Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT)

Management of mass casualty incidents: a systematic review and clinical practice guideline update

PURPOSE

Our aim was to generate evidence- and consensus-based recommendations for the management of mass casualty incidents (MCIs) based on current evidence. This guideline topic is part of the 2022 update of the German guideline on the treatment of patients with severe/multiple injuries.

METHODS

MEDLINE and Embase were systematically searched to August 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, cross-sectional studies, prospective cohort studies, and comparative registry studies were included if they compared triage algorithms, interventions for MCI training, logistics or transport, decontamination, diagnosis or therapy during MCIs in the prehospital and hospital settings. We considered patient-relevant clinical outcomes such as mortality, diagnostic outcomes including sensitivity and specificity, rates of undertriage and overtriage as well as resource use. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength. Population, intervention, comparison, and outcome (PICO) questions from clinical questions were developed by clinical experts and guideline methodologists.

RESULTS

We screened 321 records in the original guideline version and 4225 during this update. Twenty-five studies were included, all of them from the updated search from 2009 to 2021. Twenty-five new studies were identified. Interventions covered were triage training (n = 7 studies), prehospital triage (n = 6), secondary triage (n = 2), transport/logistics (n = 3), decontamination (n = 5), and therapy (n = 2) during MCIs. Three new recommendations were developed. All achieved strong consensus.

CONCLUSION

Due to unsatisfactory evidence, recommendations could only be made on training for improving triage quality and regular exercises for testing a hospital's emergency response plan. No triage algorithm can be scientifically proven to be superior in all aspects. The key recommendation is the following: To improve triage quality, exercises or (virtual) training should be conducted in-house using verified triage systems and algorithms.

The effect of multiple triage points on the outcomes (time and accuracy) of hospital triage during mass casualty incidents

INTRODUCTION

During mass casualty incidents (MCIs), the accuracy and timing of the triage of patients by the emergency department (ED) triage officers are essential. The primary triage is performed at the event's location by paramedics and intends a quick evaluation of the victims. Secondary triage may be used when the transfer of the victim is delayed. In this study, we aimed to investigate the effectiveness of two-point triage in a simulated environment of an MCI in the hospital setting.

MATERIALS AND METHODS

In this case-control study, we used an online test module to assess single triage points (Group 1, n = 41) and two triage points (Group 2, n = 40). 60 vignettes for Group 1 and 55 vignettes (5 deceased cases removed) for Group 2 were used. The assessment utilized clinical MCI scenarios in a scheduled online meeting by using the Simple Triage and Rapid Treatment (START) system. Triage time and accuracy of the triage, along with the experience, and previous training of the participants, were assessed.

RESULTS

A total of 81 triage officers participated in this study. The participants were divided into two independent groups homogenously according to their profession and experience. Groups were comparable primarily without any statistically significant difference in terms of the profession (p = 0.101), sex (p = 0.923), and MCI experience (p = 0.785). The difference between the two groups was not significant with regard to having received practical or theoretical triage training (p = 0.099). The mean time of a single vignette triage was 19.2 (SD 6.5) seconds and mean percentage of correct triage score was 65.0 (SD 12.6). The participants had a statistically significantly better performance in the single-point triage group regarding the median triage time (p < 0.001) and median percentages of under triage (p = 0.001), but a worse median percentage of over triage (p < 0.001). However, there was no significant difference between the two groups in terms of the percentage of accurate triage. Emergency residents performed better in accuracy and triage time than their non-physician colleagues (p = 0.019).

CONCLUSIONS

Two-point triage does not demonstrate better outcomes in terms of accuracy and timing. Triage officers should be trained frequently with the preferred training methodology to prevent improper triage accuracy and timing. Well-defined medical disaster planning should include frequent training of the triage officers with case scenarios.

An assessment of mass casualty triage systems using the Alberta trauma registry

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.

New NHS Prehospital Major Incident Triage Tool: from MIMMS to MITT

Triage is a key principle in the effective management of major incidents and is the process by which patients are prioritised on the basis of their clinical acuity. However, work published over the last decade has demonstrated that existing methods of triage perform poorly when trying to identify patients in need of life-saving interventions. As a result, a review of major incident triage was initiated by NHS England with the remit to determine the optimum way in which to triage patients of all ages in a major incident for the UK. This article describes the output from this review, the changes being undertaken to UK major incident triage and the introduction of the new NHS Major Incident Triage Tool from the Spring of 2023.

Accuracy of prehospital triage systems for mass casualty incidents in trauma register studies - A systematic review and meta-analysis of diagnostic test accuracy studies

BACKGROUND

Prioritising patients in mass casualty incidents (MCI) can be extremely difficult. Therefore, triage systems are important in every emergency medical service. This study reviews the accuracy of primary triage systems for MCI in trauma register studies.

