demonstrates the importance of understanding factors that create individual differences in how people make decisions during MCI events, especially those decisions that involve the use of potentially lifesaving treatments.
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Affiliation(s)
- Laurence Alison
- Institute for Risk and Uncertainty, Department of Psychology, University of Liverpool, USA
| | - Neil Shortland
- School of Criminology and Justice Studies, University of Massachusetts Lowell, USA.
| | - Cicely Herrod-Taylor
- Institute for Risk and Uncertainty, Department of Psychology, University of Liverpool, USA
| | - Catherine Stevens
- School of Criminology and Justice Studies, University of Massachusetts Lowell, USA
| | - Paul Christiansen
- Institute for Risk and Uncertainty, Department of Psychology, University of Liverpool, USA
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Lord S, Lee J. Critical Care in the Austere Environment. Crit Care Clin 2024; 40:451-462. [PMID: 38796220 DOI: 10.1016/j.ccc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Practice of critical care in austere settings involves navigating rapidly evolving environments, where physical resources, provider availability, and healthcare capacity are constrained. Austere Critical Care focuses on maintaining the highest standard of care possible for patients while also identifying resource limitations, responding to patient surges, and adhering to proper triage practices at the austere site. This includes transferring the patient when able and necessary. This article describes the current practice of critical care medicine in the austere environment, using recent natural disasters, pandemics, and conflicts as case studies.
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Affiliation(s)
- Spencer Lord
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Quah JLJ, Bierens J, Anantharaman V. Evaluation of an On-Site Disaster Medical Management Course in Nepal. Healthcare (Basel) 2024; 12:1308. [PMID: 38998843 PMCID: PMC11241171 DOI: 10.3390/healthcare12131308] [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: 06/12/2024] [Revised: 06/26/2024] [Accepted: 06/28/2024] [Indexed: 07/14/2024] Open
Abstract
The great 2015 Nepal earthquake of magnitude 7.6 killed about 9000 people. To better ensure a more coordinated disaster response, a Basic On-Site Disaster Medical Support (BOS-DMS) course was designed in 2017. This study evaluates the effectiveness of the BOS-DM course. The course was conducted twice and attended by 135 participants, of whom 113 (83.7%) answered pre-test and post-test based multiple-choice questions. Qualitative and quantitative feedback was provided by 94 participants (69.6%). Mean test scores for the participants increased from 4.24 ± 1.42 to 6.55 ± 2.16 (p-value < 0.0001; paired t-test). More than 92.0% of participants felt that the course prepared healthcare workers to manage acute medical situations at a disaster site. Subject knowledge scores increased from 34.8% to 90.2%. A three-day BOS_DMS course has the potential to improve on-site disaster management knowledge. Our study noted that precise scheduling, making attendance compulsory, translating course materials into the local language, inclusion of disaster exercises and training local master trainers can enhance course effectiveness.
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Affiliation(s)
- Joy Li-Juan Quah
- Department of Emergency Medicine, Singapore General Hospital, Emergency Medicine Academic Clinical Programme, Duke-NUS Academic Medical Centre, 1 Outram Road, Singapore 169608, Singapore
| | - Joost Bierens
- Research Group Emergency and Disaster Medicine, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
| | - Venkataraman Anantharaman
- Department of Emergency Medicine, Singapore General Hospital, Emergency Medicine Academic Clinical Programme, Duke-NUS Academic Medical Centre, 1 Outram Road, Singapore 169608, Singapore
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Yari A, Hassanzadeh H, Akhbari K, Motlagh ME, Rahmani K, Zarezadeh Y. Hospital preparedness assessment for road traffic accidents with mass casualties: a cross-sectional study in Kurdistan Province, Iran. BMC Emerg Med 2024; 24:68. [PMID: 38649853 PMCID: PMC11036739 DOI: 10.1186/s12873-024-00981-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Road traffic accidents (RTAs) are predicted to become the world's seventh leading cause of death by 2030. Given the significant impact of RTAs on public health, effective hospital preparedness plays a pivotal role in managing and mitigating associated health and life-threatening issues. This study aims to meticulously evaluate the preparedness of selected hospitals in western Iran to handle road traffic accidents with mass casualties (RTAs-MC). METHODS The study employed a descriptive-analytical approach, utilizing a reliable and valid questionnaire to measure hospitals' preparedness levels. Descriptive statistics (frequency distribution and mean) were utilized to provide an overview of the data, followed by analytical statistics (Spearman correlation test) to examine the relationship between hospital preparedness and its dimensions with the hospital profile. Data analysis, performed using SPSS software, categorized preparedness levels as weak, moderate, or high. RESULTS The study found that hospitals in Kurdistan province had a favorable preparedness level (70.30) to respond to RTAs-MC. The cooperation and coordination domain had the highest preparedness level (98.75), while the human resource management (59.44) and training and exercise (54.00) domains had the lowest preparedness levels. The analysis revealed a significant relationship between hospital preparedness and hospital profile, including factors such as hospital specialty, number of beds, ambulances, staff, and specialized personnel, such as emergency medicine specialists. CONCLUSION Enhancing preparedness for RTAs-MC necessitates developing response plans to improve hospital profile, considering the region's geographic and topographic features, utilizing past experiences and lessons learned, implementing of Hospital Incident Command System (HICS), providing medical infrastructure and equipment, establishing communication channels, promoting cooperation and coordination, and creating training and exercise programs.
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Affiliation(s)
- Arezoo Yari
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
- Department of Health in Emergencies and Disasters, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Hamed Hassanzadeh
- Department of Health in Emergencies and Disasters, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Kourosh Akhbari
- Department of Emergency Medicine, Kosar Hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | | | - Khaled Rahmani
- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Yadolah Zarezadeh
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran.
- Department of Medical Education, Medical School, Pasdaran Ave, Kurdistan University of Medical Sciences, 66186-34683, Sanandaj, Iran.
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Tiyawat G, Liu JM, Huabbangyang T, Roza-Alonso CL, Castro-Delgado R. Comparative Analysis of META and SALT Disaster Triage in an Adult Trauma Population: A Retrospective Observational Study. Prehosp Disaster Med 2024; 39:142-150. [PMID: 38404235 PMCID: PMC11035921 DOI: 10.1017/s1049023x24000098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/17/2024] [Accepted: 01/24/2024] [Indexed: 02/27/2024]
Abstract
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.
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Affiliation(s)
- Gawin Tiyawat
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - J. Marc Liu
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WisconsinUSA
| | - Thongpitak Huabbangyang
- Department of Disaster and Emergency Medical Operation, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - Cesar Luis Roza-Alonso
- Health Service of the Principality of Asturias (SAMU-Asturias), Health Research Institute of the Principality of Asturias (Research Group on Prehospital Care and Disasters, GIAPREDE), Oviedo, Spain
| | - Rafael Castro-Delgado
- Health Service of the Principality of Asturias (SAMU-Asturias), Health Research Institute of the Principality of Asturias (Research Group on Prehospital Care and Disasters, GIAPREDE), Oviedo, Spain
- Department of Medicine, Oviedo University, Oviedo, Spain
- RINVEMER-SEMES (Research Network on Prehospital Care-Spanish Society of Emergency Medicine), Madrid, Spain
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Harada S, Suga R, Suzuki K, Kitano S, Fujimoto K, Narikawa K, Nakazawa M, Ogawa S. Usefulness of Self-Selected Scenarios for Simple Triage and Rapid Treatment Method Using Virtual Reality. J NIPPON MED SCH 2024; 91:99-107. [PMID: 38072419 DOI: 10.1272/jnms.jnms.2024_91-111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND Repeated triage training is necessary to maintain and improve the accuracy of simple triage and rapid treatment (START), a popular triage method. Virtual reality (VR) may be more effective than conventional training methods. This study aimed to verify the educational usefulness of START using VR originally developed for students. METHODS A VR was initially developed with a function that allowed students to select the triage procedure and its evaluation. Triage was performed using a simple modified START method, and eight scenarios were developed. The participants included 70 paramedic students classified into VR and live lecture groups. They took a 20-question written test that evaluated their academic ability before the course. After the course, a practical test and a 20-question written test were conducted. The total score of the practical test was 43 points. Triage procedure (1 point), observation and evaluation (1-5 points), and triage categories (1 point) were evaluated in this test. RESULTS The VR and live lecture groups consisted of 33 and 29 participants, respectively. No significant differences were observed pre- and post-test. In the practical test, the median (interquartile range) score was 29 (26-32) and 25 (23-29) for the VR and live lecture groups, respectively, with the VR group scoring significantly higher (P=0.03). CONCLUSION Our results confirmed the educational usefulness of selective VR for active learning of START. Therefore, VR combined with live lectures and simulations would be an optimal educational technique.
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Affiliation(s)
- Satoshi Harada
- Department of Emergency Medical Science, Faculty of Medical and Health Science, Nippon Sport Science University
- Graduate School of Medical and Health Science, Nippon Sport Science University
| | - Ryotaro Suga
- Graduate School of Medical and Health Science, Nippon Sport Science University
- Department of Emergency and Critical Care Medicine, Nippon Medical School
| | - Kensuke Suzuki
- Department of Emergency Medical Science, Faculty of Medical and Health Science, Nippon Sport Science University
- Graduate School of Medical and Health Science, Nippon Sport Science University
| | - Shinnosuke Kitano
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital
| | | | - Kenji Narikawa
- Department of Emergency Medical Science, Faculty of Medical and Health Science, Nippon Sport Science University
- Graduate School of Medical and Health Science, Nippon Sport Science University
| | - Mayumi Nakazawa
- Department of Emergency Medical Science, Faculty of Medical and Health Science, Nippon Sport Science University
- Graduate School of Medical and Health Science, Nippon Sport Science University
| | - Satoo Ogawa
- Department of Emergency Medical Science, Faculty of Medical and Health Science, Nippon Sport Science University
- Graduate School of Medical and Health Science, Nippon Sport Science University
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12
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Karamouzis K, Perdikakis M, Michaleas SN, Karamanou M. Baron Dominique-Jean Larrey (1766-1842): innovator of the triage. Acta Chir Belg 2024; 124:66-72. [PMID: 37815405 DOI: 10.1080/00015458.2023.2269343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/05/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND During times of war, it is common for some of the most valiant physicians to practice their skills at the battlefields. Only few of them, however, manage to excel. Among those physicians who seemed like the battlefield was their natural environment, was the military surgeon of the French army, Baron Dominique Jean Larrey (1766-1842). He studied medicine and served in the French Navy. Baron Larrey was one of the most significant medical innovators. METHODS International literature was digitally searched. DISCUSSION Larrey optimized a variety of procedures, even early neurosurgical ones. He also wrote medical treatises and most importantly invented the world famous 'flying ambulance'. During his 53-year service in the army he became the symbol of protection of the French warrior. That is why he was widely known as the 'protector of the soldier'. Nevertheless, his most eminent invention was the formation of the new 'triage' method. Due to Larrey's priceless impact in the domain of surgical innovation, a notable NATO award was created that is named after him. CONCLUSION All references presented describe clearly Baron Larrey's contribution to medicine. His innovations in the sphere of the medical science renovated radically the medical ideas of his era.
