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Jerome D, Savage DW, Pietrosanu M. An assessment of mass casualty triage systems using the Alberta trauma registry. CAN J EMERG MED 2023; 25:659-666. [PMID: 37306923 DOI: 10.1007/s43678-023-00529-8] [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: 12/07/2022] [Accepted: 05/23/2023] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Triage is the process of identifying patients with both the greatest clinical need and the greatest likelihood of benefit in the setting of limited clinical resources. The primary objective of this study was to assess the ability of formal mass casualty incident triage tools to identify patients requiring urgent lifesaving interventions. METHODS Data from the Alberta Trauma Registry (ATR) was used to assess seven triage tools: START, JumpSTART, SALT, RAMP, MPTT, BCD and MITT. Clinical data captured in the ATR was used to determine which triage category each of the seven tools would have applied to each patient. These categorizations were compared to a reference standard definition based on the patients' need for specific urgent lifesaving interventions. RESULTS Of the 9448 records that were captured 8652 were included in our analysis. The most sensitive triage tool was MPTT, which demonstrated a sensitivity of 0.76 (0.75, 0.78). Four of the seven triage tools evaluated had sensitivities below 0.45. JumpSTART had the lowest sensitivity and the highest under-triage rate for pediatric patients. All the triage tools evaluated had a moderate to high positive predictive value (> 0.67) for patients who had experienced penetrating trauma. CONCLUSIONS There was a wide range in the sensitivity of triage tools to identify patients requiring urgent lifesaving interventions. MPTT, BCD and MITT were the most sensitive triage tools assessed. All of the triage tools assessed should be employed with caution during mass casualty incidents as they may fail to identify a large proportion of patients requiring urgent lifesaving interventions.
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Affiliation(s)
- David Jerome
- Division of Clinical Sciences, NOSM University, Thunder Bay, ON, Canada.
- Department of Family Medicine, University of Alberta, Edmonton, AB, Canada.
| | - David W Savage
- Division of Clinical Sciences, NOSM University, Thunder Bay, ON, Canada
| | - Matthew Pietrosanu
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, Canada
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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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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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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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METASTART: A Systematic Review and Meta-Analysis of the Diagnostic Accuracy of the Simple Triage and Rapid Treatment (START) Algorithm for Disaster Triage. Prehosp Disaster Med 2021; 37:106-116. [PMID: 34915954 DOI: 10.1017/s1049023x2100131x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The goal of disaster triage at both the prehospital and in-hospital level is to maximize resources and optimize patient outcomes. Of the disaster-specific triage methods developed to guide health care providers, the Simple Triage and Rapid Treatment (START) algorithm has become the most popular system world-wide. Despite its appeal and global application, the accuracy and effectiveness of the START protocol is not well-known. OBJECTIVES The purpose of this meta-analysis was two-fold: (1) to estimate overall accuracy, under-triage, and over-triage of the START method when used by providers across a variety of backgrounds; and (2) to obtain specific accuracy for each of the four START categories: red, yellow, green, and black. METHODS A systematic review and meta-analysis was conducted that searched Medline (OVID), Embase (OVID), Global Health (OVID), CINAHL (EBSCO), Compendex (Engineering Village), SCOPUS, ProQuest Dissertations and Theses Global, Cochrane Library, and PROSPERO. The results were expanded by hand searching of journals, reference lists, and the grey literature. The search was executed in March 2020. The review considered the participants, interventions, context, and outcome (PICO) framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Accuracy outcomes are presented as means with 95% confidence intervals (CI) as calculated using the binomial method. Pooled meta-analyses of accuracy outcomes using fixed and random effects models were calculated and the heterogeneity was assessed using the Q statistic. RESULTS Thirty-two studies were included in the review, most of which utilized a non-randomized study design (84%). Proportion of victims correctly triaged using START ranged from 0.27 to 0.99 with an overall triage accuracy of 0.73 (95% CI, 0.67 to 0.78). Proportion of over-triage was 0.14 (95% CI, 0.11 to 0.17) while the proportion of under-triage was 0.10 (95% CI, 0.072 to 0.14). There was significant heterogeneity of the studies for all outcomes (P < .0001). CONCLUSION This meta-analysis suggests that START is not accurate enough to serve as a reliable disaster triage tool. Although the accuracy of START may be similar to other models of disaster triage, development of a more accurate triage method should be urgently pursued.
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Vassallo J, Chernbumroong S, Malik N, Xu Y, Keene D, Gkoutos G, Lyttle MD, Smith J. Comparative analysis of major incident triage tools in children: a UK population-based analysis. Emerg Med J 2021; 39:emermed-2021-211706. [PMID: 34706900 PMCID: PMC9510399 DOI: 10.1136/emermed-2021-211706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/08/2021] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Triage is a key principle in the effective management of major incidents. There is currently a paucity of evidence to guide the triage of children. The aim of this study was to perform a comparative analysis of nine adult and paediatric triage tools, including the novel 'Sheffield Paediatric Triage Tool' (SPTT), assessing their ability in identifying patients needing life-saving interventions (LSIs). METHODS A 10-year (2008-2017) retrospective database review of the Trauma Audit Research Network (TARN) Database for paediatric patients (<16 years) was performed. Primary outcome was identification of patients receiving one or more LSIs from a previously defined list. Secondary outcomes included mortality and prediction of Injury Severity Score (ISS) >15. Primary analysis was conducted on patients with complete prehospital physiological data with planned secondary analyses using first recorded data. Performance characteristics were evaluated using sensitivity, specificity, undertriage and overtriage. RESULTS 15 133 patients met TARN inclusion criteria. 4962 (32.8%) had complete prehospital physiological data and 8255 (54.5%) had complete first recorded physiological data. The majority of patients were male (69.5%), with a median age of 11.9 years. The overwhelming majority of patients (95.4%) sustained blunt trauma, yielding a median ISS of 9 and overall, 875 patients (17.6%) received at least one LSI. The SPTT demonstrated the greatest sensitivity of all triage tools at identifying need for LSI (92.2%) but was associated with the highest rate of overtriage (75.0%). Both the Paediatric Triage Tape (sensitivity 34.1%) and JumpSTART (sensitivity 45.0%) performed less well at identifying LSI. By contrast, the adult Modified Physiological Triage Tool-24 (MPTT-24) triage tool had the second highest sensitivity (80.8%) with tolerable rates of overtriage (70.2%). CONCLUSION The SPTT and MPTT-24 outperform existing paediatric triage tools at identifying those patients requiring LSIs. This may necessitate a change in recommended practice. Further work is needed to determine the optimum method of paediatric major incident triage, but consideration should be given to simplifying major incident triage by the use of one generic tool (the MPTT-24) for adults and children.