METHODS

We registered a protocol at PROSPERO ID: CRD42018115438. We searched MEDLINE, EMBASE, Central, Web of Science, Scopus, Clinical Trials, Google Scholar, and reference lists for eligible studies. We included studies that both examined a primary triage system for MCI in trauma registers and provided sensitivity and specificity for critically injured vs non-critically injured as results. We excluded studies that used paediatric, chemical, biological, radiological or nuclear MCIs populations or triage systems. Finally, we calculated intra-study relative sensitivity, specificity and diagnostic odds ratio for each triage system.

RESULTS

Triage Sieve (TS) significantly underperformed in relative diagnostic odds ratio (DOR) when compared to START and CareFlight (CF) (START vs TS: 19.85 vs 13.23 (p<0.0001)│CF vs TS: 23.72 vs 12.83 (p<0.0001)). There was no significant difference in DOR between TS and Military Sieve (MS) (p<0.710). Compared to START, MS and CF TS had significantly higher relative specificity (START vs TS: 93.6% vs 96.1% (p=0.047)│CF vs TS: 96% vs 95.3% (p=0.0006)│MS vs TS: 94% vs 88.3% (p=0.0002)) and lower relative sensitivity (START vs TS: 57.8% vs 34.8% (p<0.0001)│CF vs TS: 53.9% vs 34.7% (p<0.0001)│MS vs TS: 51.9% vs 35.2% p<0.0001)). CF had significantly better relative DOR than START (CF vs START: 23.56 vs 27.79 (p=0.043)). MS had significantly better relative sensitivity than CF and START (MS vs CF: 49.5% vs 38.7% (p<0.0001)│MS vs START: 49.4% vs 43.9% (p=0.01)). In contrast, CF had significantly better relative specificity than MS (MS vs CF: 91.3% vs 93.3% (p<0.0001)). The remaining comparisons did not yield any significant differences.

CONCLUSION

As the included studies were at risk of bias and had heterogenic characteristics, our results should be interpreted with caution. Nonetheless, our results point towards inferior accuracy of Triage Sieve compared to START and CareFlight, and less firmly point towards superior accuracy of Military Sieve compared to START, CareFlight and Triage Sieve.

Developing a translational triage research tool: part two-evaluating the tool through a Delphi study among experts

Background

There are different prehospital triage systems, but no consensus on what constitutes the optimal choice. This heterogeneity constitutes a threat in a mass casualty incident in which triage is used during multiagency collaboration to prioritize casualties according to the injuries’ severity. A previous study has confirmed the feasibility of using a Translational Triage Tool consisting of several steps which translate primary prehospital triage systems into one. This study aims to evaluate and verify the proposed algorithm using a panel of experts who in their careers have demonstrated proficiency in triage management through research, experience, education, and practice.

Method

Several statements were obtained from earlier reports and were presented to the expert panel in two rounds of a Delphi study.

Results

There was a consensus in all provided statements, and for the first time, the panel of experts also proposed the manageable number of critical victims per healthcare provider appropriate for proper triage management.

Conclusion

The feasibility of the proposed algorithm was confirmed by experts with some minor modifications. The utility of the translational triage tool needs to be evaluated using authentic patient cards used in simulation exercises before being used in actual triage scenarios.

Prehospital Triage by Lay Person First Responders: A Scoping Review and Proposal for a new Prehospital Triage Tool

OBJECTIVE

The primary aim of this study is to review the available tools for prehospital triage in case of mass casualty incidents and secondly, to develop a tool which enables lay person first responders (LPFRs) to perform triage and start basic life support in mass casualty incidents.

METHODS

In July 2019, online databases were consulted. Studies addressing prehospital triage methods for lay people were analyzed. Secondly, a new prehospital triage tool for LPFRs was developed. Therefore, a search for prehospital triage models available in literature was conducted and triage actions were extracted.

RESULTS

The search resulted in 6188 articles, and after screening, a scoping review of 4 articles was conducted. All articles stated that there is great potential to provide accurate prehospital triage by people with no healthcare experience. Based on these findings, and combined with the pre-existing prehospital triage tools, we developed a, not-yet validated, prehospital triage tool for lay people, which may improve disaster awareness and preparedness and might positively contribute to community resilience.

CONCLUSION

The prehospital triage tool for lay person first responders may be useful and may help professional medical first responders to determine faster, which casualties most urgently need help in a mass casualty incident.

Review of the requirements for effective mass casualty preparedness for trauma systems. A disaster waiting to happen?