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Affiliation(s)
- Konstantinos Karamouzis
- Department of History of Medicine and Medical Ethics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Miltiadis Perdikakis
- Department of History of Medicine and Medical Ethics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyros N Michaleas
- Department of History of Medicine and Medical Ethics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Karamanou
- Department of History of Medicine and Medical Ethics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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13
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Hosseinzadeh M, Nematollahi AV, Afra Y, Amini P, Navaei AR. Effectiveness of Distance Training Based on Simple Triage and Quick Treatment System (START) Triage System in Pre-Hospital Emergency. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2024; 11:23821205241278658. [PMID: 39246596 PMCID: PMC11378164 DOI: 10.1177/23821205241278658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/12/2024] [Indexed: 09/10/2024]
Abstract
OBJECTIVE Triage is the key to success in managing many injured people with limited resources. Therefore, triage training for crisis team medical staff is critical. This study aimed to evaluate the effectiveness of asynchronous learning on immediate care personnel based on the Simple Triage and Quick Treatment System (START) triage system. METHODS In this quasi-experimental study, asynchronous learning based on the START triage system was performed on the immediate care staff of Ahvaz Jundishapur University of Medical Sciences from February 2021 to December 2021. Sixty pre-hospital emergency medical staff were randomly assigned to intervention and control groups. Intervention group participants were provided an asynchronous digital training module, and control group participants received the usual training. Data were collected in both groups as pre-test and post-test with demographic information and knowledge assessment questionnaires. RESULTS Distance triage training based on the START triage system has a significant effect on the level of awareness of the need for triage and knowledge (awareness) and performance (individual efficiency) of immediate care in the intervention group compared to before training (P < 0.001). CONCLUSION Considering the positive results of the pre-organizing model on raising the level of awareness of immediate care personnel, the use of this training method in triage in emergency medicine and retraining workshops could be considered.
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Affiliation(s)
- Mofid Hosseinzadeh
- Department of Emergency Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali-Vafagh Nematollahi
- Department of Emergency Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Yasin Afra
- Department of Emergency Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Payam Amini
- Department of Biostatistics and Epidemiology, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Alireza Rafati Navaei
- Department of Emergency Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Igra NM, Schmulevich D, Geng Z, Guzman J, Biddinger PD, Gates JD, Spinella PC, Yazer MH, Cannon JW. Optimizing Mass Casualty Triage: Using Discrete Event Simulation to Minimize Time to Resuscitation. J Am Coll Surg 2024; 238:41-53. [PMID: 37870239 DOI: 10.1097/xcs.0000000000000894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Urban areas in the US are increasingly focused on mass casualty incident (MCI) response. We simulated prehospital triage scenarios and hypothesized that using hospital-based blood product inventories for on-scene triage decisions would minimize time to treatment. STUDY DESIGN Discrete event simulations modeled MCI casualty injury and patient flow after a simulated blast event in Boston, MA. Casualties were divided into moderate (Injury Severity Score 9 to 15) and severe (Injury Severity Score >15) based on injury patterns. Blood product inventories were collected from all hospitals (n = 6). The primary endpoint was the proportion of casualties managed with 1:1:1 balanced resuscitation in a target timeframe (moderate, 3.5 U red blood cells in 6 hours; severe, 10 U red blood cells in 1 hour). Three triage scenarios were compared, including unimpeded casualty movement to proximate hospitals (Nearest), equal distribution among hospitals (Equal), and blood product inventory-based triage (Supply-Guided). RESULTS Simulated MCIs generated a mean ± SD of 302 ± 7 casualties, including 57 ± 2 moderate and 15 ± 2 severe casualties. Nearest triage resulted in significantly fewer overall casualties treated in the target time (55% vs Equal 86% vs Supply-Guided 91%, p < 0.001). These differences were principally due to fewer moderate casualties treated, but there was no difference among strategies for severe casualties. CONCLUSIONS In this simulation study comparing different triage strategies, including one based on actual blood product inventories, nearest hospital triage was inferior to equal distribution or a Supply-Guided strategy. Disaster response leaders in US urban areas should consider modeling different MCI scenarios and casualty numbers to determine optimal triage strategies for their area given hospital numbers and blood product availability.
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Affiliation(s)
- Noah M Igra
- From the Department of Surgery, Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Igra, Geng, Cannon)
- School of Medicine, Tel Aviv University, Tel Aviv, Israel (Igra, Yazer)
| | | | - Zhi Geng
- From the Department of Surgery, Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Igra, Geng, Cannon)
| | - Jessica Guzman
- Department of Surgery, University of California Davis Medical Center, Sacramento, CA (Guzman)
| | - Paul D Biddinger
- Center for Disaster Medicine, Massachusetts General Hospital, Boston, MA (Biddinger)
| | | | - Philip C Spinella
- Departments of Surgery (Spinella), University of Pittsburgh Medical Center, Pittsburgh, PA
- Critical Care Medicine (Spinella), University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mark H Yazer
- School of Medicine, Tel Aviv University, Tel Aviv, Israel (Igra, Yazer)
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA (Yazer)
| | - Jeremy W Cannon
- From the Department of Surgery, Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Igra, Geng, Cannon)
- Department of Surgery, Uniformed Services University F Edward Hébert School of Medicine, Bethesda, MD (Cannon)
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Khorram-Manesh A, Gray L, Goniewicz K, Cocco A, Ranse J, Phattharapornjaroen P, Achour N, Sørensen J, Peyravi M, Hertelendy AJ, Kupietz K, Bergholtz J, Carlström E. Care in emergencies and disasters: Can it be person-centered? PATIENT EDUCATION AND COUNSELING 2024; 118:108046. [PMID: 37924742 DOI: 10.1016/j.pec.2023.108046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 10/21/2023] [Accepted: 10/29/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVES While person-/patient-centered care aims to influence policymakers' rules and regulations to improve the care of individuals worldwide, exploration of the concept in the context of disaster and public health emergencies as an alternative ethical approach is lacking. This study aims to provide a nuanced understanding of the advantages and challenges of diverse ethical approaches in emergencies, to improve patient care. METHODS A survey, created after several rounds of Delphi methodology, with 22 statements, was applied to 39 participants from nine different countries. The questionnaire's results, including participants' comments, were analyzed. RESULTS The results show that practitioners chose to use a combination of diverse ethical approaches in managing victims of disasters and public health emergencies. CONCLUSION The selection of an approach is context- and situation-dependent and seems to primarily respond to the nature of underlying etiology, creating a possibility to use diverse approaches to offer individualized care on a later occasion and when a flexible surge capacity is available. PRACTICE IMPLICATIONS The outcomes of this study will enhance the future ethical discussion in person/patient-centered care during situations with limited resources and help to develop necessary ethical and educational guidelines.
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Affiliation(s)
- Amir Khorram-Manesh
- Centre for Person-centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Disaster Medicine Center, Gothenburg University, 405 30 Gothenburg, Sweden; Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45 Gothenburg, Sweden; Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 405 30 Gothenburg, Sweden.
| | - Lesley Gray
- Department of Primary Health Care & General Practice, University of Otago, Wellington, New Zealand; Joint Centre for Disaster Research, Massey University, Wellington, New Zealand
| | | | - Annelise Cocco
- Translational Health Research Institute, Western Sydney University, Sydney, Australia
| | - Jamie Ranse
- Department of Emergency Medicine, Griffith University, Gold Coast, QLD 4215, Australia; Menzies Health Institute, Griffith University, Gold Coast, QLD 4215, Australia
| | - Phatthranit Phattharapornjaroen
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 405 30 Gothenburg, Sweden; Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Nebil Achour
- School of Allied Health, Anglia Ruskin University, East Road, Cambridge CB1 1PT, United Kingdom
| | - Jarle Sørensen
- USN School of Business, University of South-Eastern Norway, 3199 Borre, Norway
| | - Mahmoudreza Peyravi
- Department of Health in Disasters and Emergencies, Health Human Resources Research Center, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Attila J Hertelendy
- Department of Information Systems and Business Analytics, College of Business, Florida International University, Miami, Florida, USA; Fellowship in Disaster Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Kevin Kupietz
- Department of Aviation and Emergency Management, Elizabeth City State University, Elizabeth, NC, USA
| | - Jana Bergholtz
- Centre for Person-centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Disaster Medicine Center, Gothenburg University, 405 30 Gothenburg, Sweden; European Cavernoma Alliance, Rare Diseases Sweden, P.O. Box 1386, 17227 Sundbyberg, Sweden
| | - Eric Carlström
- Centre for Person-centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Disaster Medicine Center, Gothenburg University, 405 30 Gothenburg, Sweden; Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45 Gothenburg, Sweden; USN School of Business, University of South-Eastern Norway, 3199 Borre, Norway
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16
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Heller AR, Neidel T, Klotz PJ, Solarek A, Kowalzik B, Juncken K, Kleber C. Validation of secondary triage algorithms for mass casualty incidents : A simulation-based study-English version. DIE ANAESTHESIOLOGIE 2023; 72:1-9. [PMID: 37823925 PMCID: PMC10692258 DOI: 10.1007/s00101-023-01292-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND In the event of a mass casualty incident (MCI), the situation-related shortage of medical resources does not end when the patients are transported from the scene of the incident. Consequently, an initial triage is required in the receiving hospitals. In the first step, the aim of this study was to create a reference patient vignette set with defined triage categories. This allowed a computer-aided evaluation of the diagnostic quality of triage algorithms for MCI situations in the second step. METHODS A total of 250 case vignettes validated in practice were entered into a multistage evaluation process by initially 6 and later 36 triage experts. This algorithm-independent expert evaluation of all vignettes-served as the gold standard for analyzing the diagnostic quality of the following triage algorithms: Manchester triage system (MTS module MCI), emergency severity index (ESI), Berlin triage algorithm (BER), the prehospital algorithms PRIOR and mSTaRT, and two project algorithms from a cooperation between the Federal Office of Civil Protection and Disaster Assistance (BBK) and the Hashemite Kingdom of Jordan-intrahospital Jordanian-German project algorithm (JorD) and prehospital triage algorithm (PETRA). Each patient vignette underwent computerized triage through all specified algorithms to obtain comparative test quality outcomes. RESULTS Of the original 250 vignettes, a triage reference database of 210 patient vignettes was validated independently of the algorithms. These formed the gold standard for comparison of the triage algorithms analyzed. Sensitivities for intrahospital detection of patients in triage category T1 ranged from 1.0 (BER, JorD, PRIOR) to 0.57 (MCI module MTS). Specificities ranged from 0.99 (MTS and PETRA) to 0.67 (PRIOR). Considering Youden's index, BER (0.89) and JorD (0.88) had the best overall performance for detecting patients in triage category T1. Overtriage was most likely with PRIOR, and undertriage with the MCI module of MTS. Up to a decision for category T1, the algorithms require the following numbers of steps given as the median and interquartile range (IQR): ESI 1 (1-2), JorD 1 (1-4), PRIOR 3 (2-4), BER 3 (2-6), mSTaRT 3 (3-5), MTS 4 (4-5) and PETRA 6 (6-8). For the T2 and T3 categories the number of steps until a decision and the test quality of the algorithms are positively interrelated. CONCLUSION In the present study, transferability of preclinical algorithm-based primary triage results to clinical algorithm-based secondary triage results was demonstrated. The highest diagnostic quality for secondary triage was provided by the Berlin triage algorithm, followed by the Jordanian-German project algorithm for hospitals, which, however, also require the most algorithm steps until a decision.