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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
| | - Saisakul Chernbumroong
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Nabeela Malik
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Yuanwei Xu
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Damian Keene
- Department of Anaesthesia, University Hospitals Birmingham, Birmingham, UK
| | - George Gkoutos
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- MRC Health Data Research UK (HDR UK), Birmingham, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Children's Hospital, 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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Peng Y, Hu H. Assessment of earthquake casualties and comparison of accuracy of five injury triage methods: evidence from a retrospective study. BMJ Open 2021; 11:e051802. [PMID: 34625415 PMCID: PMC8504360 DOI: 10.1136/bmjopen-2021-051802] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Yang Peng
- Center of Excellence for International Cooperation in Medicine, Sichuan University West China Hospital, Chengdu, Sichuan, China
- China International Emergency Medical Team (Type 3), Chengdu, Sichuan, China
| | - Hai Hu
- China International Emergency Medical Team (Type 3), Chengdu, Sichuan, China
- Emergency management office of West China Hospital, Sichuan University West China Hospital, Chengdu, Sichuan, China
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Malik NS, Chernbumroong S, Xu Y, Vassallo J, Lee J, Moran CG, Newton T, Arul GS, Lord JM, Belli A, Keene D, Foster M, Hodgetts T, Bowley DM, Gkoutos GV. Paediatric major incident triage: UK military tool offers best performance in predicting the need for time-critical major surgical and resuscitative intervention. EClinicalMedicine 2021; 40:101100. [PMID: 34746717 PMCID: PMC8548919 DOI: 10.1016/j.eclinm.2021.101100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Children are frequently injured during major incidents (MI), including terrorist attacks, conflict and natural disasters. Triage facilitates healthcare resource allocation in order to maximise overall survival. A critical function of MI triage tools is to identify patients needing time-critical major resuscitative and surgical intervention (Priority 1 (P1) status). This study compares the performance of 11 MI triage tools in predicting P1 status in children from the UK Trauma Audit and Research Network (TARN) registry. METHODS Patients aged <16 years within TARN (January 2008-December 2017) were included. 11 triage tools were applied to patients' first recorded pre-hospital physiology. Patients were retrospectively assigned triage categories (P1, P2, P3, Expectant or Dead) using predefined intervention-based criteria. Tools' performance in <16s were evaluated within four-yearly age subgroups, comparing tool-predicted and intervention-based priority status. FINDINGS Amongst 4962 patients, mortality was 1.1% (n = 53); median Injury Severity Score (ISS) was 9 (IQR 9-16). Blunt injuries predominated (94.4%). 1343 (27.1%) met intervention-based criteria for P1, exhibiting greater intensive care requirement (60.2% vs. 8.5%, p < 0.01) and ISS (median 17 vs 9, p < 0.01) compared with P2 patients. The Battlefield Casualty Drills (BCD) Triage Sieve had greatest sensitivity (75.7%) in predicting P1 status in children <16 years, demonstrating a 38.4-49.8% improvement across all subgroups of children <12 years compared with the UK's current Paediatric Triage Tape (PTT). JumpSTART demonstrated low sensitivity in predicting P1 status in 4 to 8 year olds (35.5%) and 0 to 4 year olds (28.5%), and was outperformed by its adult counterpart START (60.6% and 59.6%). INTERPRETATION The BCD Triage Sieve had greatest sensitivity in predicting P1 status in this paediatric trauma registry population: we recommend it replaces the PTT in UK practice. Users of JumpSTART may consider alternative tools. We recommend Lerner's triage category definitions when conducting MI evaluations.
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Affiliation(s)
- Nabeela S. Malik
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
- 212 (Yorkshire) Field Hospital, Endcliffe Hall, Endcliffe Vale Road, Sheffield S10 3EU, United Kingdom
- Corresponding author at: NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom.
| | - Saisakul Chernbumroong
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Yuanwei Xu
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - James Vassallo
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Justine Lee
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- NHS England London, Skipton House, 80 London Road, London SE1 6LH, United Kingdom
| | - Christopher G. Moran
- NHS England London, Skipton House, 80 London Road, London SE1 6LH, United Kingdom
- Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, United Kingdom
| | - Tina Newton
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - G. Suren Arul
- 212 (Yorkshire) Field Hospital, Endcliffe Hall, Endcliffe Vale Road, Sheffield S10 3EU, United Kingdom
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - Janet M. Lord
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Damian Keene
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Mark Foster
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Timothy Hodgetts
- Headquarters Defence Medical Services, Coltman House, Lichfield WS14 9PY, United Kingdom
| | - Douglas M. Bowley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Georgios V. Gkoutos
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, United Kingdom
- MRC Health Data Research UK (HDR UK), Midlands Site, Birmingham B15 2TT, United Kingdom
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Khorram-Manesh A, Nordling J, Carlström E, Goniewicz K, Faccincani R, Burkle FM. A translational triage research development tool: standardizing prehospital triage decision-making systems in mass casualty incidents. Scand J Trauma Resusc Emerg Med 2021; 29:119. [PMID: 34404443 PMCID: PMC8369703 DOI: 10.1186/s13049-021-00932-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background There is no global consensus on the use of prehospital triage system in mass casualty incidents. The purpose of this study was to evaluate the most commonly used pre-existing prehospital triage systems for the possibility of creating one universal translational triage tool. Methods The Rapid Evidence Review consisted of (1) a systematic literature review (2) merging and content analysis of the studies focusing on similarities and differences between systems and (3) development of a universal system. Results There were 17 triage systems described in 31 eligible articles out of 797 identified initially. Seven of the systems met the predesignated criteria and were selected for further analysis. The criteria from the final seven systems were compiled, translated and counted for in means of 1/7’s. As a product, a universal system was created of the majority criteria. Conclusions This study does not create a new triage system itself but rather identifies the possibility to convert various prehospital triage systems into one by using a triage translational tool. Future research should examine the tool and its different decision-making steps either by using simulations or by experts’ evaluation to ensure its feasibility in terms of speed, continuity, simplicity, sensitivity and specificity, before final evaluation at prehospital level. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00932-z.
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Affiliation(s)
- Amir Khorram-Manesh
- Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 413 45, Gothenburg, Sweden. .,Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden. .,Department of Research and Development, Armed Forces Center for Defense Medicine, 426 76, Västra Frölunda, Gothenburg, Sweden.
| | - Johan Nordling
- Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 413 45, Gothenburg, Sweden
| | - Eric Carlström
- Gothenburg Emergency Medicine Research Group (GEMREG), Sahlgrenska Academy, 413 45, Gothenburg, Sweden.,Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden.,USN School of Business, University of South-Eastern Norway, 3616, Kongsberg, Norway
| | - Krzysztof Goniewicz
- Department of Aviation Security, Military University of Aviation, 08-521, Dęblin, Poland
| | - Roberto Faccincani
- Emergency Department, Humanitas Mater Domini, 210 53, Castellanza, Italy
| | - Frederick M Burkle
- T.H. Chan School of Public Health, Harvard Humanitarian Initiative, Harvard University, Boston, MA, 02115, USA
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Prehospital Disaster Triage Does Not Predict Pediatric Outcomes: Comparing the Criteria Outcomes Tool to Three Mass-Casualty Incident Triage Algorithms. Prehosp Disaster Med 2021; 36:503-510. [PMID: 34392857 DOI: 10.1017/s1049023x21000856] [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] [Indexed: 11/07/2022]
Abstract
INTRODUCTION It remains unclear which mass-casualty incident (MCI) triage tool best predicts outcomes for child disaster victims. STUDY OBJECTIVES The primary objective of this study was to compare triage outcomes of Simple Triage and Rapid Treatment (START), modified START, and CareFlight in pediatric patients to an outcomes-based gold standard using the Criteria Outcomes Tool (COT). The secondary outcomes were sensitivity, specificity, under-triage, over-triage, and overall accuracy at each level for each MCI triage algorithm. METHODS Singleton trauma patients under 16 years of age with complete prehospital, emergency department (ED), and in-patient data were identified in the 2007-2009 National Trauma Data Bank (NTDB). The COT outcomes and procedures were translated into ICD-9 procedure codes with added timing criteria. Gold standard triage levels were assigned using the COT based on outcomes, including mortality, injury type, admission to the hospital, and surgical procedures. Comparison triage levels were determined based on algorithmic depictions of the three MCI triage tools. RESULTS A total of 31,093 patients with complete data were identified from the NTDB. The COT was applied to these patients, and the breakdown of gold standard triage levels, based on their actual clinical outcomes, was: 17,333 (55.7%) GREEN; 11,587 (37.3%) YELLOW; 1,572 (5.1%) RED; and 601 (1.9%) BLACK. CareFlight had the best sensitivity for predicting COT outcomes for BLACK (83% [95% confidence interval, 80%-86%]) and GREEN patients (79% [95% CI, 79%-80%]) and the best specificity for RED patients (89% [95% CI, 89%-90%]). CONCLUSION Among three prehospital MCI triage tools, CareFlight had the best performance for correlating with outcomes in the COT. Overall, none of three tools had good test characteristics for predicting pediatric patient needs for surgical procedures or hospital admission.
