A review of the literature on the validity of mass casualty triage systems with a focus on chemical exposures

Recommendations for Placement of Bleeding Control Kits in Public Spaces-A Simulation Study

OBJECTIVE

Bleeding control measures performed by members of the public can prevent trauma deaths. Equipping public spaces with bleeding control kits facilitates these actions. We modeled a mass casualty incident to investigate the effects of public bleeding control kit location strategies.

METHODS

We developed a computer simulation of a bomb exploding in a shopping mall. We used evidence and expert opinion to populate the model with parameters such as the number of casualties, the public's willingness to aid, and injury characteristics. Four alternative placement strategies of public bleeding control kits in the shopping mall were tested: co-located with automated external defibrillators (AEDs) separated by 90-second walking intervals, dispersed throughout the mall at 10 locations, located adjacent to 1 exit, located adjacent to 2 exits.

RESULTS

Placing bleeding control kits at 2 locations co-located with AEDs resulted in the most victims surviving (18.2), followed by 10 kits dispersed evenly throughout the mall (18.0). One or 2 kit locations placed at the mall's main exits resulted in the fewest surviving victims (15.9 and 16.1, respectively).

CONCLUSIONS

Co-locating bleeding control kits with AEDs at 90-second walking intervals results in the best casualty outcomes in a modeled mass casualty incident in a shopping mall.

Evidence-based Principles of Time, Triage and Treatment; Refining the Initial Medical Response to Massive Casualty Incidents

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.

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

INTRODUCTION

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Assessment of earthquake casualties and comparison of accuracy of five injury triage methods: evidence from a retrospective study

OBJECTIVE

The use of an injury triage method among earthquake injury patients can facilitate the reasonable allocation of resources, but the various existing injury triage methods need further confirmation. This study aims to assess the accuracy of several injury triage methods, namely, the Simple Triage and Rapid Treatment (START) technique; CareFlight Injury Triage (CareFlight); Rapid Emergency Medicine Score (REMS); Triage Revised Trauma Score (T-RTS) and Triage Early Warning Score (TEWS), based on their effects on earthquake injury patients.

DESIGN

Data in the Huaxi Earthquake Casualty Database were analysed retrospectively.

SETTING

This study was conducted in China.

PARTICIPANTS

Data on 29 523 earthquake casualties were separately evaluated using the START technique, CareFlight, REMS, T-RTS and TEWS, with these being the five types of injury triage studied.

PRIMARY OUTCOME MEASURE

The receiver operating characteristic (ROC) curves for the five injury triages were calculated based on hospital deaths, injury severity scores greater than 15 points, and whether casualties stayed in the intensive care unit.

RESULTS

The ROC curve areas of the START technique, CareFlight, REMS, T-RTS and TEWS were 0.750, 0.737, 0.835, 0.736 and 0.797, respectively. Among the five injury triages, the most accurate in predicting hospital deaths was REMS, with an average area under the curve (AUC) of 0.835, with this due to the inclusion of more evaluation indicators.

CONCLUSION

All methods had an effect on the triage of earthquake mass casualties. Among them, the REMS injury triage method had the largest AUC of the five triage methods. Except for REMS, no obvious difference was found in the effect of the other four injury triage methods.

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

Background

There is no global consensus on the use of prehospital triage system in mass casualty incidents. The purpose of this study was to evaluate the most commonly used pre-existing prehospital triage systems for the possibility of creating one universal translational triage tool.

Methods

The Rapid Evidence Review consisted of (1) a systematic literature review (2) merging and content analysis of the studies focusing on similarities and differences between systems and (3) development of a universal system.

Results

There were 17 triage systems described in 31 eligible articles out of 797 identified initially. Seven of the systems met the predesignated criteria and were selected for further analysis. The criteria from the final seven systems were compiled, translated and counted for in means of 1/7’s. As a product, a universal system was created of the majority criteria.

Conclusions

This study does not create a new triage system itself but rather identifies the possibility to convert various prehospital triage systems into one by using a triage translational tool. Future research should examine the tool and its different decision-making steps either by using simulations or by experts’ evaluation to ensure its feasibility in terms of speed, continuity, simplicity, sensitivity and specificity, before final evaluation at prehospital level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00932-z.

Simulated Mass Casualty Incident Triage Exercise for Training Medical Personnel

Audience

The target audience is any medical professional who requires training in mass casualty incident (MCI) triage. This could apply to pre-hospital specialists, nurses, medical students, residents, and physicians.

