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

Strengthening trauma resuscitation education and training in low-resource settings: A call for global inclusion

Trauma is a leading cause of preventable death worldwide, disproportionately affecting low-resource settings where access to specialized care is limited. Systemic barriers, including fragmented trauma networks and workforce shortages, contribute to poor outcomes. Strengthening trauma resuscitation through structured education and training is critical to improving survival and reducing disparities. However, traditional trauma training models often fail to address regional constraints, limiting their effectiveness. Brazil has developed a comprehensive trauma resuscitation education model by integrating public awareness campaigns, medical student-led initiatives, digital learning, simulation-based training, and telemedical support. A horizontal approach to trauma patient management, combined with hands-on immersive simulation training, has further enhanced this framework, emphasizing the team approach and non-technical skills essential for high-performance trauma care. This narrative review examines Brazil's trauma resuscitation training strategies and explores their potential to serve as a template for low-resource settings. By analyzing key educational components, we identify cost-effective solutions to strengthen trauma system capacity. To bridge disparities, trauma education must extend beyond well-resourced environments. Faculty development, sustainable mentorship, and access to technology-driven education are critical to equipping providers with the skills needed to manage complex trauma scenarios. Mobile simulation units and telemedicine platforms expand training to remote regions, while scalable digital platforms enable real-time collaboration. Despite these advancements, funding constraints, logistical barriers, and the need for culturally tailored education hinder widespread implementation. Embedding trauma education into national health policies and disaster response systems is essential to ensuring sustainable, high-quality trauma care worldwide.

The State of the Union: Trauma System Development in the United States

Injury is both a national and international epidemic that affects people of all age, race, religion, and socioeconomic class. Injury was the fourth leading cause of death in the United States (U.S.) in 2021 and results in an incalculable emotional and financial burden on our society. Despite this, when prevention fails, trauma centers allow communities to prepare to care for the traumatically injured patient. Using lessons learned from the military, trauma care has grown more sophisticated in the last 50 years. In 1966, the first civilian trauma center was established, bringing management of injury into the new age. Now, the American College of Surgeons recognizes 4 levels of trauma centers (I-IV), with select states recognizing Level V trauma centers. The introduction of trauma centers in the U.S. has been proven to reduce morbidity and mortality for the injured patient. However, despite the proven benefits of trauma centers, the U.S. lacks a single, unified, trauma system and instead operates within a "system of systems" creating vast disparities in the level of care that can be received, especially in rural and economically disadvantaged areas. In this review we present the history of trauma system development in the U.S, define the different levels of trauma centers, present evidence that trauma systems and trauma centers improve outcomes, outline the current state of trauma system development in the U.S, and briefly mention some of the current challenges and opportunities in trauma system development in the U.S. today.

Use of Mobile Technologies to Streamline Pretriage Patient Flow in the Emergency Department: Observational Usability Study

BACKGROUND

In emergency departments (EDs), triage nurses are under tremendous daily pressure to rapidly assess the acuity level of patients and log the collected information into computers. With self-service technologies, patients could complete data entry on their own, allowing nurses to focus on higher-order tasks. Kiosks are a popular working example of such self-service technologies; however, placing a sufficient number of unwieldy and fixed machines demands a spatial change in the greeting area and affects pretriage flow. Mobile technologies could offer a solution to these issues.

OBJECTIVE

The aim of this study was to investigate the use of mobile technologies to improve pretriage flow in EDs.

METHODS

The proposed stack of mobile technologies includes patient-carried smartphones and QR technology. The web address of the self-registration app is encoded into a QR code, which was posted directly outside the walk-in entrance to be seen by every ambulatory arrival. Registration is initiated immediately after patients or their proxies scan the code using their smartphones. Patients could complete data entry at any site on the way to the triage area. Upon completion, the result is saved locally on smartphones. At the triage area, the result is automatically decoded by a portable code reader and then loaded into the triage computer. This system was implemented in three busy metropolitan EDs in Shanghai, China. Both kiosks and smartphones were evaluated randomly while being used to direct pretriage patient flow. Data were collected during a 20-day period in each center. Timeliness and usability of medical students simulating ED arrivals were assessed with the After-Scenario Questionnaire. Usability was assessed by triage nurses with the Net Promoter Score (NPS). Observations made during system implementation were subject to qualitative thematic analysis.