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Affiliation(s)
- Axel R Heller
- Department of Anesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
| | - Tobias Neidel
- Department of Anesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
- Interdisciplinary Emergency Department, Medical Faculty, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Patrick J Klotz
- Department of Anesthesiology and Operative Intensive Care Medicine, Faculty of Medicine, University of Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - André Solarek
- Department of Disaster preparedness and Emergency Planning, Charité, Berlin, Germany
| | - Barbara Kowalzik
- Division III.3 Protection of Health, German Federal Office for Civil Protection and Disaster Assistance, Bonn, Germany
| | - Kathleen Juncken
- Medical Directorate, Dresden Municipal Hospital, Dresden, Germany
| | - Christan Kleber
- Clinic and Polyclinic for Orthopaedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig AöR, Leipzig, Germany
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Yılmaz S, Cetinkaya R, Ozel M, Tatliparmak AC, Ak R. Enhancing Triage and Management in Earthquake-Related Injuries: The SAFE-QUAKE Scoring System for Predicting Dialysis Requirements. Prehosp Disaster Med 2023; 38:716-724. [PMID: 37789711 DOI: 10.1017/s1049023x23006453] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
OBJECTIVES Identifying early predictors of dialysis requirements in earthquake-related injuries is crucial for optimal resource allocation and timely intervention. This study aimed to develop a predictive scoring system, named SAFE-QUAKE (Seismic Assessment of Kidney Function to Rule Out Dialysis Requirement), to identify patients at high risk of developing acute kidney injury (AKI) and requiring dialysis. METHODS A retrospective analysis was conducted on a cohort of 205 patients presenting with earthquake-related injuries. Patients were divided into two groups based on their need for dialysis: the no dialysis group (n = 170) and the dialysis group (n = 35). Demographic, clinical, and laboratory data were collected and compared between the two groups to identify significant predictors of dialysis requirements. The parameters that would form the score were determined by conducting an importance analysis using artificial neural networks (ANNs) to identify parameters that exhibited statistically significant differences in univariate analysis. RESULTS The dialysis group had a significantly longer median duration of being trapped under debris (48 hours) compared to the no dialysis group (eight hours). Blood gas and laboratory analyses revealed significant differences in pH levels, lactate values, creatinine levels, lactate dehydrogenase (LDH) levels, and aspartate transaminase (AST)-to-alanine transaminase (ALT) ratio between the two groups. Based on these findings, the SAFE-QUAKE rule-out scoring system was developed, incorporating entrapment duration (<45 hours), pH levels (>7.31), creatinine levels (<2mg/dL), LDH levels (<1600mg/dL), and the AST-to-ALT ratio (<2.4) as key predictors of dialysis requirements. This score included 139 patients, and among them, only one patient required dialysis, resulting in a negative predictive value of 99.29%. CONCLUSIONS The SAFE-QUAKE scoring system demonstrated a high negative predictive value of 99.29% in ruling out the need for dialysis among earthquake-related injury cases. This scoring system offers a practical approach for health care providers to identify patients at high risk of developing AKI and requiring dialysis in earthquake-affected regions.
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Affiliation(s)
- Sarper Yılmaz
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey; Secretary of the Disaster Commission of the Turkish Emergency Medicine Association, Ankara, Turkey
| | - Remzi Cetinkaya
- University of Health Sciences, Dept. of Emergency Medicine, Diyarbakır Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Mehmet Ozel
- University of Health Sciences, Dept. of Emergency Medicine, Diyarbakır Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | | | - Rohat Ak
- University of Health Sciences, Dept. of Emergency Medicine, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
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Gan RK, Uddin H, Gan AZ, Yew YY, González PA. ChatGPT's performance before and after teaching in mass casualty incident triage. Sci Rep 2023; 13:20350. [PMID: 37989755 PMCID: PMC10663620 DOI: 10.1038/s41598-023-46986-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 11/07/2023] [Indexed: 11/23/2023] Open
Abstract
Since its initial launching, ChatGPT has gained significant attention from the media, with many claiming that ChatGPT's arrival is a transformative milestone in the advancement of the AI revolution. Our aim was to assess the performance of ChatGPT before and after teaching the triage of mass casualty incidents by utilizing a validated questionnaire specifically designed for such scenarios. In addition, we compared the triage performance between ChatGPT and medical students. Our cross-sectional study employed a mixed-methods analysis to assess the performance of ChatGPT in mass casualty incident triage, pre- and post-teaching of Simple Triage And Rapid Treatment (START) triage. After teaching the START triage algorithm, ChatGPT scored an overall triage accuracy of 80%, with only 20% of cases being over-triaged. The mean accuracy of medical students on the same questionnaire yielded 64.3%. Qualitative analysis on pre-determined themes on 'walking-wounded', 'respiration', 'perfusion', and 'mental status' on ChatGPT showed similar performance in pre- and post-teaching of START triage. Additional themes on 'disclaimer', 'prediction', 'management plan', and 'assumption' were identified during the thematic analysis. ChatGPT exhibited promising results in effectively responding to mass casualty incident questionnaires. Nevertheless, additional research is necessary to ensure its safety and efficacy before clinical implementation.
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Affiliation(s)
- Rick Kye Gan
- Unit for Research in Emergency and Disaster, Faculty of Medicine and Health Sciences, University of Oviedo, 33006, Oviedo, Spain
| | - Helal Uddin
- Unit for Research in Emergency and Disaster, Faculty of Medicine and Health Sciences, University of Oviedo, 33006, Oviedo, Spain.
- Department of Global Public Health, Karolinska Institute, 17177, Solna, Sweden.
- Department of Sociology, East West University, Dhaka, 1212, Bangladesh.
| | - Ann Zee Gan
- Tenghilan Health Clinic, 89208, Tuaran, Sabah, Malaysia
| | - Ying Ying Yew
- Unit for Research in Emergency and Disaster, Faculty of Medicine and Health Sciences, University of Oviedo, 33006, Oviedo, Spain
| | - Pedro Arcos González
- Unit for Research in Emergency and Disaster, Faculty of Medicine and Health Sciences, University of Oviedo, 33006, Oviedo, Spain
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Masoumian Hosseini M, Masoumian Hosseini ST, Qayumi K, Hosseinzadeh S, Ahmady S. Crossover design in triage education: the effectiveness of simulated interactive vs. routine training on student nurses' performance in a disaster situation. BMC Res Notes 2023; 16:313. [PMID: 37926836 PMCID: PMC10626668 DOI: 10.1186/s13104-023-06596-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 10/25/2023] [Indexed: 11/07/2023] Open
Abstract
INTRODUCTION This study investigates the effectiveness of incorporating simulated interactive guidelines in nursing students' performance during disaster situations, compared to routine training. METHOD This study was a crossover design with pre-and post-tests for two groups. Each group consisted of 60 students selected using the census method. SIG and routine (Face-to-Face) training sessions were conducted as a crossover design. Triage knowledge questionnaires were used in the pretest to assess triage knowledge. An OSCE test was administered in the posttest to assess student performance, followed by a triage skills questionnaire. Both questionnaires were highly reliable, as indicated by Cronbach's alpha coefficients (0.9 and 0.95, respectively). Statistical analysis was performed using SPSS version 26 software at a significance level 0.05. RESULT The chi-square test showed that the two groups were homogeneous regarding age. Regarding knowledge level, both groups were homogeneous before the intervention (P = 0.99). Nevertheless, the results of the OSCE test showed that the students in Group A had a higher level of skill than the students in Group B (93% versus 70%). Also, 18% of the students in group B had low skills. DISCUSSION The study found that student outcomes improved in both groups receiving SIG, suggesting that interaction and simulation improve learning. However, gamification is an ideal precursor to learning and not a substitute for education. Therefore, gamification should not be used as a stand-alone teaching method. CONCLUSIONS The crossover study found that simulators and games should not be considered stand-alone teaching methods but can contribute to learning sustainability when used alongside instruction.
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Affiliation(s)
- Mohsen Masoumian Hosseini
- Department of E-learning in Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
- CyberPatient Research Affiliate, Interactive Health International, Department of the surgery, University of British Columbia, Vancouver, Canada
| | - Seyedeh Toktam Masoumian Hosseini
- CyberPatient Research Affiliate, Interactive Health International, Department of the surgery, University of British Columbia, Vancouver, Canada.
- Department of Nursing, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
| | - Karim Qayumi
- Professor at Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Shahriar Hosseinzadeh
- CyberPatient Research Coordinator, Interactive Health International, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Soleiman Ahmady
- Department of Medical Education, Virtual School of Medical Education & Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of LIME, Research Affiliated Faculty, Karolinska Institute, Solna, Sweden
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Hansen PM, Mikkelsen S, Alstrøm H, Damm-Hejmdal A, Rehn M, Berlac PA. The Field's mass shooting: emergency medical services response. Scand J Trauma Resusc Emerg Med 2023; 31:71. [PMID: 37919753 PMCID: PMC10621148 DOI: 10.1186/s13049-023-01140-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/25/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Major incidents (MI) happen infrequently in Scandinavia and mass shootings are even less frequently occurring. Case reports and research are called for, as literature is scarce. On 3rd July 2022, a mass shooting took place at the shopping mall Field's in Copenhagen, Denmark. Three people were killed and seven injured by a gunman, firing a rifle inside the mall. A further 21 people suffered minor injuries during the evacuation of the mall. In this case report, we describe the emergency medical services (EMS) incident response and evaluate the EMS´ adherence to the MI management guidelines to identify possible areas of improvement. CASE PRESENTATION Forty-eight EMS units including five Tactical Emergency Medical Service teams were dispatched to the incident. Four critically injured patients were taken to two trauma hospitals. The deceased patients were declared dead at the scene and remained there for the sake of the investigation. A total of 24 patients with less severe and minor injuries were treated at four different hospitals in connection with the attack. The ambulance resources were inherently limited in the initial phase of the MI, mandating improvisation in medical incident command. Though challenged, Command and Control, Safety, Communication, Assessment, Triage, Treatment, Transport (CSCATTT) principles were followed. CONCLUSIONS The EMS response generally adhered to national guidelines for MI. The activation of EMS and the hospital preparedness program was relevant. Important findings were communication shortcomings; inherent lack of readily available ambulance resources in the initial critical phase; uncertainty regarding the number of perpetrators; uncertainty regarding number of casualties and social media rumors that unnecessarily hampered and prolonged the response. The incident command had to use non-standard measures to mitigate potential challenges.
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Affiliation(s)
- Peter Martin Hansen
- The Mobile Emergency Care Unit, Department of Anesthesiology and Intensive Care, Odense University Hospital Svendborg, Svendborg, Denmark.
- Danish Air Ambulance, Aarhus, Denmark.
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
- The Mobile Emergency Care Unit, Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Alstrøm
- Department of Anesthesiology and Intensive Care, Herlev and Gentofte Hospital, Herlev, Denmark
- Copenhagen Emergency Medical Services, Ballerup, Denmark
| | | | - Marius Rehn
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Dept. of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Air Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peter Anthony Berlac
- Copenhagen Emergency Medical Services, Ballerup, Denmark
- Department of Anesthesiology and Intensive Care, Hvidovre and Amager Hospital, Hvidovre, Denmark
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Asgarzadeh S, Ebadi A, Shahrbabaki AS, Safari S, Aghili SH, Farhang Ranjbar M, Sadeghi S. National Early Warning Score in Predicting Adverse Outcomes for Patients Admitted to Emergency Department; a Prognostic Accuracy Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 12:e1. [PMID: 38022714 PMCID: PMC10674069 DOI: 10.22037/aaem.v12i1.2155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Introduction Overcrowding in emergency departments (ED) is a global concern, emphasizing the need for effective resource allocation. Triage plays a crucial role in prioritizing patients based on medical needs. This study aimed to evaluate the accuracy of National Early Warning Score (NEWS) in predicting the ED patients' outcomes. Methods A cross-sectional study was conducted in two tertiary hospitals in Tehran, Iran, from June to July 2023. Adult patients presenting to ED were included. Data for calculating the NEWs and emergency severity index (ESI), as well as outcomes were recorded by trained nurses, and then the accuracy of each score in predicting the outcomes was evaluated. Results A total of 2,085 patients were analyzed. The majority were male (57%) with a mean age of 54.4 years. The primary outcome, cardiopulmonary resuscitation (CPR) within 24 hours of admission, occurred in 1.9% of patients, while the need for intensive care unit (ICU) care and/or mechanical ventilation happened in 3.4%, and CPR or need for ICU care and/or mechanical ventilation was observed in 4.3% of studied cases. Each one-point increase in NEWS was associated with a 52% higher likelihood of CPR (95% confidence interval (CI): 1.41 to 1.65, p<0.001). Receiver operating characteristic curve analyses for the NEWS yielded the optimum cut-off value to be 6 for all three outcomes, with an overall area under the curve (AUC) of 0.856 (95% CI: 0.840 to 0.871), 0.834 (95% CI: 0.817 to 0.850), and 0.854 (95% CI: 0.838 to 0.869) for the primary, secondary, and tertiary outcomes, respectively. Conclusion NEWS ≥ 6 was associated with a higher incidence of adverse outcomes, including ICU admission and need for CPR. The good predictive validity of NEWS highlights its value in identifying patients at higher risk of adverse outcomes.