Introduction

Emergency medicine specialists must be able to triage patients quickly, especially in an MCI scenario. The simple triage and rapid treatment (START) system allows providers to categorize patients according to the urgency with which patients must access limited resources. Providers should be comfortable utilizing the START triage system before an MCI or disaster so that they can be prepared to implement it if necessary. This exercise uses simulation and gamification as instructional strategies to encourage knowledge of and comfort with the START triage system for emergency providers.

Educational Objectives

By the end of this exercise, learners should be able to (1) recite the basic START patient categories (2) discuss the physical exam signs associated with each START category, (3) assign roles to medical providers in a mass casualty scenario, (4) accurately categorize patients into triage categories: green, yellow, red, and black, and (5) manage limited resources when demand exceeds availability.

Educational Methods

Gamification is the use of elements of game design in non-game contexts.1 Gamification was implemented in this scenario by assigning participants to roles and teams, while creating an engaging, fun, and competitive environment. The exercise also uses low fidelity simulation (without simulation equipment) to encourage learners to practice using the START triage system in a low stakes environment.2 It is possible for the learners to be divided into two groups that each have the same patients, resources, and objectives. The team that finishes triaging all patients first would be declared the winner. However, in our implementation, we completed the exercise as a single group of learners and patients.

Research Methods

Learners were given a survey at the end of implementation and also given the opportunity to discuss feedback with the instructors in a group discussion after completing the exercise. There was no formal assessment completed after the exercise.

Results

Informal feedback was collected at the end of the exercise. Residents and medical students all enjoyed the experience. The feedback was overwhelmingly positive. All participants providing feedback stated they would enjoy participating in the exercise again and suggested that it is implemented annually for review of triage topics. We also received informal feedback for suggested changes which we will discuss in this article. An optional, anonymous survey was given to participants at the end of the exercise. There were six responses. Of those surveyed, 100% of participants stated the effectiveness and value of the exercise was outstanding (a rating of five on a scale of one to five). Regarding the quality of the exercise, and whether the participants felt engaged, 100% of responses gave a rating of five. When asked to consider the relevance of the session, 100% of participants selected a score of five ("I loved this session"). Regarding whether the content was applicable to practice of emergency medicine, 80% of respondents stated the session was highly relevant and 20% of responses selected a score of mostly relevant. One question asked for points of improvement for the session to which there were no responses.

Discussion

Learners were assigned roles in the exercise by the incident commander, fulfilling objective three. The START categories were discussed at the beginning of the exercise by the lead proctor (using PowerPoint) and then utilized throughout the exercise, thus accomplishing objectives one and two. The residents/students filling the triage roles were primarily responsible for fulfilling objective four; however, all participants assisted in categorization of patients throughout the exercise. Finally, objective five was addressed through the various social situations and complications that can be implemented during the exercise. We chose not to implement the additional "radiation contamination" scenario (details available in the article text) due to time constraints; however, this is an additional option to address objective five. The implementation was effective based on informal feedback from participants and proctors as well as evidenced by the responses to the anonymous survey. Learners found the aspects of resource management, review of START triage, repetition of the START triage system, and medical management of various types of trauma informative and meaningful. We received valuable feedback from both learners and proctors, which we will discuss in this article.

Topics

Mass casualty incident, disaster, START, gamification, simulation, emergency medicine, triage, triage category, contamination, teamwork, trauma, projectile trauma, penetrating injury, blunt trauma, intracranial hemorrhage, fracture, trauma in pregnancy, active shooter, radiation, radio communication.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Designing and executing a functional exercise to test a novel informatics tool for mass casualty triage

OBJECTIVE

The testing of informatics tools designed for use during mass casualty incidents presents a unique problem as there is no readily available population of victims or identical exposure setting. The purpose of this article is to describe the process of designing, planning, and executing a functional exercise to accomplish the research objective of validating an informatics tool specifically designed to identify and triage victims of irritant gas syndrome agents.

MATERIALS AND METHODS

During a 3-year time frame, the research team and partners developed the Emergency Department Informatics Computational Tool and planned a functional exercise to test it using medical records data from 298 patients seen in 1 emergency department following a chlorine gas exposure in 2005.