RESULTS

Overall, 5928 of 8575 patients performed self-registration on kiosks, and 7330 of 8532 patients checked in on their smartphones. Referring effort was significantly reduced (43.7% vs 8.8%; P<.001) and mean pretriage waiting times were significantly reduced (4.4, SD 1.7 vs 2.9, SD 1.0 minutes; P<.001) with the use of smartphones compared to kiosks. There was a significant difference in mean usability scores for "ease of task completion" (4.4, SD 1.5 vs 6.7, SD 0.7; P<.001), "satisfaction with completion time" (4.5, SD 1.4 vs 6.8, SD 0.6; P<.001), and "satisfaction with support" (4.9, SD 1.9 vs 6.6, SD 1.2; P<.001). Triage nurses provided a higher NPS after implementation of mobile self-registration compared to the use of kiosks (13.3% vs 93.3%; P<.001). A modified queueing model was identified and qualitative findings were grouped by sequential steps.

CONCLUSIONS

This study suggests patient-carried smartphones as a useful tool for ED self-registration. With increased usability and a tailored queueing model, the proposed system is expected to minimize pretriage waiting for patients in the ED.

Incidence of overtriage and undertriage and associated factors: A cross-sectional study using a secondary data analysis

BACKGROUND

Improving triage accuracy for accurate patient identification and appropriate resource allocation is essential. Little is known about the trend of triage accuracy, and factors associated with mistriage vary from study to study.

AIM

To identify incidence and risk factors of mistriage, such as overtriage and undertriage.

DESIGN

This is a cross-sectional study.

METHODS

The data came from the National Emergency Department Information System database in 2016-2020. All patients 15 years and older visiting emergency departments in Korea were assessed for eligibility, and 20,641,411 emergency patients' data were used. Multivariable logistic regressions were conducted to confirm the associated factors with overtriage and undertriage compared to expected triage. Demographic characteristics, disease-related signs and triage-related factors were independent variables.

RESULTS

Expected triage decreased from 96.8% in 2016 to 95.7% in 2020. Overtriage (0.5%-0.7%) and undertriage (2.4%-3.3%) increased. The occupation that performed triage the most (over 85%) was nurses. Associated factors with overtriage were demographic characteristics (40-64 age group, female), disease-related signs (known disease, direct visit) and triage-related factors (regional emergency medical centre). Risk factors to undertriage were disease-related signs (systolic/diastolic blood pressure and pulse rates within normal range).

CONCLUSIONS

While the acuity degree remained within the recommended range, the accuracy of triage decreased, and there was a gradual increase in mistriaged cases. Nurses have performed most of the triage and played a key role in expected triage. Associated factors with overtriage were demographic characteristics, disease-related signs and triage-related factors and risk factors to undertriage were disease-related signs.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

IMPLICATIONS FOR THE PROFESSION

Nurses should be aware of what factors are associated with mistriage and why the factors cause mistriage to improve the triage accuracy because they are responsible for the majority of the triage assessments.

Performance of Google bard and ChatGPT in mass casualty incidents triage

AIM

The objective of our research is to evaluate and compare the performance of ChatGPT, Google Bard, and medical students in performing START triage during mass casualty situations.

METHOD

We conducted a cross-sectional analysis to compare ChatGPT, Google Bard, and medical students in mass casualty incident (MCI) triage using the Simple Triage And Rapid Treatment (START) method. A validated questionnaire with 15 diverse MCI scenarios was used to assess triage accuracy and content analysis in four categories: "Walking wounded," "Respiration," "Perfusion," and "Mental Status." Statistical analysis compared the results.

RESULT

Google Bard demonstrated a notably higher accuracy of 60%, while ChatGPT achieved an accuracy of 26.67% (p = 0.002). Comparatively, medical students performed at an accuracy rate of 64.3% in a previous study. However, there was no significant difference observed between Google Bard and medical students (p = 0.211). Qualitative content analysis of 'walking-wounded', 'respiration', 'perfusion', and 'mental status' indicated that Google Bard outperformed ChatGPT.

CONCLUSION

Google Bard was found to be superior to ChatGPT in correctly performing mass casualty incident triage. Google Bard achieved an accuracy of 60%, while chatGPT only achieved an accuracy of 26.67%. This difference was statistically significant (p = 0.002).

The role of Mangled Extremity Severity Score in amputation triage in a transport health facility with catastrophic earthquake admissions

BACKGROUND

The purpose of this study is to assess the diagnostic utility of the Mangled Extremity Severity Score (MESS) in the prediction of amputation after a major earthquake, and its utility in disaster triage.

METHODS

Study results were presented from a tertiary hospital in Diyarbakır, which was affected by the earthquake but served as a transport hub for other cities in the region affected by the earthquake. MESS was calculated and its diagnostic value is analyzed in predicting amputations. MESS scores were divided into low risk, intermediate risk, and high risk groups by the researchers based on their diagnostic value analysis.