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Affiliation(s)
- Setareh Asgarzadeh
- Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Research Center for Trauma in Police Operations, Directorate of Health, Rescue & Treatment, Police Headquarter, Tehran, Iran
- Behavioral Sciences Research Centre, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Saeed Safari
- Research Center for Trauma in Police Operations, Directorate of Health, Rescue & Treatment, Police Headquarter, Tehran, Iran
| | - Seyed Hadi Aghili
- Research Center for Trauma in Police Operations, Directorate of Health, Rescue & Treatment, Police Headquarter, Tehran, Iran
| | - Mehri Farhang Ranjbar
- Research Center for Trauma in Police Operations, Directorate of Health, Rescue & Treatment, Police Headquarter, Tehran, Iran
| | - Shayan Sadeghi
- Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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22
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Staribacher D, Rauner MS, Niessner H. Hospital Resource Planning for Mass Casualty Incidents: Limitations for Coping with Multiple Injured Patients. Healthcare (Basel) 2023; 11:2713. [PMID: 37893787 PMCID: PMC10606697 DOI: 10.3390/healthcare11202713] [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: 07/10/2023] [Revised: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Using a discrete-event simulation (DES) model, the current disaster plan regarding the allocation of multiple injured patients from a mass casualty incident was evaluated for an acute specialty hospital in Vienna, Austria. With the current resources available, the results showed that the number of severely injured patients currently assigned might have to wait longer than the medically justifiable limit for lifesaving surgery. Furthermore, policy scenarios of increasing staff and/or equipment did not lead to a sufficient improvement of this outcome measure. However, the mean target waiting time for critical treatment of moderately injured patients could be met under all policy scenarios. Using simulation-optimization, an optimal staff-mix could be found for an illustrative policy scenario. In addition, a multiple regression model of simulated staff-mix policy scenarios identified staff categories (number of radiologists and rotation physicians) with the highest impact on waiting time and survival. In the short term, the current hospital disaster plan should consider reducing the number of severely injured patients to be treated. In the long term, we would recommend expanding hospital capacity-in terms of both structural and human resources as well as improving regional disaster planning. Policymakers should also consider the limitations of this study when applying these insights to different areas or circumstances.
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Affiliation(s)
- Daniel Staribacher
- Medical University Vienna, Spitalgasse 23, A-1090 Vienna, Austria;
- Clinic for Neurosurgery, Sozialstiftung Bamberg, Buger Straße 80, D-96049 Bamberg, Germany
| | - Marion Sabine Rauner
- Department of Business Decisions and Analytics, Faculty of Business, Economics, and Statistics, University of Vienna, Oskar-Morgen-Stern-Platz 1, A-1090 Vienna, Austria
| | - Helmut Niessner
- SimPlan Optimizations e. U., Ilse-Arlt-Straße 12/161, A-1220 Vienna, Austria;
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Cuthbertson J, Weinstein E, Franc JM, Jones P, Lamine H, Magalini S, Gui D, Lennquist K, Marzi F, Borrello A, Fransvea P, Fidanzio A, Benítez CY, Achaz G, Dobson B, Malik N, Neeki M, Pirrallo R, Castro Delgado R, Strapazzon G, Farah Dell’Aringa M, Brugger H, Rafalowsky C, Marzoli M, Fresu G, Kolstadbraaten KM, Lennquist S, Tilsed J, Claudius I, Cheeranont P, Callcut R, Bala M, Kerbage A, Vale L, Hecker NP, Faccincani R, Ragazzoni L, Caviglia M. Sudden-Onset Disaster Mass-Casualty Incident Response: A Modified Delphi Study on Triage, Prehospital Life Support, and Processes. Prehosp Disaster Med 2023; 38:570-580. [PMID: 37675480 PMCID: PMC10548019 DOI: 10.1017/s1049023x23006337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 09/08/2023]
Abstract
The application and provision of prehospital care in disasters and mass-casualty incident response in Europe is currently being explored for opportunities to improve practice. The objective of this translational science study was to align common principles of approach and action and to identify how technology can assist and enhance response. To achieve this objective, the application of a modified Delphi methodology study based on statements derived from key findings of a scoping review was undertaken. This resulted in 18 triage, eight life support and damage control interventions, and 23 process consensus statements. These findings will be utilized in the development of evidence-based prehospital mass-casualty incident response tools and guidelines.
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Affiliation(s)
- Joe Cuthbertson
- CRIMEDIM – Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Monash University Disaster Resilience Initiative, Monash University, ClaytonVICAustralia
| | - Eric Weinstein
- CRIMEDIM – Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Jeffrey Michael Franc
- CRIMEDIM – Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Peter Jones
- Assistance Publique – Hópitaux de Paris (APHP), SAMU de Paris Hôpital Necker, Paris, France
| | - Hamdi Lamine
- CRIMEDIM – Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
| | - Sabina Magalini
- Department of Surgery, Catholic University of the Sacred Heart, Policlinico Gemelli, Rome, Italy
| | - Daniele Gui
- Department of Neurosciences, Catholic University of the Sacred Heart, Policlinico Gemelli, Rome, Italy
| | - Kristina Lennquist
- Department of Neurosciences, Catholic University of the Sacred Heart, Policlinico Gemelli, Rome, Italy
| | - Federica Marzi
- Department of Neurosciences, Catholic University of the Sacred Heart, Policlinico Gemelli, Rome, Italy
| | - Alessandro Borrello
- Department of Neurosciences, Catholic University of the Sacred Heart, Policlinico Gemelli, Rome, Italy
| | - Pietro Fransvea
- Department of Neurosciences, Catholic University of the Sacred Heart, Policlinico Gemelli, Rome, Italy
| | - Andrea Fidanzio
- Department of Neurosciences, Catholic University of the Sacred Heart, Policlinico Gemelli, Rome, Italy
| | | | - Gerhard Achaz
- London Ambulance Service NHS Trust, London, London, United Kingdom
| | - Bob Dobson
- London Ambulance Service NHS Trust, London, London, United Kingdom
| | - Nabeela Malik
- University Hospitals Birmingham NHS Trust, Edgbaston, Birmingham, United Kingdom
| | - Michael Neeki
- Clinical Professor of Emergency Medicine, Arrowhead Regional Medical Center, Colton, CaliforniaUSA; Professor of Medical Education, California University of Science and Medicine, Colton, California USA
| | - Ronald Pirrallo
- Department of Emergency Medicine, Prisma Health University of South Carolina School of Medicine Greenville, Greenville, South CarolinaUSA
| | - Rafael Castro Delgado
- Health Service of the Principality of Asturias (SAMU-Asturias), Health Research Institute of the Principality of Asturias (Team Leader of the Research Group on Prehospital Care and Disasters, GIAPREDE), Oviedo, Spain
- Department of Medicine, Oviedo University, Oviedo, Spain
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy; University of Padova, Padova, Italy; International Commission for Mountain Emergency Medicine, Zurich, Switzerland
| | - Marcelo Farah Dell’Aringa
- CRIMEDIM – Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy; Medical University Innsbruck, Innsbruck, Austria; International Commission of Mountain Emergency Medicine-ICAR MedCom, Zurich, Switzerland
| | - Chaim Rafalowsky
- Department of General Surgery, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Marcello Marzoli
- Department of Fire Service, Public Rescue and Civil Defence, Ministero dell’Interno, Rome, Italy
| | - Giovanni Fresu
- Department of Surgery, Catholic University of the Sacred Heart, Policlinico Gemelli, Rome, Italy
| | | | - Stenn Lennquist
- Department of Neurosciences, Catholic University of the Sacred Heart, Policlinico Gemelli, Rome, Italy
| | - Jonathan Tilsed
- London Ambulance Service NHS Trust, London, London, United Kingdom
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA, Torrence, CaliforniaUSA
| | - Piyapan Cheeranont
- Faculty of Medicine, Praboromarajchanok Institute, Ministry of Public Health, Nonthaburi, Thailand
| | - Rachel Callcut
- University of California Davis Department of Surgery, Sacramento, CaliforniaUSA
| | - Miklosh Bala
- Department of Fire Service, Public Rescue and Civil Defence, Ministero dell’Interno, Rome, Italy
| | - Anthony Kerbage
- Department of Internal Medicine, Hôtel-Dieu de France hospital, Beirut, Lebanon
| | - Luis Vale
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
| | - Norman Philipp Hecker
- ESTES—European Society for Trauma and Emergency Surgery, Disaster and Military Surgery Section, Milan, Italy
| | - Roberto Faccincani
- ESTES—European Society for Trauma and Emergency Surgery, Disaster and Military Surgery Section, Milan, Italy
| | - Luca Ragazzoni
- CRIMEDIM – Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
| | - Marta Caviglia
- CRIMEDIM – Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
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Susanti H, Hamid AYS, Putri AF, Setiawan A, Frida A, Fadilah R. Disaster Training for Nurses in Indonesia: Balancing Physical, Psychological, and Managerial Competencies. J Contin Educ Nurs 2023; 54:378-384. [PMID: 37531655 DOI: 10.3928/00220124-20230711-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
BACKGROUND Indonesian nurses receive training for disasters when they take an undergraduate nursing program at the university, but there have been variations in the curriculum. Moreover, there is still limited informal training available specifically for disaster nursing. Therefore, needs assessments are necessary to identify the gap between Indonesian disaster nurses' existing and expected competencies. This study was conducted to identify competencies needed by disaster nurses. METHOD A descriptive qualitative approach was used in this study. Data were collected from August to September 2019 from three areas in Indonesia: Yogyakarta, Lombok, and Jakarta. These areas frequently experience natural disasters, such as volcanic eruptions, earthquakes, and floods. Thirty-two nurses were interviewed. Data were analyzed with a descriptive qualitative approach. RESULTS The study highlighted three main competencies needed by Indonesian nurses, which are physical, psychological, and managerial. CONCLUSION Training for disaster nurses needs to balance the achievement of competencies related to physical, psychological, and managerial needs. [J Contin Educ Nurs. 2023;54(8):378-384.].
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Mehralian G, Pazokian M, Akbari Shahrestanaki Y, Salari A, Saberinia A, Soltani S. Development and validation of SALT Triage method to facilitate the identification and classification of patients in Mass Casualty Incidents. J Inj Violence Res 2023; 15:137-146. [PMID: 37452627 PMCID: PMC10915875 DOI: 10.5249/jivr.v15i2.1681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 07/02/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Mass Casualty Incidents (MCIs) have caused great financial losses. These incidents are referred to a situation in which the number of casualties caused by the accident temporarily increases to such an extent that it is not possible to treat all these patients with the facilities and capacities available in the area. To offer fair and proportionate medical services to all patients, it is necessary to use a process called patient triage. This study aimed to modify the Sort Assess Lifesaving Intervention Treatment/transport (SALT) triage method to simplify the differentiation of patients from green from yellow and gray from red. METHODS This is a methodological study with a descriptive cross-sectional approach that by studying the SALT triage method and using the criteria defined in the Reference Standard, facilitates the identification of patients with a minor (Outpatient) and fatal injury (Expectant). Then, using two common and modified SALT triage methods, 100 simulated patients were triaged and the obtained data were evaluated and compared in terms of accuracy and speed. RESULTS The improvement made in the SALT triage method was able to reduce 22% of the total triage error of the first nurse and improved 18% in green, 43% in yellow, 15% in red, and 13% in the gray category. In the second nurse, this method was able to reduce 29% of the errors and in the category of green patients, 41%, yellow 47%, red was unchanged, and gray 38% improvement was observed. Furthermore, the average triage rate was 4 and 5 seconds shorter per patient in the first and second nurses, respectively. CONCLUSIONS With this modification, the diagnostic power has increased by 22% in the first nurse and 29% in the second nurse. Due to the significant increase in the accuracy of the mSALT (Modified SALT) triage method, this modification can be considered useful and can be used to advance the goals of triage in MCIs.