RESULTS

The research team learned valuable lessons throughout the planning process that will assist future researchers with developing a functional exercise to test informatics tools. Key considerations for a functional exercise include contributors, venue, and information technology needs (ie, hardware, software, and data collection methods).

DISCUSSION

Due to the nature of mass casualty incidents, testing informatics tools and technology for these incidents is challenging. Previous studies have shown a functional exercise as a viable option to test informatics tools developed for use during mass casualty incidents.

CONCLUSION

Utilizing a functional exercise to test new mass casualty management technology and informatics tools involves a painstaking and complex planning process; however, it does allow researchers to address issues inherent in studying informatics tools for mas casualty incidents.

Operation continued care: A large mass-casualty, full-scale exercise as a test of regional preparedness

BACKGROUND

Our regional trauma organization, which comprises 7 trauma centers, 30 acute care hospitals and free-standing emergency departments, and 42 emergency medical services agencies, conducted possibly the largest mass-casualty drill to date, totaling 445 victims at 3 sites involving 11 hospitals and 25 agencies and organizations.

METHODS

The drill was preceded by a tabletop exercise 4 months beforehand called Operation Continued Care Full-Scale Exercise, which consisted of simulated terrorist events at 3 sites to wound 445 moulaged patients. Four law enforcement and 5 fire and emergency medical services departments and 16 supporting organizations and agencies were involved in transporting patients to 11 different hospitals. The 7 objectives for the event addressed coordinating emergency operations, sustaining adequate communications, updating regional bed status, processing resource requests, triaging patients, tracking patients, and patient identification.

RESULTS

Of the 445 transported patients, 270 (60%) were entered correctly into the state patient tracking system; 68 (25.2%) upgrades and 34 (12.6%) downgrades from scene triage categories were noted. Multiple opportunities for improvement were identified, with major weaknesses noted in communication and coordination from event sites to the regional trauma organizations and hospitals.

CONCLUSION

The size and complexity of the drill provided experience and knowledge to facilitate future disaster preparedness and highlighted weaknesses in communication and coordination. Large, multijurisdictional, multiagency exercises provide opportunities to stress, evaluate, and improve regional disaster preparedness.

Pediatric disaster preparedness: identifying challenges and opportunities for emergency department planning

PURPOSE OF REVIEW

To review the current literature on best practices for pediatric disaster preparedness in an emergency department (ED).

RECENT FINDINGS

Children have unique anatomical, physiologic, immunologic, and psychosocial needs that impact their vulnerability to and resilience in a disaster, yet they have been historically underrepresented in disaster planning at local and national levels. Lessons learned from recent disaster events, disaster research, and disaster experts provide guidance on pediatric disaster preparedness for ED.

SUMMARY

All EDs should include children in their disaster plans and exercises. ED staff should be knowledgeable about their role in institutional disaster operations and familiar with standard disaster management principles.

Clinical Management of Patients Infected with Highly Pathogenic Microorganisms

The clinical management of high consequence infectious diseases (HCID) poses an immense challenge, seen largely varying standards in terms of infection prevention control (IPC) as well as in quality of clinical care. This chapter gives an overview of possible treatment as well as IPC options. Lessons learned within the German Permanent Working Group of Competence and Treatment Centres for highly infectious, life-threatening diseases (STAKOB) are taken into account.

Intuitive versus Algorithmic Triage

Introduction

The most commonly used methods for triage in mass-casualty incidents (MCIs) rely upon providers to take exact counts of vital signs or other patient parameters. The acuity and volume of patients which can be present during an MCI makes this a time-consuming and potentially costly process.

Hypothesis

This study evaluates and compares the speed of the commonly used Simple Triage and Rapid Treatment (START) triage method with that of an “intuitive triage” method which relies instead upon the abilities of an experienced first responder to determine the triage category of each victim based upon their overall first-impression assessment. The research team hypothesized that intuitive triage would be faster, without loss of accuracy in assigning triage categories.

Methods

Local adult volunteers were recruited for a staged MCI simulation (active-shooter scenario) utilizing local police, Emergency Medical Services (EMS), public services, and government leadership. Using these same volunteers, a cluster randomized simulation was completed comparing START and intuitive triage. Outcomes consisted of the time and accuracy between the two methods.

Results

The overall mean speed of the triage process was found to be significantly faster with intuitive triage (72.18 seconds) when compared to START (106.57 seconds). This effect was especially dramatic for Red (94.40 vs 138.83 seconds) and Yellow (55.99 vs 91.43 seconds) patients. There were 17 episodes of disagreement between intuitive triage and START, with no statistical difference in the incidence of over- and under-triage between the two groups in a head-to-head comparison.