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Developing a Context-Bound Model for Hospital Triage in Disasters and Mass Casualty Incidents in the Health System of Iran. Disaster Med Public Health Prep 2021; 16:991-998. [PMID: 34100342 DOI: 10.1017/dmp.2020.469] [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: 11/07/2022]
Abstract
OBJECTIVE The aim of this study was to develop a context-bound model of hospital triage in disasters and mass casualty incidents in the health system of Iran. METHODS This study was done using a sequential mixed method. Data were analyzed using Expert Choice software program. RESULTS In the qualitative phase, 27 specialists were interviewed. Walking and purposeful movement, airway and respiration, circulatory status, and mental indices were included in the finalized model. In the quantitative phase, 21 participants responded to a questionnaire for weighting and ranking the final indices based on 3 competing options, including clinical importance of the index, lack of complexity and simplicity in implementation, and speed of implementation. The index of walking and purposeful movements weighing 0.300 and ranking 1, airway and respiration weighing 0.276 and ranking 2, blood circulatory status weighing 0.245 and ranking 3, and finally mental status weighing 0.179 and ranking 4 were obtained. CONCLUSIONS This is the first attempt to design and develop a new context-bound model of hospital triage in disasters and mass casualties in Iran. The development of new triage models is a dynamic and continuous process, and changes will be applied to them, in case further developments and improvements are required.
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Malik NS, Chernbumroong S, Xu Y, Vassallo J, Lee J, Bowley DM, Hodgetts T, Moran CG, Lord JM, Belli A, Keene D, Foster M, Gkoutos GV. The BCD Triage Sieve outperforms all existing major incident triage tools: Comparative analysis using the UK national trauma registry population. EClinicalMedicine 2021; 36:100888. [PMID: 34308306 PMCID: PMC8257989 DOI: 10.1016/j.eclinm.2021.100888] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Natural disasters, conflict, and terrorism are major global causes of death and disability. Central to the healthcare response is triage, vital to ensure the right care is provided to the right patient at the right time. The ideal triage tool has high sensitivity for the highest priority (P1) patients with acceptably low over-triage. This study compared the performance of major incident triage tools in predicting P1 casualty status in adults in the prospective UK Trauma Audit and Research Network (TARN) registry. METHODS TARN patients aged 16+ years (January 2008-December 2017) were included. Ten existing triage tools were applied using patients' first recorded pre-hospital physiology. Patients were subsequently assigned triage categories (P1, P2, P3, Expectant or Dead) based on pre-defined, intervention-based criteria. Tool performance was assessed by comparing tool-predicted and intervention-based priority status. FINDINGS 195,709 patients were included; mortality was 7·0% (n=13,601); median Injury Severity Score (ISS) was 9 (IQR 9-17); 97·1% sustained blunt injuries. 22,144 (11·3%) patients fulfilled intervention-based criteria for P1 status, exhibiting higher mortality (12·8% vs. 5·0%, p<0.001), increased intensive care requirement (52·4% vs 5·0%, p<0.001), and more severe injuries (median ISS 21 vs 9, p<0.001) compared with P2 patients.In 16-64 year olds, the highest performing tool was the Battlefield Casualty Drills (BCD) Triage Sieve (Prediction of P1 status: 70·4% sensitivity, over-triage 70·9%, area under the receiver operating curve (AUC) 0·068 [95%CI 0·676-0·684]). The UK National Ambulance Resilience Unit (NARU) Triage Sieve had sensitivity of 44·9%; over-triage 56·4%; AUC 0·666 (95%CI 0·662-0·670). All tools performed poorly amongst the elderly (65+ years). INTERPRETATION The BCD Triage Sieve performed best in this nationally representative population; we recommend it supersede the NARU Triage Sieve as the UK primary major incident triage tool. Validated triage category definitions are recommended for appraising future major incidents. FUNDING This study is funded by the National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre. GVG also acknowledges support from the MRC Heath Data Research UK (HDRUK/CFC/01). The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care, or the Ministry of Defence.
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Affiliation(s)
- Nabeela S. Malik
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
- 212 (Yorkshire) Field Hospital, Endcliffe Hall, Endcliffe Vale Road, Sheffield S10 3EU, UK
- Corresponding author at: NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK.
| | - Saisakul Chernbumroong
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Yuanwei Xu
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - James Vassallo
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Justine Lee
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
- NHS England London, Skipton House, 80 London Road, London SE1 6LH, UK
| | - Douglas M. Bowley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Timothy Hodgetts
- Army Health, Army Headquarters, Monxton Road, Andover SP11 8HT, UK
| | - Christopher G Moran
- NHS England London, Skipton House, 80 London Road, London SE1 6LH, UK
- Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK
| | - Janet M Lord
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Damian Keene
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Mark Foster
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Georgios V Gkoutos
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
- MRC Health Data Research UK (HDR UK), Midlands Site, B15 2TT UK
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Whitfill T, Auerbach M, Diaz MCG, Walsh B, Scherzer DJ, Gross IT, Cicero MX. Cost-effectiveness of a video game versus live simulation for disaster training. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2020; 6:268-273. [DOI: 10.1136/bmjstel-2019-000497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/16/2019] [Indexed: 11/04/2022]
Abstract
IntroductionDisaster triage training for emergency medical service (EMS) providers is unstandardised. We hypothesised that disaster triage training with the paediatric disaster triage (PDT) video game ‘60 s to Survival’ would be a cost-effective alternative to live simulation-based PDT training.MethodsWe synthesised data for a cost-effectiveness analysis from two previous studies. The video game data were from the intervention arm of a randomised controlled trial that compared triage accuracy in a live simulation scenario of exposed vs unexposed groups to the video game. The live simulation and feedback data were from a prospective cohort study evaluating live simulation and feedback for improving disaster triage skills. Postintervention scores of triage accuracy were measured for participants via live simulations and compared between both groups. Cost-effectiveness between the live simulation and video game groups was assessed using (1) A net benefit regression model at various willingness-to-pay (WTP) values. (2) A cost-effectiveness acceptability curve (CEAC).ResultsThe total cost for the live simulation and feedback training programme was $81 313.50 and the cost for the video game was $67 822. Incremental net benefit values at various WTP values revealed positive incremental net benefit values, indicating that the video game is more cost-effective compared with live simulation and feedback. Moreover, the CEAC revealed a high probability (>0.6) at various WTP values that the video game is more cost-effective.ConclusionsA video game-based simulation disaster triage training programme was more cost-effective than a live simulation and feedback-based programme. Video game-based training could be a simple, scalable and sustainable solution to training EMS providers.
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Abstract
INTRODUCTION Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed. METHODS Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs). DISCUSSION Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and "tactical triage." CONCLUSION Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.
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Follows A, Vassallo J. Paediatric major incident triage tools for identifying those in need of life-saving interventions. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408619897517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A short cut review was carried out to establish whether existing paediatric major incident triage tools identify patients requiring life-saving interventions. Sixteen papers presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. In summary, there is limited evidence for the validity of existing paediatric major incident triage tools.