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Affiliation(s)
- Ghasem Mehralian
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marzieh Pazokian
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Yousof Akbari Shahrestanaki
- Department of Pre-hospital Medical Emergencies, School of Paramedical Sciences, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Amir Salari
- Imam Khomeini Hospital Complex, Deputy of University Affairs, Tehran University of Medical Sciences, Tehran, Iran
| | - Amin Saberinia
- Department of Emergency Medicine, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Soheil Soltani
- Emergency Department of the Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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26
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Heller AR, Neidel T, Klotz PJ, Solarek A, Kowalzik B, Juncken K, Kleber C. [Validation of secondary triage algorithms for mass casualty incidents-A simulation-based study-German version]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01291-3. [PMID: 37318526 DOI: 10.1007/s00101-023-01291-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND In the event of a mass casualty incident (MCI), the situation-related shortage of medical resources does not end when the patients are transported from the scene of the incident. Consequently, an initial triage is required in the receiving hospitals. In the first step, the aim of this study was to create a reference patient vignette set with defined triage categories. This allowed a computer-aided evaluation of the diagnostic quality of triage algorithms for MCI situations in the second step. METHODS A total of 250 case vignettes validated in practice were entered into a multistage evaluation process by initially 6 and later 36 triage experts. This algorithm-independent expert evaluation of all vignettes-served as the gold standard for analyzing the diagnostic quality of the following triage algorithms: Manchester triage system (MTS module MCI), emergency severity index (ESI), Berlin triage algorithm (BER), the prehospital algorithms PRIOR and mSTaRT, and two project algorithms from a cooperation between the Federal Office of Civil Protection and Disaster Assistance (BBK) and the Hashemite Kingdom of Jordan-intrahospital Jordanian-German project algorithm (JorD) and prehospital triage algorithm (PETRA). Each patient vignette underwent computerized triage through all specified algorithms to obtain comparative test quality outcomes. RESULTS Of the original 250 vignettes, a triage reference database of 210 patient vignettes was validated independently of the algorithms. These formed the gold standard for comparison of the triage algorithms analyzed. Sensitivities for intrahospital detection of patients in triage category T1 ranged from 1.0 (BER, JorD, PRIOR) to 0.57 (MCI module MTS). Specificities ranged from 0.99 (MTS and PETRA) to 0.67 (PRIOR). Considering Youden's index, BER (0.89) and JorD (0.88) had the best overall performance for detecting patients in triage category T1. Overtriage was most likely with PRIOR, and undertriage with the MCI module of MTS. Up to a decision for category T1, the algorithms require the following numbers of steps given as the median and interquartile range (IQR): ESI 1 (1-2), JorD 1 (1-4), PRIOR 3 (2-4), BER 3 (2-6), mSTaRT 3 (3-5), MTS 4 (4-5) and PETRA 6 (6-8). For the T2 and T3 categories the number of steps until a decision and the test quality of the algorithms are positively interrelated. CONCLUSION In the present study, transferability of preclinical algorithm-based primary triage results to clinical algorithm-based secondary triage results was demonstrated. The highest diagnostic quality for secondary triage was provided by the Berlin triage algorithm, followed by the Jordanian-German project algorithm for hospitals, which, however, also require the most algorithm steps until a decision.
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Affiliation(s)
- Axel R Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| | - Tobias Neidel
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
- Interdisziplinäre Notaufnahme, Medizinische Fakultät, Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel, Deutschland
| | - Patrick J Klotz
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät, Universität Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - André Solarek
- Stabsstelle Katastrophenschutz, Charité, Berlin, Deutschland
| | - Barbara Kowalzik
- Referat III.3 Schutz der Gesundheit, Bundesamt für Bevölkerungsschutz und Katastrophenhilfe, Bonn, Deutschland
| | - Kathleen Juncken
- Medizinisches Direktorium, Städtisches Klinikum Dresden, Dresden, Deutschland
| | - Christan Kleber
- Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie (OUP), Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
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27
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Tan YT, Shin CKJ, Park B, Bharath A, Wing R, Monteilh C, Sanseau E, Boswell B, Pearce JI, Luetje M, Enriquez B, Cicero M, Thomas A. Pediatric Emergency Medicine Didactics and Simulation: JumpSTART Secondary Triage for Mass Casualty Incidents. Cureus 2023; 15:e40009. [PMID: 37425609 PMCID: PMC10322648 DOI: 10.7759/cureus.40009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/01/2023] [Indexed: 07/11/2023] Open
Abstract
Mass casualty incidents (MCI), particularly involving pediatric patients, are high-risk, low-frequency occurrences that require exceptional emergency arrangements and advanced preparation. In the aftermath of an MCI, it is essential for medical personnel to accurately and promptly triage patients according to their acuity and urgency for care. As first responders bring patients from the field to the hospital, medical personnel are responsible for prompt secondary triage of these patients to appropriately delegate hospital resources. The JumpSTART triage algorithm (a variation of the Simple Triage and Rapid Treatment, or START, triage system) was originally designed for prehospital triage by prehospital providers but can also be used for secondary triage in the emergency department setting. This technical report describes a novel simulation-based curriculum for pediatric emergency medicine residents, fellows, and attendings involving the secondary triage of patients in the aftermath of an MCI in the emergency department. This curriculum highlights the importance of the JumpSTART triage algorithm and how to effectively implement it in the MCI setting.
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Affiliation(s)
- Yongtian Tina Tan
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
| | | | - Brian Park
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
| | - Anita Bharath
- Pediatric Emergency Medicine, University of Arizona College of Medicine, Phoenix, USA
| | - Robyn Wing
- Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, USA
| | - Cecilia Monteilh
- Pediatric Emergency Medicine, University of Arizona College of Medicine, Phoenix, USA
| | - Elizabeth Sanseau
- Pediatric Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Brittany Boswell
- Pediatric Emergency Medicine, Stanford University School of Medicine, Palo Alto, USA
| | - Jean I Pearce
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Maureen Luetje
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Brianna Enriquez
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
| | - Mark Cicero
- Pediatric Emergency Medicine, Yale School of Medicine, New Haven, USA
| | - Anita Thomas
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
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Lubkowski P, Krygier J, Sondej T, Dobrowolski AP, Apiecionek L, Znaniecki W, Oskwarek P. Decision Support System Proposal for Medical Evacuations in Military Operations. SENSORS (BASEL, SWITZERLAND) 2023; 23:s23115144. [PMID: 37299871 DOI: 10.3390/s23115144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/20/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023]
Abstract
The area of military operations is a big challenge for medical support. A particularly important factor that allows medical services to react quickly in the case of mass casualties is the ability to rapidly evacuation of wounded soldiers from a battlefield. To meet this requirement, an effective medical evacuation system is essential. The paper presented the architecture of the electronically supported decision support system for medical evacuation during military operations. The system can also be used by other services such as police or fire service. The system meets the requirements for tactical combat casualty care procedures and is composed of following elements: measurement subsystem, data transmission subsystem and analysis and inference subsystem. The system, based on the continuous monitoring of selected soldiers' vital signs and biomedical signals, automatically proposes a medical segregation of wounded soldiers (medical triage). The information on the triage was visualized using the Headquarters Management System for medical personnel (first responders, medical officers, medical evacuation groups) and for commanders, if required. All elements of the architecture were described in the paper.
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Affiliation(s)
- Piotr Lubkowski
- Faculty of Electronics, Military University of Technology, Gen. Sylwestra Kaliskiego 2, 00-908 Warsaw, Poland
| | - Jaroslaw Krygier
- Faculty of Electronics, Military University of Technology, Gen. Sylwestra Kaliskiego 2, 00-908 Warsaw, Poland
| | - Tadeusz Sondej
- Faculty of Electronics, Military University of Technology, Gen. Sylwestra Kaliskiego 2, 00-908 Warsaw, Poland
| | - Andrzej P Dobrowolski
- Faculty of Electronics, Military University of Technology, Gen. Sylwestra Kaliskiego 2, 00-908 Warsaw, Poland
| | - Lukasz Apiecionek
- Institute of Computer Science, Kazimierz Wielki University, Jana Karola Chodkiewicza 30, 85-064 Bydgoszcz, Poland
- Teldat Sp. z o.o. sp.k, Cicha 19, 85-650 Bydgoszcz, Poland
| | | | - Pawel Oskwarek
- Military Institute of Medicine-National Research Institute, Szaserów 128, 04-141 Warsaw, Poland
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Benson J, Wolfson D, van den Broek-Altenburg E. Tradeoffs in Triage of Motor Vehicle Trauma by Rural 911 Emergency Medical Services Practitioners. Med Decis Making 2023; 43:311-324. [PMID: 36597349 DOI: 10.1177/0272989x221145677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE Identification and triage of severely injured patients to trauma centers is paramount to survival. Many patients are undertriaged in rural areas and do not receive proper care. The decision-making processes involved in triage are not well understood and should be assessed to improve the triage process and outcomes. METHODS Triage decision-making processes were explored through emergency medical services (EMS) practitioner focus groups and a discrete choice experiment (DCE). Attributes of trauma determined from focus groups and the literature included patient demography, injury mechanism, and trauma center distance. DCE data were analyzed using mixed logit models. RESULTS High-risk mechanism, decreased age, multiple comorbidities, and pregnancy were found to increase the preference for triage. Greater trauma center distance was found to decrease preference for triage, but practitioners were willing to trade off up to 2 h of travel time to transport a third-trimester pregnancy and 48 min of travel time to transport a 25-y-old than they would a 50-y-old with the same comorbidities, injuries, and stability. CONCLUSIONS Our findings suggest that current forms of EMS protocols may not be appropriately tailored to support the mechanisms underlying practitioner decision making. Public health professionals and researchers should consider using DCEs to better understand EMS practitioner decision making and identify structures and incentives that may improve patient outcomes and optimally guide appropriate triage decisions. HIGHLIGHTS Discrete choice experiments are an effective method to elicit prehospital practitioners' preferences around transport of the traumatized patient.Practitioner biases observed in EMS transport data are recovered in stated preference models incorporating individual preference heterogeneity.There is a discrepancy between the triage priorities recommended by protocol and those measured from prehospital practitioners' decisions-this may have implications in over- and undertriage rates and prehospital protocol design.
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Affiliation(s)
- Jamie Benson
- Department of Radiology, Larner College of Medicine at the University of Vermont, Burlington, VT, USA.,Department of Surgery, Division of Acute Care Surgery, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Daniel Wolfson
- Department of Surgery, Division of Emergency Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT, USA.,Vermont Department of Health, Division of Emergency Preparedness, Response & Injury Prevention, Burlington, VT, USA
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Zhao F, Zhao C, Bai S, Yao L, Zhang Y. Triage Algorithms for Mass-Casualty Bioterrorism: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20065070. [PMID: 36981980 PMCID: PMC10049471 DOI: 10.3390/ijerph20065070] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To understand existing triage algorithms, propose improvement measures through comparison to better deal with mass-casualty incidents caused by bioterrorism. STUDY DESIGN Systematic review. METHODS Medline, Scopus and Web of Science were searched up to January 2022. The studies investigating triage algorithms for mass-casualty bioterrorism. Quality assessment was performed using the International Narrative Systematic Assessment tool. Data extractions were performed by four reviewers. RESULTS Of the 475 titles identified in the search, 10 studies were included. There were four studies on triage algorithms for most bioterrorism events, four studies on triage algorithms for anthrax and two studies on triage algorithms for mental or psychosocial problems caused by bioterrorism events. We introduced and compared 10 triage algorithms used for different bioterrorism situations. CONCLUSION For triage algorithms for most bioterrorism events, it is necessary to determine the time and place of the attack as soon as possible, control the number of exposed and potentially exposed people, prevent infection and determine the type of biological agents used. Research on the effects of decontamination on bioterrorism attacks needs to continue. For anthrax triage, future research should improve the distinction between inhalational anthrax symptoms and common disease symptoms and improve the efficiency of triage measures. More attention should be paid to triage algorithms for mental or psychosocial problems caused by bioterrorism events.