Conclusion:

Significant time may be saved using the intuitive triage method. Comparing START and intuitive triage groups, there was a very high degree of agreement between triage categories. More prospective research is needed to validate these results.

HartA, NammourE, MangoldsV, BroachJ. Intuitive versus algorithmic triagePrehosp Disaster Med.2018;33(4):355–361.

Mobile Decision Support Tool for Emergency Departments and Mass Casualty Incidents (EDIT): Initial Study

BACKGROUND

Chemical exposures pose a significant threat to life. A rapid assessment by first responders and emergency nurses is required to reduce death and disability. Currently, no informatics tools exist to process victims of chemical exposures efficiently. The surge of patients into a hospital emergency department during a mass casualty incident creates additional stress on an already overburdened system, potentially placing patients at risk and challenging staff to process patients for appropriate care and treatment efficacy. Traditional emergency department triage models are oversimplified during highly stressed mass casualty incident scenarios in which there is little margin for error. Emerging mobile technology could alleviate the burden placed on nurses by allowing the freedom to move about the emergency department and stay connected to a decision support system.

OBJECTIVE

This study aims to present and evaluate a new mobile tool for assisting emergency department personnel in patient management and triage during a chemical mass casualty incident.

METHODS

Over 500 volunteer nurses, students, and first responders were recruited for a study involving a simulated chemical mass casualty incident. During the exercise, a mobile application was used to collect patient data through a kiosk system. Nurses also received tablets where they could review patient information and choose recommendations from a decision support system. Data collected was analyzed on the efficiency of the app to obtain patient data and on nurse agreement with the decision support system.

RESULTS

Of the 296 participants, 96.3% (288/296) of the patients completed the kiosk system with an average time of 3 minutes, 22 seconds. Average time to complete the entire triage process was 5 minutes, 34 seconds. Analysis of the data also showed strong agreement among nurses regarding the app's decision support system. Overall, nurses agreed with the system 91.6% (262/286) of the time when it came to choose an exposure level and 84.3% (241/286) of the time when selecting an action.

CONCLUSIONS

The app reliably demonstrated the ability to collect patient data through a self-service kiosk system thus reducing the burden on hospital resources. Also, the mobile technology allowed nurses the freedom to triage patients on the go while staying connected to a decision support system in which they felt would give reliable recommendations.

Validation of a novel irritant gas syndrome triage algorithm

OBJECTIVE

Our objective was to validate a novel irritant gas syndrome agent (IGSA) triage algorithm for use in an emergency department (ED). We assessed efficiency, accuracy, and precision of our IGSA triage algorithm based on signs/symptoms of actual patients.

DESIGN

After characterizing the signs/symptoms of an actual IGSA exposure event, we developed and validated the IGSA triage algorithm using a simulated computer exercise to compare the IGSA triage algorithm to the preferred hospital triage algorithm, the Emergency Severity Index (ESI).

SETTING

This study was a simulated computer exercise using surveys developed in Research Electronic Data Capture software. Nurse volunteers simulated triaging 298 patients.

PARTICIPANTS

Patient data included 146 patients treated during the disaster as well as 152 unexposed patients. Twenty-six nurse volunteers were assigned to triage the patients using one of the algorithms in the simulated computer exercise.

MAIN OUTCOME MEASURE(S)

The precision of the IGSA triage algorithm was 0.82 (confidence interval [CI] 0.78-0.85) and ESI 0.73 (CI 0.69-0.77). Weighted κ for ESI and IGSA accuracy for exposed patients was 0.32 (95% CI 0.26-0.37) and 0.81 (95% CI 0.77-0.85), respectively.

RESULTS

The IGSA triage algorithm was more accurate and precise than the ESI algorithm for triaging patients exposed to an irritant gas.

CONCLUSIONS

This study validates the IGSA triage algorithm as the basis for the development of a prototype software application to quickly identify victims of a chemical disaster and triage patients efficiently and accurately with the potential to dramatically improve the processing of patients in EDs.

Analysis of performance and stress caused by a simulation of a mass casualty incident

OBJECTIVE

To determine the stress that is potentially produced in professional health workers due to a mass casualty incident (MCI) simulated exercise, and its relation to prior academic training and the role played in the simulation.

