METASTART: A Systematic Review and Meta-Analysis of the Diagnostic Accuracy of the Simple Triage and Rapid Treatment (START) Algorithm for Disaster Triage

Digitalisation of information and management optimisation in Multiple Victim Incidents. Analytical study

INTRODUCTION

Triage is a crucial tool for managing a Multiple Victim Incident (MVI). One particularly problematic issue is the communication of results to the chain of command and control. Favourable data exists to suggest that digital triage can improve some features of analogue triage. Within this context we have witnessed the emergence of the Valkyries Project, which is working to develop strategies to respond to MVIs, and especially cross-border incidents. To that end, an IT platform called "SIGRUN" has been created which distributes, in real time, all the information to optimise MVI management. A full-scale simulation, held on the Spain-Portugal border and featuring contributions from different institutions on both sides of the border, put to the test the role of information digitalisation in this type of incidents.

OBJECTIVE

To evaluate the impact of the synchronous digitalisation of information on the optimal management of Multiple Victim Incidents.

METHOD

Clinical evaluation study carried out on a cross-border simulation between Spain and Portugal. A Minimum Data Set (MDS) was established by means of a modified Delphi by a group of experts. The digital platform "SIGRUN" integrated all the information, relaying it in real time to the chain of command and control. Each country assigned two teams that would carry out digital and analogue triage synchronously. Analogue triage variables were gathered by observers accompanying the first responders. Digital triage times were recorded automatically. Each case was evaluated and classified simultaneously by the two participating teams, to carry out a reliability study in a real time scenario.

RESULTS

The total duration of the managing of the incident in the A group of countries involved compared to the B group was 72.5 minutes as opposed to 73 minutes. The total digital assistance triage (AT) time was 37.5 seconds in the digital group, as opposed to 32 minutes in the analogue group. Total evacuation (ET) time was 28 minutes in the digital group compared with 65 minutes in the analogue group. The average differences in total times between the analogue and the digital system, both for primary and secondary evaluation, were statistically significant: p = 0.048 and p = 0.000 respectively. For the "red" category, AT obtained a sensitivity of 100%, also for ET, while with regard to AT safety it obtained a PPV of 61.54% and an NPV of 100%, and for ET it obtained a PPV of 83.33% and an NPV of 100%. For the analogue group, for AT it obtained a sensitivity of 62.50%, for ET, 70%, for AT safety it obtained a PPV of 45.45% and an NPV of 92.31%, while for ET it obtained a PPV of 70% and an NPV of 92.50%. The gap analysis obtained a Kappa index of 0.7674.

CONCLUSION

The triage system using the developed digital tool demonstrated its validity compared to the analogue tool, as a result of which its use is recommended.

Use of virtual reality exercises in disaster preparedness training: A scoping review

Background

The scope and number of disasters have increased over the years. This has called for more robust disaster preparedness training and plans. The use of virtual reality exercises in addition to tabletop exercises is considered a new approach to the preparation of disaster preparedness plans. Virtual reality exercises are being developed to either replace or complement current traditional approaches to disaster preparedness training.

Objectives

To review and summarize the current existing literature regarding the effectiveness, advantages and limitations of using virtual reality exercises in disaster preparedness as a complementary/replacement mechanism for real-time drills and tabletop exercises.

Methods

In this scoping review, we searched PubMed, Cochrane, EMBASE, PLOS, and Google Scholar for research publications involving virtual reality exercises in disaster training from 2008 to 2022 using "AND" and "OR" operators for the keywords "disaster," "preparedness," "virtual reality," and "tabletop." From a total of 333 articles that resulted in our search and were then evaluated by the authors, 55 articles were finally included in this review.

Results

Virtual reality exercises are found to be better in the formulation of disaster preparedness plans compared to tabletop exercises. Virtual reality exercises can be used as the primary means of creating a real-life-like experience in disaster preparedness training and proved at least as better complementary to tabletop exercises. Virtual reality exercises have many advantages over traditional real-life or tabletop exercises and are more cost-effective, but some drawbacks are still identified.

Conclusion

The advantages of virtual reality exercises are remarkable and underline their benefits and uses versus costs. We highly encourage decision-makers and institutions dealing in disaster preparedness to adopt using virtual reality exercises in training for disaster preparedness.