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Affiliation(s)
- Feida Zhao
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
| | - Chao Zhao
- Center for Biosafety Research and Strategy, Tianjin University, Tianjin 300072, China
| | - Song Bai
- Evaluation and Optimization of Health Emergency Response Capacity, Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
| | - Lulu Yao
- Emergency Medicine, Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
| | - Yongzhong Zhang
- Epidemiology and Health Statistics, Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China
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Yoon JA, Park BH, Chang SO. Perspective of Emergency Pediatric Nurses Triaging Pediatric Patients in the Emergency Department: A Phenomenographic Study. J Emerg Nurs 2023; 49:244-254. [PMID: 36424285 DOI: 10.1016/j.jen.2022.10.007] [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: 07/08/2022] [Revised: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Triage, a process to determine illness severity, is implemented by emergency nurses to prioritize treatment and provide care for a maximum number of patients using limited resources. The competency of emergency nurses and a highly reliable triage are crucial for the provision of emergency care. Pediatric patients are different from adult patients in certain aspects, such as growth-phase characteristics, communication ability, and the onset of disease; these aspects often pose challenges during their primary triage. This study explored how emergency nurses triage pediatric patients using the Korean Triage and Acuity Scale. METHODS Eleven emergency nurses (N = 11) working in the pediatric emergency department of a university hospital in Seoul, South Korea, were recruited using purposive sampling methods. Phenomenography was used to investigate the strategies by which these nurses use the Korean Triage and Acuity Scale to triage pediatric patients. RESULTS The findings comprised 2 descriptive categories: 6 approaches on how to triage patients (categories of how) and 3 strategies (categories of what) used by pediatric emergency nurses to triage pediatric patients with the Korean Triage and Acuity Scale. DISCUSSION The experience and proficiency of emergency nurses are essential factors for the effective triage of pediatric patients. Our findings qualitatively elucidate different ways of understanding pediatric triage and indicate the need for pediatric triage education programs.
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Al-Hajj S, Ghamlouche L, Nasser AlDeen K, El Sayed M. Beirut Blast: The Experiences of Acute Care Hospitals. Disaster Med Public Health Prep 2023; 17:e318. [PMID: 36789650 DOI: 10.1017/dmp.2022.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Mass Casualty Incidents recently increased in intensity and frequency at an unprecedented rate globally. On August 4, 2020, a massive blast hit the Port of Beirut severely damaging its healthcare sector. This study aims to provide a comprehensive understanding of the impact of the Beirut blast on acute care hospitals in the Beirut area, with a focus on understanding healthcare professionals' (HCPs) responses and encountered challenges. A qualitative research design method was adopted to evaluate the experiences of HCPs at acute hospitals located within 5 kilometers of the blast epicenter. 9 hospitals participated in the study. 11 semi-structured interviews were conducted with key informant HCPs using a designed interview guide. HCPs reported severe infrastructural damages in their corresponding hospitals, and 2 were completely non-functional post-blast. Other than physical injuries sustained by HCPs, the blast imposed substantial strains on their mental health, exacerbated by the ongoing socio-economic crises in Lebanon. Moreover, the findings revealed critical challenges which hindered hospitals' emergency responses at the level of communication, coordination, and human resources, as well as supplies. Participants urged for the need to conduct proper triage, arrange emergency operating centers, and deploy outdoor treatment tents among others, to effectively respond to future disasters. The Beirut blast overwhelmed the Lebanese healthcare system and challenged its level of emergency preparedness. This generated evidence to address the deficiencies and strengthen the existing hospitals' emergency response plans. Future efforts should include prioritizing hospitals' emergency preparedness to ensure the provision of care at increased capacity following the impact of a large-scale disaster.
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Affiliation(s)
- Samar Al-Hajj
- Faculty of Health Sciences, MENA Program for Advanced Injury Research, American University of Beirut, Beirut, Lebanon
| | - Layal Ghamlouche
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Mazen El Sayed
- Department of Emergency Medicine, Emergency Medical Services and Prehospital Care Program, American of Beirut Medical Center, Beirut, Lebanon
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El Tawil C, Bergeron A, Khalil E. A Scoping Review of Pediatric Mass-Casualty Incident Triage Algorithms. Disaster Med Public Health Prep 2023; 17:e317. [PMID: 36789661 DOI: 10.1017/dmp.2022.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVE For the pediatric population, there is no consensus on which triage system to use for mass-casualty incidents (MCI). A scoping review was conducted to identify the most accurate triage system for pediatric patients in MCIs. METHODS MEDLINE (NLM, Bethesda, MA, USA), Embase (Elsevier Inc., Amsterdam, Netherlands), CINAHL (EBSCO Information Services, Ipswitch, MA, USA), and The Cochrane CENTRAL Register of Controlled Trials (John Wiley & Sons, Hoboken, NJ, USA), as well as Scopus (Elsevier Inc., Amsterdam, Netherlands), Global Health (Centre for Agriculture and Bioscience International, Wallingford, UK), Global Health Archive (Centre for Agriculture and Bioscience International, Wallingford, UK), and Global Index Medicus (World Health Organization, Geneva, Switzerland) were searched for relevant studies that were divided into 3 categories: accuracy of a single system, comparison of 2 or more primary triage system and comparison of secondary triage systems. Grey literature was also searched. RESULTS 996 studies were identified from which 18 studies were included. Systems studied were found to have poor inter-rater reliability, had a low level of agreement between providers, had missed critically ill patients or were not externally validated. 11 studies compared pediatric MCI triage algorithms using different strategies and the most accurate algorithm was not identified. A recently developed secondary triage system, specifically for pediatric patients, was found to perform better than the comparison triage system. CONCLUSION Although some algorithms performed better than others, no primary triage algorithm was accurate enough for the pediatric population. However, only 1 secondary triage algorithm was found to be superior to the others.
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Affiliation(s)
- Chady El Tawil
- Division of Pediatric Emergency Medicine, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Amy Bergeron
- McGill University Health Centre Medical Libraries, Montreal, Quebec, Canada
| | - Elene Khalil
- Division of Pediatric Emergency Medicine, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
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Vassallo J, Blakey S, Cowburn P, Surridge J, Smith JE, Scholefield B, Lyttle MD. Paediatric major incident triage: A Delphi process to determine clinicians' attitudes and beliefs within the United Kingdom and Ireland. Acta Paediatr 2023; 112:154-161. [PMID: 36219507 DOI: 10.1111/apa.16567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/14/2022] [Accepted: 10/10/2022] [Indexed: 12/13/2022]
Abstract
AIM Triage is key to effective management of major incidents, yet there is scarce evidence surrounding the optimal method of paediatric major incident triage (MIT). This study aimed to derive consensus on key components of paediatric MIT among healthcare professionals responsible for triage during paediatric major incidents. METHODS Two-round online Delphi consensus study delivered July 2021-October 2021, including participants from pre-hospital and hospital specialities responsible for triage during paediatric major incidents. A 5-point Likert scale was used to determine consensus, set a priori at 70%. RESULTS 111 clinicians completed both rounds; 13 of 17 statements reached consensus. Positive consensus was reached on rescue breaths in mechanisms associated with hypoxia or asphyxiation, mobility assessment as a crude discriminator and use of adult physiology for older children. Whilst positive consensus was reached on the benefits of a single MIT tool across all adult and paediatric age ranges, there was negative consensus in relation to clinical implementation. CONCLUSIONS This Delphi study has established consensus among a large group of clinicians involved in the management of major incidents on several key elements of paediatric major incident triage. Further work is required to develop a triage tool that can be implemented based on emerging and ongoing research and which is acceptable to clinicians.
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Affiliation(s)
- James Vassallo
- Institute of Naval Medicine, Gosport, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Sarah Blakey
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Research in Emergency Care, Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
| | - Philip Cowburn
- Emergency Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.,South Western Ambulance Service NHS Foundation Trust, North Bristol Operations Centre, Bristol, UK.,National Ambulance Resilience Unit (NARU), College of Policing, Ryton on Dunsmore, UK
| | - Julia Surridge
- Emergency Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.,Emergency department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Barney Scholefield
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Paediatric Intensive Care, Birmingham Women & Children's Hospital, NHS Foundation Trust, Birmingham, UK
| | - Mark D Lyttle
- Research in Emergency Care, Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK.,Emergency Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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Shabrandi N, Bagheri-Saweh MI, Nouri B, Valiee S. Accuracy of nurses’ performance in triage using the emergency severity index and its relationship with clinical outcome measures. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Emergency department (ED) triage in hospitals is part of their emergency structure carried out by nurses in emergency units. There have not been many studies available on nurses' performance in triage based on the emergency severity index (ESI). This present study aimed to investigate the nurses’ performance in triage with regard to the emergency severity index and its relation to clinical outcome measures in the emergency department. This was a cross-sectional study. The hospitalization record of 600 patients who arrived at the emergency department of Sanandaj Social Security Hospital was randomly assessed based on the accuracy of triage performed by nurses. The data analysis procedure was done by employing STATA software version 12, as well as Fisher's exact test, independent t-test, and one-way ANOVA. Findings of the study revealed that nurses’ overall performance in triage showed that 82.67% of nurses had perfect triage accuracy, 12.17% had low-level triage accuracy and 5.17% had high-level triage accuracy. There was an association between nurses' performance in triage with the disposition of patients (p=0.029) and length of stay (p=0.009). Results of the study highlighted the importance of theoretical and practical triage training courses for nurses and provided a foundation for identifying effective factors for decreasing the length of stay and disposition of patients in emergency care units.
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Yánez Benítez C, Tilsed J, Weinstein ES, Caviglia M, Herman S, Montán C, Achatz G, Cuthbertson J, Ragazzoni L, Sdongos E, Ashkenazi I, Faccincani R. Education, training and technological innovation, key components of the ESTES-NIGHTINGALE project cooperation for Mass Casualty Incident preparedness in Europe. Eur J Trauma Emerg Surg 2022; 49:653-659. [PMID: 36513839 PMCID: PMC9747076 DOI: 10.1007/s00068-022-02198-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
Disasters induced by extreme weather events and terrorism-related activities, causing mass casualty incidents (MCIs) in Europe, are expected to increase in the upcoming years. This challenging scenario demands a high level of readiness and coordinated multi-disciplinary response to reduce morbidity and mortality. The European Society of Trauma and Emergency Surgery (ESTES) is one of the 23 partners of the European-funded project Novel Integrated Toolkit for Enhanced Pre-Hospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE), whose primary objective is to promote the exchange in experiences and define the best practices among first responders. Additionally, the project promotes multi-disciplinary and multi-institutional efforts to achieve technological innovation that will enhance preparedness in MCI management. This manuscript aims to describe the challenges of MCI triage, the education and training programs for MCI response in Europe, and the technological innovation that may aid optimal response. These three elements were discussed by ESTES Disaster and Military Surgery Section members during the German Society for Trauma Surgery session at the ECTES 2022 in Oslo "TDSC® and beyond: ideas and concepts for education and training in Terror Preparedness", additionally the manuscript describes the first steps of the cooperation between ESTES and the rest of the NIGHTINGALE consortium.