METHODS

Observational study of stress in a MCI. For this work, two MCI drills comprised of 40 victims each were conducted. Two randomized groups of 36 students each were created: Master's Students Group (MSG) and Undergraduate Student Group (USG). The role performed by each student (triage or sectorization) was assessed. The stress level was determined by prior and subsequent measurements of alpha-amylase (αA), HR, SBP and DBP.

RESULTS

The percentage of victims that were correctly triaged was 88.6%, 91.84% for MSG and 83.76% for the USG (p=0.004). The basal αA was 97,107.50±72,182.67IU/L and the subsequent αA was 136,195.55±90,176.46±IU/L (p<0.001). The baseline HR was 78.74±14.92beats/min and the subsequent HR was 95.65±23.59beats/min (p=0.000). We found significant differences in the αA between students who performed the triage and those who performed sectorization but there were no differences between undergraduate and Masters' students.

CONCLUSION

Conducting a simulated exercise caused stress in personnel involved in the MCI, with a greater impact on participants who performed triage, although it was not influenced by their prior academic level. The stress level in our case did not affect or determine the performance of acquired skills.

Data Capture and Analysis of Signs and Symptoms in a Chemically Exposed Population

This manuscript provides a practical case study to demonstrate data collection from paper-based medical records so that the occurrence of specific signs/symptoms indicative of a chemical exposure can be studied.

Experiences of civilian nurses in triage during the Iran-Iraq War: An oral history

PURPOSE

Nurses played a critical role in performing triage during the Iran-Iraq War. However, their experiences in triage have not been discussed. Therefore, the current study aimed to investigate the triage experiences of civilian nurses during the Iran-Iraq War.

METHODS

Oral history method and in-depth interviews were used to collect data to gain the nurses' experiences in triage.

RESULTS

Four themes were extracted from the data, which were the development of triage, challenging environment to perform triage, development of mobile triage teams, and challenges of triage chemical victims for nurses.

CONCLUSION

Triage is an important skill for nurses to manage critical situations such as disasters and wars. Nurses have to be competent in performing triage. Involvement in critical situations helps the nurses learn and gain more experience on how to manage unexpected events.

Validating Signs and Symptoms From An Actual Mass Casualty Incident to Characterize An Irritant Gas Syndrome Agent (IGSA) Exposure: A First Step in The Development of a Novel IGSA Triage Algorithm

CONTRIBUTION TO EMERGENCY NURSING PRACTICE

• Chemical exposures daily pose a significant threat to life. Rapid assessment by first responders/emergency nurses is required to reduce death and disability. Currently, no informatics tools for Irritant Gas Syndrome Agents (IGSA) exposures exist to process victims efficiently, continuously monitor for latent signs/symptoms, or make triage recommendations. • This study uses actual patient data from a chemical incident to characterize and validate signs/symptoms of an IGSA Syndrome. Validating signs/symptoms is the first step in developing new emergency department informatics tools with the potential to revolutionize the process by which emergency nurses manage triage victims of chemical incidents.

ABSTRACTINTRODUCTION

Chemical exposures can pose a significant threat to life. Rapid assessment by first responders/emergency nurses is required to reduce death and disability. Currently, no informatics tools for irritant gas syndrome agents (IGSA) exposures exist to process victims efficiently, continuously monitor for latent signs/symptoms, or make triage recommendations. This study describes the first step in developing ED informatics tools for chemical incidents: validation of signs/symptoms that characterize an IGSA syndrome.

METHODS

Data abstracted from 146 patients treated for chlorine exposure in one emergency department during a 2005 train derailment and 152 patients not exposed to chlorine (a comparison group) were mapped to 93 possible signs/symptoms within 2 tools (WISER and CHEMM-IST) designed to assist emergency responders/emergency nurses with managing hazardous material exposures. Inferential statistics (χ²/Fisher's exact test) and diagnostics tests were used to examine mapped signs/symptoms of persons who were and were not exposed to chlorine.

RESULTS

Three clusters of signs/symptoms are statistically associated with an IGSA syndrome (P < .01): respiratory (shortness of breath, wheezing, coughing, and choking); chest discomfort (tightness, pain, and burning), and eye, nose and/or throat (pain, irritation, and burning). The syndrome requires the presence of signs/symptoms from at least 2 of these clusters. The latency period must also be considered for exposed/potentially exposed persons.