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Affiliation(s)
| | - Jamie Vassallo
- Emergency Department, Queen Alexandra Hospital, Portsmouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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McKee CH, Heffernan RW, Willenbring BD, Schwartz RB, Liu JM, Colella MR, Lerner EB. Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population. PREHOSP EMERG CARE 2019; 24:515-524. [PMID: 31287350 DOI: 10.1080/10903127.2019.1641579] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To use a previously published criterion standard to compare the accuracy of 4 different mass casualty triage systems (Sort, Assess, Lifesaving Interventions, Treatment/Transport [SALT], Simple Triage and Rapid Treatment [START], Triage Sieve, and CareFlight) when used in an emergency department-based adult population. Methods: We performed a prospective, observational study of a convenience sample of adults aged 18 years or older presenting to a single tertiary care hospital emergency department. A co-investigator with prior emergency medical services (EMS) experience observed each subject's initial triage in the emergency department and recorded all data points necessary to assign a triage category using each of the 4 mass casualty triage systems being studied. Subjects' medical records were reviewed after their discharge from the hospital to assign the "correct" triage category using the criterion standard. The 4 mass casualty triage system assignments were then compared to the "correct" assignment. Descriptive statistics were used to compare accuracy and over- and under-triage rates for each triage system. Results: A total of 125 subjects were included in the study. Of those, 53% were male and 59% were transported by private vehicle. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (52%; 95% CI 43-60) compared to START (36%; 95% CI 28-44), CareFlight (36%; 95% CI 28-44), and TriageSieve (37%; 95% CI 28-45). SALT also had the lowest under-triage rate (26%; 95% CI 19-34) compared to START (57%; 95% CI 48-66), CareFlight (58%; 95% CI 49-66), and TriageSieve (58%; 95% CI 49-66). SALT had the highest over-triage rate (22%; 95% CI 14-29) compared to START (7%; 95% CI 3-12), CareFlight (6%; 95% CI 2-11) and TriageSieve (6%; 95% CI 2-11). Conclusion: We found that SALT triage most often correctly triaged adult emergency department patients when compared to a previously published criterion standard. While there are no target under- and over-triage rates that have been published for mass casualty triage, all 4 systems had relatively high rates of under-triage.
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Investigating the effects of under-triage by existing major incident triage tools. Eur J Emerg Med 2019; 26:139-144. [DOI: 10.1097/mej.0000000000000513] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Follmann A, Ohligs M, Hochhausen N, Beckers SK, Rossaint R, Czaplik M. Technical Support by Smart Glasses During a Mass Casualty Incident: A Randomized Controlled Simulation Trial on Technically Assisted Triage and Telemedical App Use in Disaster Medicine. J Med Internet Res 2019; 21:e11939. [PMID: 30609988 PMCID: PMC6682285 DOI: 10.2196/11939] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/06/2018] [Accepted: 10/06/2018] [Indexed: 01/19/2023] Open
Abstract
Background To treat many patients despite lacking personnel resources, triage is important in disaster medicine. Various triage algorithms help but often are used incorrectly or not at all. One potential problem-solving approach is to support triage with Smart Glasses. Objective In this study, augmented reality was used to display a triage algorithm and telemedicine assistance was enabled to compare the duration and quality of triage with a conventional one. Methods A specific Android app was designed for use with Smart Glasses, which added information in terms of augmented reality with two different methods—through the display of a triage algorithm in data glasses and a telemedical connection to a senior emergency physician realized by the integrated camera. A scenario was created (ie, randomized simulation study) in which 31 paramedics carried out a triage of 12 patients in 3 groups as follows: without technical support (control group), with a triage algorithm display, and with telemedical contact. Results A total of 362 assessments were performed. The accuracy in the control group was only 58%, but the assessments were quicker (on average 16.6 seconds). In contrast, an accuracy of 92% (P=.04) was achieved when using technical support by displaying the triage algorithm. This triaging took an average of 37.0 seconds. The triage group wearing data glasses and being telemedically connected achieved 90% accuracy (P=.01) in 35.0 seconds. Conclusions Triage with data glasses required markedly more time. While only a tally was recorded in the control group, Smart Glasses led to digital capture of the triage results, which have many tactical advantages. We expect a high potential in the application of Smart Glasses in disaster scenarios when using telemedicine and augmented reality features to improve the quality of triage.
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Affiliation(s)
- Andreas Follmann
- Medical Technology Section, Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marian Ohligs
- Medical Technology Section, Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany.,Docs in Clouds GmbH, Aachen, Germany
| | - Nadine Hochhausen
- Medical Technology Section, Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Stefan K Beckers
- Medical Technology Section, Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany.,Medical Direction, Emergency Medical Service, City of Aachen, Aachen, Germany
| | - Rolf Rossaint
- Medical Technology Section, Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Czaplik
- Medical Technology Section, Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany.,Docs in Clouds GmbH, Aachen, Germany
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Abstract
Children can be victims of mass casualty or illness, but their needs, with respect to their care and recovery are substantially different from adults. Emergency or urgent care physicians must be prepared to evaluate and manage child victims presenting to their facility in numbers or acuity that could significantly overwhelm normal operations. This article presents the general approach to pediatric disaster preparation in the United States, the expectations of emergency department providers, and different methods of disaster triage, and introduces the most likely types of mass illness (some of which are bioweapons or chemical agents) and their management.
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Affiliation(s)
- Marie M Lozon
- Department of Emergency Medicine, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
| | - Stuart Bradin
- Department of Emergency Medicine, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
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Heffernan RW, Lerner EB, McKee CH, Browne LR, Colella MR, Liu JM, Schwartz RB. Comparing the Accuracy of Mass Casualty Triage Systems in a Pediatric Population. PREHOSP EMERG CARE 2018; 23:304-308. [PMID: 30196737 DOI: 10.1080/10903127.2018.1520946] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION It was previously difficult to compare the accuracy of different mass casualty triage systems to one another. This pilot study is one of the first attempts to operationalize an expert panel's criterion standard definitions of triage categories in a pediatric population in order to compare accuracy between different systems. OBJECTIVE To compare the accuracy of 4 different mass casualty triage systems (SALT, JumpSTART, Triage Sieve, and CareFlight) when used for children. METHODS We observed the emergency department triage of patients less than 18 years old presenting to the only pediatric specialty hospital/Level 1 trauma center in Milwaukee County, Wisconsin. A single, certified EMS provider observed each patient's initial triage in the emergency department and recorded all findings that were necessary to categorize the patient using each of the 4 mass casualty triage systems being studied. Hospital medical records were then reviewed for each patient and assigned a criterion standard triage category based on the treatments received and final disposition. Descriptive statistics were used to compare accuracy, over-, and under-triage rates for each of the triage systems. RESULTS A total of 115 subjects were enrolled. Of those, 51% were male and 57% were transported by ambulance. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (59%; 95% CI 50-68) compared to JumpSTART (57%; 95% CI 48-66), CareFlight (56%; 95% CI 47-65), and TriageSieve (56%; 95% CI 46-65). SALT also had the lowest under-triage rate (33%; 95% CI 24-42) compared to JumpSTART (39%; 95% CI 30-48), CareFlight (39%; 95% CI 30-48), and TriageSieve (39%; 95% CI 30-48). SALT had the highest over-triage rate (6%; 95% CI 2-11) compared to JumpSTART (4%; 95% CI 1-8), CareFlight (5%; 95% CI 1-9), and TriageSieve (5%; 95% CI 1-9). However, the confidence intervals for both the accuracy and under-triage rates overlapped between all triage systems. For each triage system, the most common error was designating a patient as "minimal" that, according to the criterion standard, should have been triaged as "delayed." CONCLUSION We found that the 4 most popular mass casualty triage systems preformed similarly in an emergency department-based pediatric population. None of the systems were extremely accurate, and each demonstrated an unacceptable amount of under-triage. Better differentiating between patients categorized as "minimal" and "delayed" may improve the accuracy of mass casualty triage systems.