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Affiliation(s)
- Carlos Yánez Benítez
- European Society of Trauma and Emergency Surgery (ESTES), St. Pölten, Austria ,General and Acute Care Surgery, San Jorge University Hospital, Huesca, Spain
| | - Jonathan Tilsed
- European Society of Trauma and Emergency Surgery (ESTES), St. Pölten, Austria ,grid.9481.40000 0004 0412 8669Surgery Health Care Group, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Eric S. Weinstein
- grid.16563.370000000121663741Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), Università del Piemonte Orientale, Novara, Italy ,grid.16563.370000000121663741Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
| | - Marta Caviglia
- grid.16563.370000000121663741Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), Università del Piemonte Orientale, Novara, Italy
| | - Simon Herman
- European Society of Trauma and Emergency Surgery (ESTES), St. Pölten, Austria ,grid.29524.380000 0004 0571 7705Department of Traumatology, University Medical Centre, Ljubljana, Slovenia
| | - Carl Montán
- European Society of Trauma and Emergency Surgery (ESTES), St. Pölten, Austria ,grid.24381.3c0000 0000 9241 5705Vascular and General Surgeon, Karolinska University Hospital, Stockholm, Sweden
| | - Gerhard Achatz
- European Society of Trauma and Emergency Surgery (ESTES), St. Pölten, Austria ,grid.415600.60000 0004 0592 9783Department for Orthopedics and Trauma Surgery, Reconstructive and Septic Surgery, Sportstraumatology, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081 Ulm, Germany
| | - Joe Cuthbertson
- grid.16563.370000000121663741Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), Università del Piemonte Orientale, Novara, Italy ,grid.1002.30000 0004 1936 7857Monash University Disaster Resilience Initiative, Monash University, Melbourne, Australia
| | - Luca Ragazzoni
- grid.16563.370000000121663741Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), Università del Piemonte Orientale, Novara, Italy
| | | | - Itamar Ashkenazi
- European Society of Trauma and Emergency Surgery (ESTES), St. Pölten, Austria ,grid.413731.30000 0000 9950 8111Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Roberto Faccincani
- European Society of Trauma and Emergency Surgery (ESTES), St. Pölten, Austria ,grid.459849.dEmergency Department, Humanitas Mater Domini, Castellanza, Italy
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Prescott T, May S, Horne S, Barnard E. Prehospital emergency care in a humanitarian environment: an overview of the ethical considerations. BMJ Mil Health 2022; 168:431-434. [PMID: 37778873 DOI: 10.1136/military-2022-002201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/14/2022] [Indexed: 11/04/2022]
Abstract
Recent history has demonstrated that UK Defence personnel can be used, potentially with little notice, in humanitarian disaster zones. The provision of prehospital emergency care (PHEC) in a humanitarian environment requires an innovative approach to overcome the technical challenges of a resource-limited setting. In addition to technical challenges, prehospital practitioners working in a humanitarian environment can expect to be faced with ethically testing situations that they are not familiar with in their usual practice. The organisational and individual ethical decision-making burden can result in significant harms. Therefore, the aim of this paper is to discuss the ethical considerations relevant to providing PHEC during a humanitarian disaster in order that personnel can be more prepared to optimally deliver care. This is a paper commissioned as a part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.
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Affiliation(s)
- Tim Prescott
- Army Medical Service, Camberley, Surrey, UK
- Department of Anaesthesia, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - S May
- Emergency Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - S Horne
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - E Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Agri J, Montán C, Söderin L, Lennquist-Montán K, Hammarberg E. Prehospital Preparedness for Major Incidents in Sweden: A National Survey with Focus on Mass-Casualty Incidents. Prehosp Disaster Med 2022; 38:1-8. [PMID: 36440661 DOI: 10.1017/s1049023x22002229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Major incidents (MIs) put great demands on the medical response to effectively organize and redistribute resources and personnel, in prehospital care as well as hospital care, and coordinating functions. Studies indicate that regular training and well-established contingency plans are vital for the medical response to MIs. Previous assessments have concluded that Swedish disaster preparedness requires improved organization and coordination. There is currently no method to easily follow-up the preparedness work of the prehospital medical response organizations for MIs in Sweden. PROBLEM The aim of the study was to assess qualifications and training requirements for central individual roles, to examine frequency and focus of training and simulation, as well as to examine current regional routines for MIs in Sweden. The aim was also to identify, to evaluate, and to investigate areas for improvement in prehospital health care preparedness for MIs in Sweden. METHODS Descriptive comparative study of Sweden's prehospital organization, planning, education, and training for MIs through a web-based survey sent to all 21 regions in Sweden. The survey included 64 questions and was based on national legislation and guidelines for preparedness and previous investigations of real MIs. RESULTS A total of 37 answers to the survey were collected representing 17/21 regions (80.9%) from which Regional Management Individuals (RMIs) were selected from 15 regions and used as representative primary responses. The initial routines regarding alarm and establishment of management functions were mainly in-line with national guidelines. Staffing and qualification requirements for certain leadership roles differed substantially between regions. The requirements for the health care staff's knowledge of the contingency plan were generally low and routines for follow-up were often lacking. The frequency of exercises in certain areas were deficient. CONCLUSIONS The results of the study showed several potential areas for improvement within the prehospital emergency medical preparedness for MIs in Sweden. Methodology and adherence of national guidelines for medical response preparedness differ between regions in Sweden, which motivates recurring assessments. It is possible to use a well-prepared questionnaire study to follow-up and to examine parts of the regional prehospital preparedness work and organization for MIs.
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Affiliation(s)
- Joakim Agri
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
| | - Carl Montán
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
| | - Louise Söderin
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
| | | | - Elsa Hammarberg
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
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Zhang A, Lou J, Pan Z, Luo J, Zhang X, Zhang H, Li J, Wang L, Cui X, Ji B, Chen L. Prediction of anemia using facial images and deep learning technology in the emergency department. Front Public Health 2022; 10:964385. [PMID: 36438300 PMCID: PMC9682145 DOI: 10.3389/fpubh.2022.964385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/03/2022] [Indexed: 11/11/2022] Open
Abstract
Background According to the WHO, anemia is a highly prevalent disease, especially for patients in the emergency department. The pathophysiological mechanism by which anemia can affect facial characteristics, such as membrane pallor, has been proven to detect anemia with the help of deep learning technology. The quick prediction method for the patient in the emergency department is important to screen the anemic state and judge the necessity of blood transfusion treatment. Method We trained a deep learning system to predict anemia using videos of 316 patients. All the videos were taken with the same portable pad in the ambient environment of the emergency department. The video extraction and face recognition methods were used to highlight the facial area for analysis. Accuracy and area under the curve were used to assess the performance of the machine learning system at the image level and the patient level. Results Three tasks were applied for performance evaluation. The objective of Task 1 was to predict patients' anemic states [hemoglobin (Hb) <13 g/dl in men and Hb <12 g/dl in women]. The accuracy of the image level was 82.37%, the area under the curve (AUC) of the image level was 0.84, the accuracy of the patient level was 84.02%, the sensitivity of the patient level was 92.59%, and the specificity of the patient level was 69.23%. The objective of Task 2 was to predict mild anemia (Hb <9 g/dl). The accuracy of the image level was 68.37%, the AUC of the image level was 0.69, the accuracy of the patient level was 70.58%, the sensitivity was 73.52%, and the specificity was 67.64%. The aim of task 3 was to predict severe anemia (Hb <7 g/dl). The accuracy of the image level was 74.01%, the AUC of the image level was 0.82, the accuracy of the patient level was 68.42%, the sensitivity was 61.53%, and the specificity was 83.33%. Conclusion The machine learning system could quickly and accurately predict the anemia of patients in the emergency department and aid in the treatment decision for urgent blood transfusion. It offers great clinical value and practical significance in expediting diagnosis, improving medical resource allocation, and providing appropriate treatment in the future.
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Affiliation(s)
- Aixian Zhang
- Medical School of the Chinese PLA, Beijing, China,Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Jingjiao Lou
- Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China,School of Control Science and Engineering, Shandong University, Jinan, Shandong, China
| | - Zijie Pan
- Luoyang Outpatient Department of 63650 Army Hospital of the Chinese PLA, Luoyang, China
| | - Jiaqi Luo
- Medical School of the Chinese PLA, Beijing, China
| | - Xiaomeng Zhang
- Medical School of the Chinese PLA, Beijing, China,Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Han Zhang
- Medical School of the Chinese PLA, Beijing, China,Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Jianpeng Li
- Medical School of the Chinese PLA, Beijing, China,Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Lili Wang
- Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China
| | - Xiang Cui
- Department of Orthopedics, Chinese PLA General Hospital, National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Bing Ji
- School of Control Science and Engineering, Shandong University, Jinan, Shandong, China,*Correspondence: Bing Ji
| | - Li Chen
- Department of General Medicine, The First Center of the Chinese PLA General Hospital, Beijing, China,Li Chen
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Vassallo J, Moran CG, Cowburn P, Smith J. New NHS Prehospital Major Incident Triage Tool: from MIMMS to MITT. Emerg Med J 2022; 39:800-802. [PMID: 36244685 PMCID: PMC9613863 DOI: 10.1136/emermed-2022-212569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022]
Abstract
Triage is a key principle in the effective management of major incidents and is the process by which patients are prioritised on the basis of their clinical acuity. However, work published over the last decade has demonstrated that existing methods of triage perform poorly when trying to identify patients in need of life-saving interventions. As a result, a review of major incident triage was initiated by NHS England with the remit to determine the optimum way in which to triage patients of all ages in a major incident for the UK. This article describes the output from this review, the changes being undertaken to UK major incident triage and the introduction of the new NHS Major Incident Triage Tool from the Spring of 2023.
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Affiliation(s)
- James Vassallo
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Chris G Moran
- Department of Orthopaedic Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip Cowburn
- Emergency Department, Bristol Royal Infirmary, Bristol, UK
| | - Jason Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
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Developing a translational triage research tool: part two-evaluating the tool through a Delphi study among experts. Scand J Trauma Resusc Emerg Med 2022; 30:48. [PMID: 35907858 PMCID: PMC9338674 DOI: 10.1186/s13049-022-01035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background There are different prehospital triage systems, but no consensus on what constitutes the optimal choice. This heterogeneity constitutes a threat in a mass casualty incident in which triage is used during multiagency collaboration to prioritize casualties according to the injuries’ severity. A previous study has confirmed the feasibility of using a Translational Triage Tool consisting of several steps which translate primary prehospital triage systems into one. This study aims to evaluate and verify the proposed algorithm using a panel of experts who in their careers have demonstrated proficiency in triage management through research, experience, education, and practice. Method Several statements were obtained from earlier reports and were presented to the expert panel in two rounds of a Delphi study. Results There was a consensus in all provided statements, and for the first time, the panel of experts also proposed the manageable number of critical victims per healthcare provider appropriate for proper triage management. Conclusion The feasibility of the proposed algorithm was confirmed by experts with some minor modifications. The utility of the translational triage tool needs to be evaluated using authentic patient cards used in simulation exercises before being used in actual triage scenarios.
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Evidence-based Principles of Time, Triage and Treatment; Refining the Initial Medical Response to Massive Casualty Incidents. J Trauma Acute Care Surg 2022; 93:S160-S164. [PMID: 35583968 DOI: 10.1097/ta.0000000000003699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The overall approach to massive casualty triage has changed little in the past 200 years. As the military and civilian organizations prepare for the possibility of future large scale combat operations, terrorist attacks and natural disasters, potentially involving hundreds or even thousands of casualties, a modified approach is needed to conduct effective triage, initiate treatment and save as many lives as possible. METHODS Military experience and review of analyses from the Department of Defense Trauma Registry are combined to introduce new concepts in triage and initial casualty management. FINDINGS The classification of the scale of MASCAL, timeline of lifesaving interventions, immediate first pass actions prior to formal triage decisions during the first hour after injury, simplification of triage decisions, and the understanding that ultra-MASCAL will primarily require casualty movement and survival needs with few prehospital life-saving medical interventions are discussed. CONCLUSION Self-aid, bystander and first responder interventions are paramount and should be trained and planned extensively. Military and disaster planning should not only train these concepts, but should seek innovations to extend the timelines of effectiveness and to deliver novel capabilities within the timelines to the greatest extent possible. LEVEL OF EVIDENCE Level III, Prognostic and Epidemiological.