DISCUSSION

This study uses actual patient data from a chemical incident to characterize and validate signs/symptoms of an IGSA syndrome. Validating signs/symptoms is the first step in developing new ED informatics tools with the potential to revolutionize the process by which emergency nurses manage triage victims of chemical incidents.

The 2015 Nepal Earthquake(s): Lessons Learned From the Disability and Rehabilitation Sector's Preparation for, and Response to, Natural Disasters

The frequency of natural disasters appears to be mounting at an alarming rate, and the degree to which people are surviving such traumatic events also is increasing. Postdisaster survival often triggers increases in population and individual disability-related outcomes in the form of impairments, activity limitations, and participation restrictions, all of which have an important impact on the individual, his or her family, and their community. The increase in postdisaster disability-related outcomes has provided a rationale for the increased role of the disability and rehabilitation sector's involvement in emergency response, including physical therapists. A recent major earthquake that has drawn the world's attention occurred in the spring of 2015 in Nepal. The response of the local and international communities was large and significant, and although the collection of complex health and disability issues have yet to be fully resolved, there has been a series of important lessons learned from the 2015 Nepal earthquake(s). This perspective article outlines lessons learned from Nepal that can be applied to future disasters to reduce overall disability-related outcomes and more fully integrate rehabilitation in preparation and planning. First, information is presented on disasters in general, and then information is presented that focuses on the earthquake(s) in Nepal. Next, field experience in Nepal before, during, and after the earthquake is described, and actions that can and should be adopted prior to disasters as part of disability preparedness planning are examined. Then, the emerging roles of rehabilitation providers such as physical therapists during the immediate and postdisaster recovery phases are discussed. Finally, approaches are suggested that can be adopted to "build back better" for, and with, people with disabilities in postdisaster settings such as Nepal.

Primary Triage in a Mass-casualty Event Possesses a Risk of Increasing Informational Confusion: A Simulation Study Using Shannon's Entropy

Introduction Primary triage in a mass-casualty event setting using low-visibility tags may lead to informational confusion and difficulty in judging triage attribution of patients. In this simulation study, informational confusion during primary triage was investigated using a method described in a prior study that applied Shannon's Information Theory to triage. Hypothesis Primary triage using a low-visibility tag leads to a risk of informational confusion in prioritizing care, owing to the intermingling of pre- and post-triage patients. It is possible that Shannon's entropy evaluates the degree of informational confusion quantitatively and improves primary triage.

METHODS

The Simple Triage and Rapid Treatment (START) triage method was employed. In Setting 1, entropy of a triage area with 32 patients was calculated for the following situations: Case 1 - all 32 patients in the triage area at commencement of triage; Case 2 - 16 randomly imported patients to join 16 post-triage patients; Case 3 - eight patients imported randomly and another eight grouped separately; Case 4 - 16 patients grouped separately; Case 5 - random placement of all 32 post-triage patients; Case 6 - isolation of eight patients of minor priority level; Case 7 - division of all patients into two groups of 16; and Case 8 - separation of all patients into four categories of eight each. In Setting 2, entropies in the triage area with 32 patients were calculated continuously with each increase of four post-triage patients in Systems A and B (System A - triage conducted in random manner; and System B - triage arranged into four categories).

RESULTS

In Setting 1, entropies in Cases 1-8 were 2.00, 3.00, 2.69, 2.00, 2.00, 1.19, 1.00, and 0.00 bits/symbol, respectively. Entropy increased with random triage. In Setting 2, entropies of System A maintained values the same as, or higher than, those before initiation of triage: 2.00 bits/symbol throughout the triage. The graphic waveform showed a concave shape and took 3.00 bits/symbol as maximal value when the probability of each category was 1/8, whereas the values in System B showed a linear decrease from 2.00 to 0.00 bits/symbol.

CONCLUSION

Informational confusion in a primary triage area measured using Shannon's entropy revealed that random triage using a low-visibility tag might increase the degree of confusion. Methods for reducing entropy, such as enhancement of triage colors, may contribute to minimizing informational confusion. Ajimi Y , Sasaki M , Uchida Y , Kaneko I , Nakahara S , Sakamoto T . Primary triage in a mass-casualty event possesses a risk of increasing informational confusion: a simulation study using Shannon's entropy. Prehosp Disaster Med. 2016;31(5):498-504.