RESULTS

79 patients were included in the study. Based on the outcome of amputation or salvage, patients were divided into two groups. 24.1% (n = 19) of the patients had amputations. Both gender and mean age did not differ statistically significantly between the groups (p > 0.05). Compared with the salvage group, the amputation group had a significantly longer prehospital stay and higher rate of vascular injury and higher median MESS (p = 0.007, p < 0.001, p < 0.001; respectively). Based on MESS scores, amputation outcomes were predicted with an accuracy of 0.889 (95% CI 0.798-0.949). Those with a MESS score below 9 were considered low risk (sensitivity = 100%) whereas those with a MESS score above 12 were considered high risk (specificity = 98.33%).

CONCLUSION

In transport centers, MESS may be useful for surgical triage of earthquake-induced limb crush injuries.

Impact of interhospital transfer on emergency department timeliness of care and in-hospital outcomes of adult non-trauma patients

Background

Patients who present to the emergency department (ED) from interhospital transfer (IHT) and non-IHT are known to have differences in various clinical outcomes including mortality. The ED timeliness of care is an effective indicator of the quality of ED care and operational efficiency. The impact of IHT on ED timeliness of care remains unclear. We evaluated the association between IHT and ED timeliness of care or in-hospital outcomes in adult non-trauma patients.

Methods

Data of consecutive hospital admission of adult non-trauma patients who visited the ED of a medical center from January 2018 to Jun 2020 were retrospectively analyzed. The patients were divided into IHT and non-IHT cohorts. Various data were recorded. The ED length of stay (LOS) was measured as the outcome of ED timeliness of care, while hospital LOS and in-hospital death were measured as the in-hospital outcomes. Multiple regression analyses were performed using unmatched and propensity-matched cohorts. In the later analyses, both groups were propensity matched for sex, age, and other covariates that showed significant differences between two groups to achieve a 1:4 balanced cohort.

Results

Data on 1856 IHT patients and 16295 non-IHT patients were analyzed. IHT was associated with a shorter ED LOS, longer hospital LOS, and higher odds of in-hospital death compared with non-IHT in unmatched and propensity-matched analyses. The shorter ED LOS was due to the slightly longer interval of arrival to ED physicians (∼1 min) and considerably shorter intervals of ED physicians to decision (∼120 min) and decision to departure (∼105 min). Risk stratification revealed that IHT was associated with a shorter ED LOS in patients with all levels (1-5) of Taiwan Triage and Acuity Scale (TTAS) and associated with longer hospital LOS and higher odds of in-hospital death in patients with TTAS level ≥3.

Conclusions

IHT was associated with a shorter ED LOS, longer hospital LOS, and higher odds of in-hospital death in adult non-trauma patients compared with non-IHT. The expedited ED timeliness of care in the IHT cohort was due to considerably shorter intervals of both ED physicians to decision and decision to disposition.

Investigation of the usability of the REMS, RAPS, and MPM II0 scoring systems in the prediction of short-term and long-term mortality in patients presenting to the emergency department triage

BACKGROUND

Appropriate triage is an important component of patient management in emergency departments. The risk scoring system used for triage purposes in emergency departments should be obtained quickly and based on parameters directly related to prognosis.

AIMS

To investigate the success of the Rapid Emergency Medicine Score (REMS) and Rapid Acute Physiology Score (RAPS) as triage scoring systems and the Mortality Probability Model (MPM II₀) as an intensive care scoring system in identifying critical patients visited to the emergency department (ED) triage and predicting mortality, and to evaluate their superiority over each other, if any.

METHODS

This research was planned as a single-center and prospectively. The data of the study were obtained by screening the medical records of all patients who presented to the ED triage between January 1, 2020 and January 31, 2020. Patients under the age of 18 years, those with missing information in their files and pregnant women were not included in the study. Only the patients for whom the REMS, RAPS, and MPM II₀ scores could be calculated were included in the sample.

RESULTS

After excluding the patients who did not meet the inclusion criteria, the study was completed with 12,210 patients. The mean age of these patients was 44.7 ± 18.7 years, and 47.3% were male. The area under the receiver operating characteristics curve values for the prediction of 24-h, 30-day, 90-day, and 180-day mortality were determined as 0.979, 0.921, 0.904, and 0.897, respectively, for REMS; 0.929, 0.778, 0.75, and 0.725, respectively, for RAPS; and 0.925, 0.888, 0.866, and 0.861, respectively, for MPM II₀.

CONCLUSIONS

In this study, it was concluded that the REMS score was superior to the MPM II₀ and RAPS scores in predicting the short-term and long-term mortality status of patients and determining the discharge and hospitalization status of the patients.