Mass casualty incidents (MCIs) are diverse, unpredictable, and increasing in frequency, but preparation is possible and necessary. The nature of MCIs requires a trauma response but also requires effective and tested disaster preparedness planning. From an international perspective, the aims of this narrative review are to describe the key components necessary for optimisation of trauma system preparedness for MCIs, whether trauma systems and centres meet these components and areas for improvement of trauma system response. Many of the principles necessary for response to MCIs are embedded in trauma system design and trauma centre function. These include robust communication networks, established triage systems, and capacity to secure centres from threats to safety and quality of care. However, evidence from the current literature indicates the need to strengthen trauma system preparedness for MCIs through greater trauma leader representation at all levels of disaster preparedness planning, enhanced training of staff and simulated disaster training, expanded surge capacity planning, improved staff management and support during the MCI and in the post-disaster recovery phase, clear provision for the treatment of paediatric patients in disaster plans, and diversified and pre-agreed systems for essential supplies and services continuity. Mass casualty preparedness is a complex, iterative process that requires an integrated, multidisciplinary, and tiered approach. Through effective preparedness planning, trauma systems should be well-placed to deliver an optimal response when faced with MCIs.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Das Präsentationsdiagramm „Massenanfall“ des Manchester-Triage-Systems

Hintergrund und Ziel der Arbeit

Für die klinische Sichtung in der Zentralen Notaufnahme (ZNA) existiert bisher für den Massenanfall von Verletzten kein standardisierter Sichtungsalgorithmus. Mit dem Erscheinen der vierten überarbeiteten und erweiterten Auflage des Manchester-Triage-Systems (MTS) wird dem Nutzer ein spezielles Präsentationsdiagramm („Massenanfall“) angeboten. In der vorliegenden Studie wurde erstmalig das Präsentationsdiagramm „Massenanfall“ des MTS im klinischen Setting hinsichtlich seiner Güte untersucht.

Methodik

In der vorliegenden monozentrischen, prospektiven Studie wurden 215 traumatologische und 235 nichttraumatologische Patienten unter Verwendung des Präsentationsdiagramms „Massenanfall“ gesichtet und in eine der drei Sichtungskategorien (SK I–III) eingruppiert.

Ergebnisse

Das MTS-Diagramm stufte die traumatologische Kohorte in 80 % der Fälle korrekt ein. In 15,35 % erfolgte eine Über- und in 4,65 % eine Untertriage. Hierbei wurde eine Sensitivität/Spezifität von 84/99 % für die SK I, 87/78 % für SK II sowie 76/94 % für SK III erreicht. Die nichttraumatologischen Patienten wurden in 59,57 % korrekt kategorisiert sowie in 15,75 % über- und in 24,68 % untertriagiert. Die Sensitivität/Spezifität für SK I lag bei 50/95 %, für SK II bei 49/71 % und für SK III bei 73/65 %.

Diskussion

Zusammenfassend war der Algorithmus leicht und schnell anzuwenden und identifizierte traumatologische Patienten mit lebensbedrohlichen Verletzungen treffsicher. Es wurde aber auch deutlich, dass die Diskriminante „Gehfähigkeit“ zu Beginn der Sichtung bzw. rein physiologische Entscheidungskriterien mit einer schlechten Testgüte einhergingen. Nichttraumatologische Krankheitsbilder wurden qualitativ ungenügend kategorisiert.

Developing a Context-Bound Model for Hospital Triage in Disasters and Mass Casualty Incidents in the Health System of Iran

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.

Assessment of the mass casualty triage during the November 2015 Paris area terrorist attacks: towards a simple triage rule

BACKROUND

Triage is key in the management of mass casualty incidents.

OBJECTIVE

The objective of this study was to assess the prehospital triage performed during the 2015 Paris area terrorist attack.

DESIGN SETTING AND PARTICIPANT

This was a retrospective cohort study that included all casualties of the attacks on 13 November 2015 in Paris area, France, that were admitted alive at the hospital within the first 24 h after the events. Patients were triaged as absolute emergency or relative emergency by a prehospital physician or nurse. This triage was then compared to the one of an expert panel that had retrospectively access to all prehospital and hospital files.

OUTCOMES MEASURES AND ANALYSIS

The primary endpoints were the rate of overtriage and undertriage, defined as number of patients misclassified in one triage category, divided by the total number of patients in this triage category.

MAIN RESULT

Among 337 casualties admitted to the hospital, 262 (78%) were triaged during prehospital care, with, respectively, 74 (28%) and 188 (72%) as absolute and relative emergencies. Among these casualties, the expert panel classified 96 (37%) patients as absolute emergencies and 166 (63%) as relative emergency. The rate of undertriage and overtriage was 36% [95% confidence interval (CI), 27-47%] and 8% (95% CI, 4-13%), respectively. Among undertriaged casualties, 8 (23%) were considered as being severely undertriaged. Among overtriaged casualties, 10 (77%) were considered as being severely overtriaged.