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Cicero MX, Whitfill T, Walsh B, Diaz MCG, Arteaga GM, Scherzer DJ, Goldberg SA, Madhok M, Bowen A, Paesano G, Redlener M, Munjal K, Auerbach M. Correlation Between Paramedic Disaster Triage Accuracy in Screen-Based Simulations and Immersive Simulations. PREHOSP EMERG CARE 2018; 23:83-89. [PMID: 30130424 DOI: 10.1080/10903127.2018.1475530] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Disaster triage is an infrequent, high-stakes skill set used by emergency medical services (EMS) personnel. Screen-based simulation (SBS) provides easy access to asynchronous disaster triage education. However, it is unclear if the performance during a SBS correlates with immersive simulation performance. Methods: This was a nested cohort study within a randomized controlled trial (RCT). The RCT compared triage accuracy of paramedics and emergency medical technicians (EMTs) who completed an immersive simulation of a school shooting, interacted with an SBS for 13 weeks, and then completed the immersive simulation again. The participants were divided into two groups: those exposed vs. those not exposed to 60 Seconds to Survival© (60S), a disaster triage SBS. The aim of the study was to measure the correlation between SBS triage accuracy and immersive simulation triage accuracy. Improvements in triage accuracy were compared among participants in the nested study before and after interacting with 60S, and with improvements in triage accuracy in a previous study in which immersive simulations were used as an educational intervention. Results: Thirty-nine participants completed the SBS; 26 (67%) completed at least three game plays and were included in the evaluation of outcomes of interest. The mean number of plays was 8.5 (SD =7.4). Subjects correctly triaged 12.4% more patients in the immersive simulation at study completion (73.1% before, 85.8% after, P = 0.004). There was no correlation between the amount of improvement in overall SBS triage accuracy, instances of overtriage (P = 0.101), instances of undertriage (P = 0.523), and improvement in the second immersive simulation. A comparison of the pooled data from a previous immersive simulation study with the nested cohort data showed similar improvement in triage accuracy (P = 0.079). Conclusions: SBS education was associated with a significant increase in triage accuracy in an immersive simulation, although triage accuracy demonstrated in the SBS did not correlate with the performance in the immersive simulation. This improvement in accuracy was similar to the improvement seen when immersive simulation was used as the educational intervention in a previous study.
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Albahri OS, Zaidan AA, Zaidan BB, Hashim M, Albahri AS, Alsalem MA. Real-Time Remote Health-Monitoring Systems in a Medical Centre: A Review of the Provision of Healthcare Services-Based Body Sensor Information, Open Challenges and Methodological Aspects. J Med Syst 2018; 42:164. [PMID: 30043085 DOI: 10.1007/s10916-018-1006-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 06/21/2018] [Indexed: 01/11/2023]
Abstract
Promoting patient care is a priority for all healthcare providers with the overall purpose of realising a high degree of patient satisfaction. A medical centre server is a remote computer that enables hospitals and physicians to analyse data in real time and offer appropriate services to patients. The server can also manage, organise and support professionals in telemedicine. Therefore, a remote medical centre server plays a crucial role in sustainably delivering quality healthcare services in telemedicine. This article presents a comprehensive review of the provision of healthcare services in telemedicine applications, especially in the medical centre server. Moreover, it highlights the open issues and challenges related to providing healthcare services in the medical centre server within telemedicine. Methodological aspects to control and manage the process of healthcare service provision and three distinct and successive phases are presented. The first phase presents the identification process to propose a decision matrix (DM) on the basis of a crossover of 'multi-healthcare services' and 'hospital list' within intelligent data and service management centre (Tier 4). The second phase discusses the development of a DM for hospital selection on the basis of integrated VIKOR-Analytic Hierarchy Process (AHP) methods. Finally, the last phase examines the validation process for the proposed framework.
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Affiliation(s)
- O S Albahri
- Department of Computing, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia
| | - A A Zaidan
- Department of Computing, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia.
| | - B B Zaidan
- Department of Computing, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia
| | - M Hashim
- Department of Computing, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia
| | - A S Albahri
- Department of Computing, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia
| | - M A Alsalem
- Department of Computing, Universiti Pendidikan Sultan Idris, Tanjong Malim, Perak, Malaysia
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Kalid N, Zaidan AA, Zaidan BB, Salman OH, Hashim M, Muzammil H. Based Real Time Remote Health Monitoring Systems: A Review on Patients Prioritization and Related "Big Data" Using Body Sensors information and Communication Technology. J Med Syst 2017; 42:30. [PMID: 29288419 DOI: 10.1007/s10916-017-0883-4] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/13/2017] [Indexed: 12/31/2022]
Abstract
The growing worldwide population has increased the need for technologies, computerised software algorithms and smart devices that can monitor and assist patients anytime and anywhere and thus enable them to lead independent lives. The real-time remote monitoring of patients is an important issue in telemedicine. In the provision of healthcare services, patient prioritisation poses a significant challenge because of the complex decision-making process it involves when patients are considered 'big data'. To our knowledge, no study has highlighted the link between 'big data' characteristics and real-time remote healthcare monitoring in the patient prioritisation process, as well as the inherent challenges involved. Thus, we present comprehensive insights into the elements of big data characteristics according to the six 'Vs': volume, velocity, variety, veracity, value and variability. Each of these elements is presented and connected to a related part in the study of the connection between patient prioritisation and real-time remote healthcare monitoring systems. Then, we determine the weak points and recommend solutions as potential future work. This study makes the following contributions. (1) The link between big data characteristics and real-time remote healthcare monitoring in the patient prioritisation process is described. (2) The open issues and challenges for big data used in the patient prioritisation process are emphasised. (3) As a recommended solution, decision making using multiple criteria, such as vital signs and chief complaints, is utilised to prioritise the big data of patients with chronic diseases on the basis of the most urgent cases.
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Affiliation(s)
- Naser Kalid
- Computing Department, Universiti Pendidikan Sultan Idris, Tg Malim, 35900, Perak, Malaysia.,Department of Computer Engineering Techniques, Al-Nisour University, Al Adhmia - Haiba Khaton, Baghdad, Iraq
| | - A A Zaidan
- Computing Department, Universiti Pendidikan Sultan Idris, Tg Malim, 35900, Perak, Malaysia.