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Bazyar J, Farrokhi M, Salari A, Safarpour H, Khankeh HR. Accuracy of Triage Systems in Disasters and Mass Casualty Incidents; a Systematic Review. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e32. [PMID: 35573710 PMCID: PMC9078064 DOI: 10.22037/aaem.v10i1.1526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction To prioritize patients to provide them with proper services and also manage the scarce resources in emergencies, the use of triage systems seems to be essential. The aim of this study was to evaluate the accuracy of the existing triage systems in disasters and mass casualty incidents. Methods The present study is a systematic review of the accuracy of all triage systems worldwide. The results of this study were based on the articles published in English language journals. In this research, all papers published from the beginning of 2000 to the end of 2021 were sought through different databases. Finally, a total of 13 articles was ultimately selected from 89 articles. Results 13 studies on the accuracy of triage systems were reviewed. The START, mSTART, SALT, Smart, Care Flight, ASAV, MPTT, Sieve and ESI triage systems, had an accuracy, sensitivity, and specificity of less than 90%. Only the Smart triage system had an overall accuracy of more than 90%. Conclusion According to the findings of the current systematic review, the performance of the existing triage systems in terms of accuracy of prioritizing the injured people and other performance indexes is not desirable. Therefore, to improve the performance and increase the precision of triage systems, the world nations are recommended to change or revise the indexes used in triage models and also identify other influential factors affecting the accuracy of triage systems.
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Affiliation(s)
- Jafar Bazyar
- Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.,Department of Nursing, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran.,Pre-hospital Medical Emergency organization, Ilam university of Medical Sciences, Ilam, Iran
| | - Mehrdad Farrokhi
- Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Amir Salari
- Department of Health in Emergencies and Disasters, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Safarpour
- Department of Nursing, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran.,Non-Communicable Diseases Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Hamid Reza Khankeh
- Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.,Corresponding Author: Hamid Reza Khankeh; Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. , Tel: +98 021 2218 0160, ORCID: https://orcid.org/0000-0002-9532-5646
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Abstract
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.
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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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Gamberini L, Imbriaco G, Ingrassia PL, Mazzoli CA, Badiali S, Colombo D, Carenzo L, Flauto A, Tengattini M, Merlo F, Azzaretto M, Monesi A, Candido F, Coniglio C, Gordini G, Della Corte F. Logistic Red Flags in Mass-Casualty Incidents and Disasters: A Problem-Based Approach. Prehosp Disaster Med 2022; 37:1-8. [PMID: 35109964 DOI: 10.1017/s1049023x22000188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Mass-casualty incidents (MCIs) and disasters are characterized by a high heterogeneity of effects and may pose important logistic challenges that could hamper the emergency rescue operations.The main objective of this study was to establish the most frequent logistic challenges (red flags) observed in a series of Italian disasters with a problem-based approach and to verify if the 80-20 rule of the Pareto principle is respected. METHODS A series of 138 major events from 1944 through 2020 with a Disaster Severity Score (DSS) ≥ four and five or more victims were analyzed for the presence of twelve pre-determined red flags.A Pareto graph was built considering the most frequently observed red flags, and eventual correlations between the number of red flags and the components of the DSS were investigated. RESULTS Eight out of twelve red flags covered 80% of the events, therefore not respecting the 80-20 rule; the number of red flags showed a low positive correlation with most of the components of the DSS score. The Pareto analysis showed that potential hazards, casualty nest area > 2.5km2, number of victims over 50, evacuation noria over 20km, number of nests > five, need for extrication, complex access to victims, and complex nest development were the most frequently observed red flags. CONCLUSIONS Logistic problems observed in MCIs and disaster scenarios do not follow the 80-20 Pareto rule; this demands for careful and early evaluation of different logistic red flags to appropriately tailor the rescue response.
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Affiliation(s)
- Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Guglielmo Imbriaco
- Emilia Est Emergency Dispatch Center - Helicopter Emergency Medical Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
- Critical Care Nursing Master course, University of Bologna, Italy
| | - Pier Luigi Ingrassia
- Centro di Simulazione (CeSi), Centro Professionale Sociosanitario, Lugano, Switzerland
| | - Carlo Alberto Mazzoli
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Stefano Badiali
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Davide Colombo
- CRIMEDIM Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Alfonso Flauto
- Emilia Est Emergency Dispatch Center - Helicopter Emergency Medical Service, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Marco Tengattini
- CRIMEDIM Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Federico Merlo
- CRIMEDIM Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Massimo Azzaretto
- CRIMEDIM Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Alessandro Monesi
- Critical Care Nursing Master course, University of Bologna, Italy
- Intensive Care Unit, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Fernando Candido
- Intensive Care Unit, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Carlo Coniglio
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Giovanni Gordini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Francesco Della Corte
- CRIMEDIM Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
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Cheng T, Staats K, Kaji AH, D'Arcy N, Niknam K, Donofrio‐Odmann JJ. Comparison of prehospital professional accuracy, speed, and interrater reliability of six pediatric triage algorithms. J Am Coll Emerg Physicians Open 2022; 3:e12613. [PMID: 35059689 PMCID: PMC8758976 DOI: 10.1002/emp2.12613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 10/27/2021] [Accepted: 11/10/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We evaluated prehospital professionals' accuracy, speed, interrater reliability, and impression in a pediatric disaster scenario both without a tool ("No Algorithm"-NA) and with 1 of 5 algorithms: CareFlight (CF), Simple Triage and Rapid Treatment (START) and JumpSTART (J-START), Pediatric Triage Tape (PTT), Sort, Assess, Life-saving interventions, Treatment/Transport (SALT), and Sacco Triage Method (STM). METHODS Prehospital professionals received disaster lectures, focusing on 1 triage algorithm. Then they completed a timed tabletop disaster exercise with 25 pediatric victims to measure speed. A predetermined criterion standard was used to assess accuracy of answers. Answers were compared to one another to determine the interrater reliability. RESULTS One hundred and seven prehospital professionals participated, with 15-28 prehospital professionals in each group. The accuracy was highest for STM (89.3%; 95% confidence interval [CI] 85.7% to 92.2%) and lowest for PTT (67.8%; 95% CI 63.4% to 72.1%). Accuracy of NA and SALT tended toward undertriage (15.8% and 16.3%, respectively). The remaining algorithms tended to overtriage, with PTT having the highest overtriage percentage (25.8%). The 3 fastest algorithms were: CF, SALT, and NA, all taking 5 minutes or less. STM was the slowest. STM demonstrated the highest interrater reliability, whereas CF and SALT demonstrated the lowest interrater reliability. CONCLUSIONS This study demonstrates the most common challenges inherent to mass casualty incident (MCI) triage systems: as accuracy and prehospital professional interrater reliability improve, speed slows. No triage algorithm in our study excelled in all these measures. Additional investigation of these algorithms in larger MCI drills requiring collection of vital signs in real time or during a real MCI event is needed.
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Affiliation(s)
| | | | - Amy H. Kaji
- Department of Emergency MedicineHarbor‐UCLA Medical CenterTorranceUSA
| | - Nicole D'Arcy
- Department of Emergency MedicineSanta Clara Valley Medical CenterSan JoseUSA
| | - Kian Niknam
- Department of Emergency MedicineStanford University Medical CenterPalo AltoUSA
| | - J. Joelle Donofrio‐Odmann
- Departments of Emergency Medicine and PediatricsUCSD; Rady Children's Hospital of San DiegoSan DiegoUSA
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Queirós Pokee D, Barbosa Pereira C, Mösch L, Follmann A, Czaplik M. Consciousness Detection on Injured Simulated Patients Using Manual and Automatic Classification via Visible and Infrared Imaging. SENSORS (BASEL, SWITZERLAND) 2021; 21:8455. [PMID: 34960551 PMCID: PMC8705922 DOI: 10.3390/s21248455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/26/2021] [Accepted: 12/15/2021] [Indexed: 12/02/2022]
Abstract
In a disaster scene, triage is a key principle for effectively rescuing injured people according to severity level. One main parameter of the used triage algorithm is the patient's consciousness. Unmanned aerial vehicles (UAV) have been investigated toward (semi-)automatic triage. In addition to vital parameters, such as heart and respiratory rate, UAVs should detect victims' mobility and consciousness from the video data. This paper presents an algorithm combining deep learning with image processing techniques to detect human bodies for further (un)consciousness classification. The algorithm was tested in a 20-subject group in an outside environment with static (RGB and thermal) cameras where participants performed different limb movements in different body positions and angles between the cameras and the bodies' longitudinal axis. The results verified that the algorithm performed better in RGB. For the most probable case of 0 degrees, RGB data obtained the following results: Mathews correlation coefficient (MMC) of 0.943, F1-score of 0.951, and precision-recall area under curve AUC (PRC) score of 0.968. For the thermal data, the MMC was 0.913, F1-score averaged 0.923, and AUC (PRC) was 0.960. Overall, the algorithm may be promising along with others for a complete contactless triage assessment in disaster events during day and night.
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Affiliation(s)
- Diana Queirós Pokee
- Acute Care Innovation Hub, Department of Anaesthesiology, RWTH Aachen University Hospital, 52074 Aachen, Germany; (C.B.P.); (L.M.); (A.F.); (M.C.)
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Simple triage and rapid treatment protocol for emergency department mass casualty incident victim triage. Am J Emerg Med 2021; 53:99-103. [PMID: 35007873 DOI: 10.1016/j.ajem.2021.12.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 11/21/2022] Open
Abstract
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.
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Gabbe BJ, Veitch W, Mather A, Curtis K, Holland AJA, Gomez D, Civil I, Nathens A, Fitzgerald M, Martin K, Teague WJ, Joseph A. Review of the requirements for effective mass casualty preparedness for trauma systems. A disaster waiting to happen? Br J Anaesth 2021; 128:e158-e167. [PMID: 34863512 DOI: 10.1016/j.bja.2021.10.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 01/06/2023] Open
Abstract
Mass casualty incidents (MCIs) are diverse, unpredictable, and increasing in frequency, but preparation is possible and necessary. The nature of MCIs requires a trauma response but also requires effective and tested disaster preparedness planning. From an international perspective, the aims of this narrative review are to describe the key components necessary for optimisation of trauma system preparedness for MCIs, whether trauma systems and centres meet these components and areas for improvement of trauma system response. Many of the principles necessary for response to MCIs are embedded in trauma system design and trauma centre function. These include robust communication networks, established triage systems, and capacity to secure centres from threats to safety and quality of care. However, evidence from the current literature indicates the need to strengthen trauma system preparedness for MCIs through greater trauma leader representation at all levels of disaster preparedness planning, enhanced training of staff and simulated disaster training, expanded surge capacity planning, improved staff management and support during the MCI and in the post-disaster recovery phase, clear provision for the treatment of paediatric patients in disaster plans, and diversified and pre-agreed systems for essential supplies and services continuity. Mass casualty preparedness is a complex, iterative process that requires an integrated, multidisciplinary, and tiered approach. Through effective preparedness planning, trauma systems should be well-placed to deliver an optimal response when faced with MCIs.
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Affiliation(s)
- Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Health Data Research UK, Swansea University Medical School, Swansea, UK.
| | - William Veitch
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anne Mather
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kate Curtis
- School of Medicine, University of Sydney, Sydney, Australia; Susan Wakil School of Nursing and Midwifery, University of Sydney, Sydney, Australia
| | - Andrew J A Holland
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney School of Medicine, Westmead, Australia
| | - David Gomez
- Division of General Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Canada
| | - Ian Civil
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Avery Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Mark Fitzgerald
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia; Trauma Service, The Alfred, Melbourne, Australia
| | - Kate Martin
- Department General Surgical Specialties, Royal Melbourne Hospital, Parkville, Australia
| | - Warwick J Teague
- Trauma Service, Royal Children's Hospital, Parkville, Australia; Surgical Research, Murdoch Children's Research Institute, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Anthony Joseph
- Royal North Shore Hospital Clinical School, School of Medicine, University of Sydney, St Leonards, Australia
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