CONCLUSION

A simple prehospital triage for trauma casualties during the 13 November terrorist attack in Paris could have been performed triaged in 78% of casualties that were admitted to the hospital, with a 36% rate of undertriage and 8% of overtriage. Qualitative analysis of undertriage and overtriage indicate some possibilities for further improvement.

Patient triage system for supporting the operation of dispatch centres and rescue teams

BACKGROUND

The Thai medical application for patient triage, namely Triagist, is an mHealth application designed to support the pre-hospital process. However, since the functions of the application that are necessary for the pre-hospital process have been found not to be fully developed, the addition of a back-end system has been considered to increase its performance and usability.

OBJECTIVE

To determine the ability of the previous version to effectively manage the pre-hospital process and analyse the current problems with the pre-hospital operation. Therefore, the new system was developed to support the connection of dispatch centres or operational centres to the Triagist mobile application and system evaluation.

METHOD

Design thinking methodology was used to analyse, design and develop a patient triage system to support the pre-hospital process in Thailand based on users' requirements. 68 active members of the rescue teams and emergency medical staff in Chiang Mai and Lampang provinces were recruited to test the reliability of the system based on a prototype application.

RESULTS

The new medical mobile application for patient triage in Thailand was validated for use due to containing the two essential functions of Initial Dispatch Code (IDC) geolocation and IDC management. When the system was tested by emergency staff who were responsible for using it, those with the least experience were found to use it better than their highly experienced colleagues. Moreover, in cases where the system had been implemented, it was found to determine the frequency of symptoms, the time period during which cases occurred, and the density of cases in each area.

CONCLUSION

This system, which has been developed based on the use of smart technology, will play an important role in supporting emergency services in Thailand by enhancing the efficiency of the pre-hospital process. Emergency centres will receive IDC information from the geolocation system so that they can determine patients' location without undue delay. Emergency services will be able to rapidly prepare the necessary resources and administrative tasks will be supported by linking the dispatch centre to central rescue teams.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Triage

This review provides an overview of triaging critically ill or injured patients during mass casualty incidents due to events such as disasters, pandemics, or terrorist incidents. Questions clinicians commonly have, including "what is triage?," "when to triage?," "what are the types of disaster triage?," "how to triage?," "what are the ethics of triage?," "how to govern triage?," and "what research is required on triage?," are addressed.

Thoracic trauma in military settings: a review of current practices and recommendations

PURPOSE OF REVIEW

To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population.

RECENT FINDINGS

Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters.

SUMMARY

The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach

BACKGROUND:

Injuries caused by emergencies and accidents are increasing in the world. To prioritise patients to provide them with proper services and to optimally use the resources and facilities of the medical centres during accidents, the use of triage systems, which are one of the key principles of accident management, seems essential.

AIM:

This study is an attempt to identify available triage systems and compare the differences and similarities of the standards of these systems during emergencies and disasters through a review study.

METHODS:

This study was conducted through a review of the triage systems used in emergencies and disasters throughout the world. Accordingly, all articles published between 1990 and 2018 in both English and Persian journals were searched based on several keywords including Triage, Disaster, Mass Casualty Incidents, in the Medlib, Scopus, Web of Science, PubMed, Cochrane Library, Science Direct, Google scholar, Irandoc, Magiran, Iranmedex, and SID databases in isolation and in combination using both and/ or conjunctions.

RESULTS:

Based on the search done in these databases, twenty different systems were identified in the primary adult triage field including START, Homebush triage Standard, Sieve, CareFlight, STM, Military, CESIRA Protocol, MASS, Revers, CBRN Triage, Burn Triage, META Triage, Mass Gathering Triage, SwiFT Triage, MPTT, TEWS Triage, Medical Triage, SALT, mSTART and ASAV. There were two primary triage systems including Jump START and PTT for children, and also two secondary triage systems encompassing SAVE and Sort identified in this respect. ESI and CRAMS were two other cases distinguished for hospital triage systems.

CONCLUSION:

There are divergent triage systems in the world, but there is no general and universal agreement on how patients and injured people should be triaged. Accordingly, these systems may be designed based on such criteria as vital signs, patient’s major problems, or the resources and facilities needed to respond to patients’ needs. To date, no triage system has been known as superior, specifically about the patients’ clinical outcomes, improvement of the scene management or allocation of the resources compared to other systems. Thus, it is recommended that different countries such as Iran design their triage model for emergencies and disasters by their native conditions, resources and relief forces.

Major incident simulation in Rwanda: A report of two exercises

INTRODUCTION

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

CASE REPORT

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

CONCLUSION

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

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

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

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

Introduction

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

Method

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

Results

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

Conclusions

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