| | - B B Zaidan
- Computing Department, Universiti Pendidikan Sultan Idris, Tg Malim, 35900, Perak, Malaysia
| | - Omar H Salman
- Networking Department, Engineering College, Al Iraqia university, Baghdad, Iraq
| | - M Hashim
- Computing Department, Universiti Pendidikan Sultan Idris, Tg Malim, 35900, Perak, Malaysia
| | - H Muzammil
- Department of Computer Science, University of Management and Technology, Lahore, Pakistan
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Vassallo J, Smith J, Bouamra O, Lecky F, Wallis LA. The civilian validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to primary major incident triage. Emerg Med J 2017; 34:810-815. [DOI: 10.1136/emermed-2017-206647] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 07/11/2017] [Accepted: 07/22/2017] [Indexed: 11/04/2022]
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Use of a Novel, Portable, LED-Based Capillary Refill Time Simulator within a Disaster Triage Context. Prehosp Disaster Med 2017; 32:451-456. [PMID: 28345508 DOI: 10.1017/s1049023x17006343] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction A simple, portable capillary refill time (CRT) simulator is not commercially available. This device would be useful in mass-casualty simulations with multiple volunteers or mannequins depicting a variety of clinical findings and CRTs. The objective of this study was to develop and evaluate a prototype CRT simulator in a disaster simulation context. METHODS A CRT prototype simulator was developed by embedding a pressure-sensitive piezo crystal, and a single red light-emitting diode (LED) light was embedded, within a flesh-toned resin. The LED light was programmed to turn white proportionate to the pressure applied, and gradually to return to red on release. The time to color return was adjustable with an external dial. The prototype was tested for feasibility among two cohorts: emergency medicine physicians in a tabletop exercise and second year medical students within an actual disaster triage drill. The realism of the simulator was compared to video-based CRT, and participants used a Visual Analog Scale (VAS) ranging from "completely artificial" to "as if on a real patient." The VAS evaluated both the visual realism and the functional (eg, tactile) realism. Accuracy of CRT was evaluated only by the physician cohort. Data were analyzed using parametric and non-parametric statistics, and mean Cohen's Kappas were used to describe inter-rater reliability. RESULTS The CRT simulator was generally well received by the participants. The simulator was perceived to have slightly higher functional realism (P=.06, P=.01) but lower visual realism (P=.002, P=.11) than the video-based CRT. Emergency medicine physicians had higher accuracy on portrayed CRT on the simulator than the videos (92.6% versus 71.1%; P<.001). Inter-rater reliability was higher for the simulator (0.78 versus 0.27; P<.001). CONCLUSIONS A simple, LED-based CRT simulator was well received in both settings. Prior to widespread use for disaster triage training, validation on participants' ability to accurately triage disaster victims using CRT simulators and video-based CRT simulations should be performed. Chang TP , Santillanes G , Claudius I , Pham PK , Koved J , Cheyne J , Gausche-Hill M , Kaji AH , Srinivasan S , Donofrio JJ , Bir C . Use of a novel, portable, LED-based capillary refill time simulator within a disaster triage context. Prehosp Disaster Med. 2017;32(4):451-456.
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Abstract
BACKGROUND Mass-casualty incidents (MCIs) present a unique challenge with regards to triage as patient volume often outweighs the number of available Emergency Medical Services (EMS) providers. A possible strategy to optimize existing triage systems includes the use of other first responder groups, namely fire and police, to decrease the triage time during MCIs, allowing for more rapid initiation of life-saving treatment and prioritization of patient transport. Hypothesis First-year primary care paramedic (PCP), fire, and police trainees can apply with similar accuracy an internationally recognized MCI triage tool, Sort, Assess, Life-saving interventions, Treatment/transport (SALT), immediately following a brief training session, and again three months later. METHODS All students enrolled in the PCP, fire, and police foundation programs at two community colleges were invited to participate in a 30-minute didactic session on SALT. Immediately following this session, a 17-item, paper-based test was administered to assess the students' ability to understand and apply SALT. Three months later, the same test was given to assess knowledge retention. RESULTS Of the 464 trainees who completed the initial test, 364 (78.4%) completed the three month follow-up test. Initial test scores were higher (P<.05) for PCPs (87.0%) compared to fire (80.2%) and police (68.0%) trainees. The mean test score for all respondents was higher following the initial didactic session compared to the three month follow-up test (75% vs 64.7%; Δ 10.3%; 95% CI, 8.0%-12.6%). Three month test scores for PCPs (75.4%) were similar to fire (71.4%) students (Δ 4.0%; 95% CI, -2.1% to 10.1%). Both PCP and fire trainees significantly outperformed police (57.8%) trainees. Over-triage errors were the most common, followed by under-triage and then critical errors, for both the initial and follow-up tests. CONCLUSIONS Amongst first responder trainees, PCPs were able to apply the SALT triage tool with the most accuracy, followed by fire, then police. Over-triage was the most frequent error, while critical errors were rare.
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Abstract
Introduction Triage is the systematic prioritization of casualties when there is an imbalance between the needs of these casualties and resource availability. The triage sieve is a recognized process for prioritizing casualties for treatment during mass-casualty incidents (MCIs). While the application of a triage sieve generally is well-accepted, the measurement of its accuracy has been somewhat limited. Obtaining reliable measures for triage sieve accuracy rates is viewed as a necessity for future development in this area. OBJECTIVE The goal of this study was to investigate how theoretical knowledge acquisition and the practical application of an aide-memoir impacted triage sieve accuracy rates. METHOD Two hundred and ninety-two paramedics were allocated randomly to one of four separate sub-groups, a non-intervention control group, and three intervention groups, which involved them receiving either an educational review session and/or an aide-memoir. Participants were asked to triage sieve 20 casualties using a previously trialed questionnaire. RESULTS The study showed the non-intervention control group had a correct accuracy rate of 47%, a similar proportion of casualties found to be under-triaged (37%), but a significantly lower number of casualties were over-triaged (16%). The provision of either an educational review or aide-memoir significantly increased the correct triage sieve accuracy rate to 77% and 90%, respectively. Participants who received both the educational review and aide-memoir had an overall accuracy rate of 89%. Over-triaged rates were found not to differ significantly across any of the study groups. CONCLUSION This study supports the use of an aide-memoir for maximizing MCI triage accuracy rates. A "just-in-time" educational refresher provided comparable benefits, however its practical application to the MCI setting has significant operational limitations. In addition, this study provides some guidance on triage sieve accuracy rate measures that can be applied to define acceptable performance of a triage sieve during a MCI. Cuttance G , Dansie K , Rayner T . Paramedic application of a triage sieve: a paper-based exercise. Prehosp Disaster Med. 2017;32(1):3-13.
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Future Developments in the Management of Explosive Incidents. Ann Emerg Med 2016; 69:S46-S51. [PMID: 27955763 DOI: 10.1016/j.annemergmed.2016.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Kouliev T. Objective triage in the disaster setting: will children and expecting mothers be treated like others? Open Access Emerg Med 2016; 8:77-86. [PMID: 27822127 PMCID: PMC5089824 DOI: 10.2147/oaem.s96913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The study of disaster triage is made difficult by the complex emotional response of potentially lifesaving intervention that a triage officer must make basing decisions on a succinct and efficient algorithm. A survey of triage professionals in international settings was designed to identify possible emotionally led bias that affects objective decision making in identifying victims most likely to benefit from immediate life support intervention. This survey suggests a lack of correlation between triage priority and predictable clinical outcomes as predicted by the Revised Trauma Score tool. Among the subjects, it was observed that a pediatric victim is uniformly overtriaged when compared to less injured victims.
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Affiliation(s)
- Timur Kouliev
- Beijing United Family Hospital, Beijing, People's Republic of China
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Cicero MX, Whitfill T, Overly F, Baird J, Walsh B, Yarzebski J, Riera A, Adelgais K, Meckler GD, Baum C, Cone DC, Auerbach M. Pediatric Disaster Triage: Multiple Simulation Curriculum Improves Prehospital Care Providers' Assessment Skills. PREHOSP EMERG CARE 2016; 21:201-208. [PMID: 27749145 DOI: 10.1080/10903127.2016.1235239] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT). METHODS Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK. RESULTS The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p < 0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073). CONCLUSION This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10% improvement in simulated triage accuracy. Future iterations of the curriculum can target greater improvements in EMT triage accuracy.
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Screen-Based Simulation and Virtual Reality for Pediatric Emergency Medicine. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2016. [DOI: 10.1016/j.cpem.2016.05.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Qualitative Analysis of Surveyed Emergency Responders and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents. PLOS CURRENTS 2016; 8. [PMID: 27651979 PMCID: PMC5016230 DOI: 10.1371/currents.dis.d69dafcfb3ad8be88b3e655bd38fba84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Introduction: After all large-scale disasters multiple papers are published describing the shortcomings of the triage methods utilized. This paper uses medical provider input to help describe attributes and patient characteristics that impact triage decisions. Methods: A survey distributed electronically to medical providers with and without disaster experience. Questions asked included what disaster experiences they had, and to rank six attributes in order of importance regarding triage. Results: 403 unique completed surveys were analyzed. 92% practiced a structural triage approach with the rest reporting they used “gestalt”.(gut feeling) Twelve per cent were identified as having placed patients in an expectant category during triage. Respiratory status, ability to speak, perfusion/pulse were all ranked in the top three. Gut feeling regardless of statistical analysis was fourth. Supplies were ranked in the top four when analyzed for those who had placed patients in the expectant category. Conclusion: Primary triage decisions in a mass casualty scenario are multifactorial and encompass patient mobility, life saving interventions, situational instincts, and logistics.