Preparedness of Finnish Emergency Medical Services for Chemical Emergencies

Introduction The preparedness level of Finnish Emergency Medical Services (EMS) for treating chemical emergencies is unknown. The aim of this study was to survey the preparedness level of EMS systems for managing and handling mass-casualty chemical incidents in the prehospital phase in Finland. Hypothesis The study hypothesis was that university hospital districts would have better clinical capability to treat patients than would central hospital districts in terms of the number of patients treated in the field within one hour after dispatching as well as patients transported to hospital within one hour or two hours after dispatching.

METHODS

This cross-sectional study was conducted as a Webropol (Wuppertal, Germany) survey. All hospital districts (n=20) in continental Finland were asked about their EMS preparedness level in terms of capability of treating and transporting chemically affected patients in the field. Their capability for decontamination of affected patients in the field was also inquired.

RESULTS

University hospital district-based EMS systems had at least 20% better absolute clinical capacity than central hospital-based EMS systems for treating chemically affected patients concerning all treatments inquired about, except the capacity for non-invasive ventilation (NIV)/continuous positive airway pressure (CPAP) treatment in the field. Overall, there was a good level of preparedness for treating chemical accident patients with supplemental oxygen, bronchodilators, and inhaled corticosteroids. Preparedness for providing antidote therapy in cases of cyanide gas exposure was, in general, low. The variation among the hospital districts was remarkable. Only nine of 15 central hospital district EMS had a mobile decontamination unit available, whereas four of five university hospital districts had one.

CONCLUSION

Emergency Medical Services capacity in Finland for treating chemically affected patients in the field needs to be improved, especially in terms of antidote therapy. Mobile decontamination units should be available in all hospital districts. Jama TJ , Kuisma MJ . Preparedness of Finnish Emergency Medical Services for chemical emergencies. Prehosp Disaster Med. 2016;31(4):392-396.

Emergency imaging after a mass casualty incident: role of the radiology department during training for and activation of a disaster management plan

In the setting of mass casualty incidents (MCIs), hospitals need to divert from normal routine to delivering the best possible care to the largest number of victims. This should be accomplished by activating an established hospital disaster management plan (DMP) known to all staff through prior training drills. Over the recent decades, imaging has increasingly been used to evaluate critically ill patients. It can also be used to increase the accuracy of triaging MCI victims, since overtriage (falsely higher triage category) and undertriage (falsely lower triage category) can severely impact resource availability and mortality rates, respectively. This article emphasizes the importance of including the radiology department in hospital preparations for a MCI and highlights factors expected to influence performance during hospital DMP activation including issues pertinent to effective simulation, such as establishing proper learning objectives. After-action reviews including performance evaluation and debriefing on issues are invaluable following simulation drills and DMP activation, in order to improve subsequent preparedness. Historically, most hospital DMPs have not adequately included radiology department operations, and they have not or to a little extent been integrated in the DMP activation simulation. This article aims to increase awareness of the need for radiology department engagement in order to increase radiology department preparedness for DMP activation after a MCI occurs.

A validation study of 5 triage systems using data from the 2005 Graniteville, South Carolina, chlorine spill

INTRODUCTION

Lack of outcomes-based research results in uncertainty about the effectiveness of any of the current triage systems in determining priority of care during actual chemical disasters. The purpose of this study was to determine whether the level of injury severity extrapolated from 5 triage systems correlated with actual injury severity outcomes of victims exposed to a chlorine disaster.

METHODS

Using secondary data analysis, data for 631 victims were merged, de-identified, and analyzed. Using logic models from the triage systems, the actual injury severity was compared with the extrapolated injury severity classifications.

RESULTS

Analysis showed weak to modest correlations between the extrapolated injury severity triage outcome classifications and the actual injury severity outcomes (Spearman correlation range 0.38 to 0.71, P < .0001). There was slight to fair agreement between the extrapolated injury severity triage outcome classifications and the actual injury severity outcomes (weighted κ = - 0.23 to 0.42).

DISCUSSION

The extrapolated injury severity triage outcome categories from the 5 triage systems did not agree with the actual injury severity categories. Oxygen saturation measured by pulse oximetry provides early indications and is very predictive of outcome severity in incidents involving irritant chemical exposures such as chlorine, and should be a part of a mass casualty protocol for any irritant chemical incident. Additional research is needed to identify the most sensitive clinical measures for triaging victims of toxic inhalation disasters.