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Donofrio JJ, Kaji AH, Claudius IA, Chang TP, Santillanes G, Cicero MX, Srinivasan S, Perez-Rogers A, Gausche-Hill M. Development of a Pediatric Mass Casualty Triage Algorithm Validation Tool. PREHOSP EMERG CARE 2016; 20:343-53. [DOI: 10.3109/10903127.2015.1111476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Comparing the Accuracy of Three Pediatric Disaster Triage Strategies: A Simulation-Based Investigation. Disaster Med Public Health Prep 2016; 10:253-60. [DOI: 10.1017/dmp.2015.171] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackgroundIt is unclear which pediatric disaster triage (PDT) strategy yields the best accuracy or best patient outcomes.MethodsWe conducted a cross-sectional analysis on a sample of emergency medical services providers from a prospective cohort study comparing the accuracy and triage outcomes for 2 PDT strategies (Smart and JumpSTART) and clinical decision-making (CDM) with no algorithm. Participants were divided into cohorts by triage strategy. We presented 10-victim, multi-modal disaster simulations. A Delphi method determined patients’ expected triage levels. We compared triage accuracy overall and for each triage level (RED/Immediate, YELLOW/Delayed, GREEN/Ambulatory, BLACK/Deceased).ResultsThere were 273 participants (71 JumpSTART, 122 Smart, and 81 CDM). There was no significant difference between Smart triage and CDM. When JumpSTART triage was used, there was greater accuracy than with either Smart (P<0.001; OR [odds ratio]: 2.03; interquartile range [IQR]: 1.30, 3.17) or CDM (P=0.02; OR: 1.76; IQR: 1.10, 2.82). JumpSTART outperformed Smart for RED patients (P=0.05; OR: 1.48; IQR: 1.01,2.17), and outperformed both Smart (P<0.001; OR: 3.22; IQR: 1.78,5.88) and CDM (P<0.001; OR: 2.86; IQR: 1.53,5.26) for YELLOW patients. Furthermore, JumpSTART outperformed CDM for BLACK patients (P=0.01; OR: 5.55; IQR: 1.47, 20.0).ConclusionOur simulation-based comparison suggested that JumpSTART triage outperforms both Smart and CDM. JumpSTART outperformed Smart for RED patients and CDM for BLACK patients. For YELLOW patients, JumpSTART yielded more accurate triage results than did Smart triage or CDM. (Disaster Med Public Health Preparedness. 2016;10:253–260)
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Comparison of the Sacco Triage Method Versus START Triage Using a Virtual Reality Scenario in Advance Care Paramedic Students. CAN J EMERG MED 2015; 18:288-92. [PMID: 26553510 DOI: 10.1017/cem.2015.102] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
BACKGROUND The American College of Surgeons has advocated for all trauma centers to participate in the National Trauma Data Bank (NTDB); however, no previous study has evaluated the accuracy of coding included in this data bank. The purpose of this study was to determine whether pelvic ring injuries are coded accurately in the NTDB and, if not, how they were misclassified. METHODS A retrospective review of all pelvic ring injuries based on Abbreviated Injury Scale (AIS) codes was performed at a single level I academic trauma center from July 2010 to June 2013. Thin-section computed tomography (CT) scans in all patients were reviewed and classified using AIS codes: posterior arch intact, incomplete posterior arch, or complete posterior arch. The surgeon was blinded to the AIS code from the registry. These CT-based classifications were then compared with the pelvic ring injury codes designated in the trauma registry for each patient to evaluate agreement. RESULTS Two hundred thirty-five patients with a mean age of 42 years had pelvic ring injuries in our registry. The agreement between trauma registry codes and CT reclassification was 24% in the intact group, 43% in the incomplete group, and 59% in the complete group. Using only the trauma registry codes, injuries were underclassified in 48% of the incomplete group and 76% of the intact group. CONCLUSIONS Many pelvic ring injuries are miscoded and misclassified in the NTDB. The etiology of this misclassification is unclear, but any research data mined from these databases should be regarded cautiously.
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Accuracy, Efficiency, and Inappropriate Actions Using JumpSTART Triage in MCI Simulations. Prehosp Disaster Med 2015; 30:457-60. [PMID: 26323610 DOI: 10.1017/s1049023x15005002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) algorithm for the triage of pediatric patients in a mass-casualty incident (MCI) requires assessing the results of each step and determining whether to move to the next appropriate action. Inappropriate application can lead to performance of unnecessary actions or failure to perform necessary actions. Hypothesis/Problem To report overall accuracy and time required for triage, and to assess if the performance of unnecessary steps, or failure to perform required steps, in the triage algorithm was associated with inaccuracy of triage designation or increased time to reach a triage decision. METHODS Medical students participated in an MCI drill in which they triaged both live actors portraying patients and computer-based simulated patients to the four triage levels: minor, delayed, immediate, and expectant. Their performance was timed and compared to intended triage designations and a priori determined critical actions. RESULTS Thirty-three students completed 363 scenarios. The overall accuracy was 85.7% and overall mean time to assign a triage designation was 70.4 seconds, with decreasing times as triage acuity level decreased. In over one-half of cases, the student omitted at least one action and/or performed at least one action that was not required. Each unnecessary action increased time to triage by a mean of 8.4 seconds and each omitted action increased time to triage by a mean of 5.5 seconds. Discussion Increasing triage level, performance of inappropriate actions, and omission of recommended actions were all associated with increasing time to perform triage.
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A modified simple triage and rapid treatment algorithm from the New York City (USA) Fire Department. Prehosp Disaster Med 2015; 30:199-204. [PMID: 25687598 DOI: 10.1017/s1049023x14001447] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The objective of this study was to determine if modification of the Simple Triage and Rapid Treatment (START) system by the addition of an Orange category, intermediate between the most critically injured (Red) and the non-critical, non-ambulatory injured (Yellow), would reduce over- and under-triage rates in a simulated mass-casualty incident (MCI) exercise. METHODS A computer-simulation exercise of identical presentations of an MCI scenario involving a 2-train collision, with 28 case scenarios, was provided for triaging to two groups: the Fire Department of the City of New York (FDNY; n=1,347) using modified START, and the Emergency Medical Services (EMS) providers from the Eagles 2012 EMS conference (Lafayette, Louisiana USA; n=110) using unmodified START. Percent correct by triage category was calculated for each group. Performance was then compared between the two EMS groups on the five cases where Orange was the correct answer under the modified START system. RESULTS Overall, FDNY-EMS providers correctly triaged 91.2% of cases using FDNY-START whereas non-FDNY-Eagles providers correctly triaged 87.1% of cases using unmodified START. In analysis of the five Orange cases (chest pain or dyspnea without obvious trauma), FDNY-EMS performed significantly better using FDNY-START, correctly triaging 86.3% of cases (over-triage 1.5%; under-triage 12.2%), whereas the non-FDNY-Eagles group using unmodified START correctly triaged 81.5% of cases (over-triage 17.3%; under-triage 1.3%), a difference of 4.9% (95% CI, 1.5-8.2). CONCLUSIONS The FDNY-START system may allow providers to prioritize casualties using an intermediate category (Orange) more properly aligned to meet patient needs, and as such, may reduce the rates of over-triage compared with START. The FDNY-START system decreases the variability in patient sorting while maintaining high field utility without needing computer assistance or extensive retraining. Comparison of triage algorithms at actual MCIs is needed; however, initial feedback is promising, suggesting that FDNY-START can improve triage with minimal additional training and cost.
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Streckbein S, Kohlmann T, Luxen J, Birkholz T, Prückner S. Sichtungskonzepte bei Massenanfällen von Verletzten und Erkrankten. Unfallchirurg 2015; 119:620-31. [DOI: 10.1007/s00113-014-2717-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Do you see what I see? Insights from using google glass for disaster telemedicine triage. Prehosp Disaster Med 2015; 30:4-8. [PMID: 25571779 DOI: 10.1017/s1049023x1400140x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Disasters are high-stakes, low-frequency events. Telemedicine may offer a useful adjunct for paramedics performing disaster triage. The objective of this study was to determine the feasibility of telemedicine in disaster triage, and to determine whether telemedicine has an effect on the accuracy of triage or the time needed to perform triage. METHODS This is a feasibility study in which an intervention team of two paramedics used the mobile device Google Glass (Google Inc; Mountain View, California USA) to communicate with an off-site physician disaster expert. The paramedic team triaged simulated disaster victims at the triennial drill of a commercial airport. The simulated victims had preassigned expected triage levels. The physician had an audio-video interface with the paramedic team and was able to observe the victims remotely. A control team of two paramedics performed disaster triage in the usual fashion. Both teams used the SMART Triage System (TSG Associates LLP; Halifax, England), which assigns patients into Red, Yellow, Green, and Black triage categories. The paramedics were video recorded, and their time required to triage was logged. It was determined whether the intervention team and the control team varied regarding accuracy of triage. Finally, the amount of time the intervention team needed to triage patients when telemedicine was used was compared to when that team did not use telemedicine. RESULTS The two teams triaged the same 20 patients. There was no significant difference between the two groups in overall triage accuracy (85.7% for the intervention group vs 75.9% for the control group; P = .39). Two patients were triaged with telemedicine. For the intervention group, there was a significant difference in time to triage patients with telemedicine versus those without telemedicine (35.5 seconds; 95% CI, 72.5-143.5 vs 18.5 seconds; 95% CI, 13.4-23.6; P = .041). CONCLUSION There was no increase in triage accuracy when paramedics evaluating disaster victims used telemedicine, and telemedicine required more time than conventional triage. There are a number of obstacles to available technology that, if overcome, might improve the utility of telemedicine in disaster response.
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Tian Y, Zhou TS, Yao Q, Zhang M, Li JS. Use of an agent-based simulation model to evaluate a mobile-based system for supporting emergency evacuation decision making. J Med Syst 2014; 38:149. [PMID: 25354665 DOI: 10.1007/s10916-014-0149-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/22/2014] [Indexed: 12/01/2022]
Abstract
Recently, mass casualty incidents (MCIs) have been occurring frequently and have gained international attention. There is an urgent need for scientifically proven and effective emergency responses to MCIs, particularly as the severity of incidents is continuously increasing. The emergency response to MCIs is a multi-dimensional and multi-participant dynamic process that changes in real-time. The evacuation decisions that assign casualties to different hospitals in a region are very important and impact both the results of emergency treatment and the efficiency of medical resource utilization. Previously, decisions related to casualty evacuation were made by an incident commander with emergency experience and in accordance with macro emergency guidelines. There are few decision-supporting tools available to reduce the difficulty and psychological pressure associated with the evacuation decisions an incident commander must make. In this study, we have designed a mobile-based system to collect medical and temporal data produced during an emergency response to an MCI. Using this information, our system's decision-making model can provide personal evacuation suggestions that improve the overall outcome of an emergency response. The effectiveness of our system in reducing overall mortality has been validated by an agent-based simulation model established to simulate an emergency response to an MCI.
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Affiliation(s)
- Yu Tian
- Engineering Research Center of EMR and Intelligent Expert System, Ministry of Education, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
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Koziel JR, Meckler G, Brown L, Acker D, Torino M, Walsh B, Cicero MX. Barriers to Pediatric Disaster Triage: A Qualitative Investigation. PREHOSP EMERG CARE 2014; 19:279-86. [DOI: 10.3109/10903127.2014.967428] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Cross KP, Petry MJ, Cicero MX. A better START for low-acuity victims: data-driven refinement of mass casualty triage. PREHOSP EMERG CARE 2014; 19:272-8. [PMID: 25153986 DOI: 10.3109/10903127.2014.942481] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Methods currently used to triage patients from mass casualty events have a sparse evidence basis. The objective of this project was to assess gaps of the widely used Simple Triage and Rapid Transport (START) algorithm using a large database when it is used to triage low-acuity patients. Subsequently, we developed and tested evidenced-based improvements to START. METHODS Using the National Trauma Database (NTDB), a large set of trauma victims were assigned START triage levels, which were then compared to recorded patient mortality outcomes using area under the receiver-operator curve (AUC). Subjects assigned to the "Minor/Green" level who nevertheless died prior to hospital discharge were considered mistriaged. Recursive partitioning identified factors associated with of these mistriaged patients. These factors were then used to develop candidate START models of improved triage, whose overall performance was then re-evaluated using data from the NTDB. This process of evaluating performance, identifying errors, and further adjusting candidate models was repeated iteratively. RESULTS The study included 322,162 subjects assigned to "Minor/Green" of which 2,046 died before hospital discharge. Age was the primary predictor of under-triage by START. Candidate models which re-assigned patients from the "Minor/Green" triage level to the "Delayed/Yellow" triage level based on age (either for patients >60 or >75), reduced mortality in the "Minor/Green" group from 0.6% to 0.1% and 0.3%, respectively. These candidate START models also showed net improvement in the AUC for predicting mortality overall and in select subgroups. CONCLUSION In this research model using trauma registry data, most START under-triage errors occurred in elderly patients. Overall START accuracy was improved by placing elderly but otherwise minimally injured-mass casualty victims into a higher risk triage level. Alternatively, such patients would be candidates for closer monitoring at the scene or expedited transport ahead of other, younger "Minor/Green" victims.
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Hu H, He Y, Zhang S, Cao Y. Streamlined focused assessment with sonography for mass casualty prehospital triage of blunt torso trauma patients. Am J Emerg Med 2014; 32:803-6. [DOI: 10.1016/j.ajem.2014.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 03/12/2014] [Accepted: 03/13/2014] [Indexed: 11/30/2022] Open
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Cross KP, Cicero MX. In reply. Ann Emerg Med 2013; 62:643-4. [DOI: 10.1016/j.annemergmed.2013.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 06/10/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022]
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Schultz CH. Comparing Disaster Triage Algorithms: Selecting the Right Metric. Ann Emerg Med 2013; 62:642-3. [DOI: 10.1016/j.annemergmed.2013.05.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 05/25/2013] [Accepted: 05/30/2013] [Indexed: 10/26/2022]
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Kaufman B, Ben-Eli D, Asaeda G, Gonzalez D, Isaacs D, Freese J, Prezant D. Comparison of Disaster Triage Methods. Ann Emerg Med 2013; 62:644-5. [DOI: 10.1016/j.annemergmed.2013.07.505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 07/11/2013] [Accepted: 07/11/2013] [Indexed: 10/26/2022]
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In reply. Ann Emerg Med 2013; 62:645. [DOI: 10.1016/j.annemergmed.2013.07.504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 07/24/2013] [Accepted: 07/25/2013] [Indexed: 11/22/2022]
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