Usefulness of Self-Selected Scenarios for Simple Triage and Rapid Treatment Method Using Virtual Reality

BACKGROUND

Repeated triage training is necessary to maintain and improve the accuracy of simple triage and rapid treatment (START), a popular triage method. Virtual reality (VR) may be more effective than conventional training methods. This study aimed to verify the educational usefulness of START using VR originally developed for students.

METHODS

A VR was initially developed with a function that allowed students to select the triage procedure and its evaluation. Triage was performed using a simple modified START method, and eight scenarios were developed. The participants included 70 paramedic students classified into VR and live lecture groups. They took a 20-question written test that evaluated their academic ability before the course. After the course, a practical test and a 20-question written test were conducted. The total score of the practical test was 43 points. Triage procedure (1 point), observation and evaluation (1-5 points), and triage categories (1 point) were evaluated in this test.

RESULTS

The VR and live lecture groups consisted of 33 and 29 participants, respectively. No significant differences were observed pre- and post-test. In the practical test, the median (interquartile range) score was 29 (26-32) and 25 (23-29) for the VR and live lecture groups, respectively, with the VR group scoring significantly higher (P=0.03).

CONCLUSION

Our results confirmed the educational usefulness of selective VR for active learning of START. Therefore, VR combined with live lectures and simulations would be an optimal educational technique.

Repeatability, reproducibility, and diagnostic accuracy of a commercial large language model (ChatGPT) to perform emergency department triage using the Canadian triage and acuity scale

PURPOSE

The release of the ChatGPT prototype to the public in November 2022 drastically reduced the barrier to using artificial intelligence by allowing easy access to a large language model with only a simple web interface. One situation where ChatGPT could be useful is in triaging patients arriving to the emergency department. This study aimed to address the research problem: "can emergency physicians use ChatGPT to accurately triage patients using the Canadian Triage and Acuity Scale (CTAS)?".

METHODS

Six unique prompts were developed independently by five emergency physicians. An automated script was used to query ChatGPT with each of the 6 prompts combined with 61 validated and previously published patient vignettes. Thirty repetitions of each combination were performed for a total of 10,980 simulated triages.

RESULTS

In 99.6% of 10,980 queries, a CTAS score was returned. However, there was considerable variations in results. Repeatability (use of the same prompt repeatedly) was responsible for 21.0% of overall variation. Reproducibility (use of different prompts) was responsible for 4.0% of overall variation. Overall accuracy of ChatGPT to triage simulated patients was 47.5% with a 13.7% under-triage rate and a 38.7% over-triage rate. More extensively detailed text given as a prompt was associated with greater reproducibility, but minimal increase in accuracy.

CONCLUSIONS

This study suggests that the current ChatGPT large language model is not sufficient for emergency physicians to triage simulated patients using the Canadian Triage and Acuity Scale due to poor repeatability and accuracy. Medical practitioners should be aware that while ChatGPT can be a valuable tool, it may lack consistency and may frequently provide false information.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Unmanned aerial vehicle based intelligent triage system in mass-casualty incidents using 5G and artificial intelligence

BACKGROUND

Rapid on-site triage is critical after mass-casualty incidents (MCIs) and other mass injury events. Unmanned aerial vehicles (UAVs) have been used in MCIs to search and rescue wounded individuals, but they mainly depend on the UAV operator's experience. We used UAVs and artificial intelligence (AI) to provide a new technique for the triage of MCIs and more efficient solutions for emergency rescue.

METHODS

This was a preliminary experimental study. We developed an intelligent triage system based on two AI algorithms, namely OpenPose and YOLO. Volunteers were recruited to simulate the MCI scene and triage, combined with UAV and Fifth Generation (5G) Mobile Communication Technology real-time transmission technique, to achieve triage in the simulated MCI scene.

RESULTS

Seven postures were designed and recognized to achieve brief but meaningful triage in MCIs. Eight volunteers participated in the MCI simulation scenario. The results of simulation scenarios showed that the proposed method was feasible in tasks of triage for MCIs.

CONCLUSION

The proposed technique may provide an alternative technique for the triage of MCIs and is an innovative method in emergency rescue.

A Qualitative Assessment of Studies Evaluating the Classification Accuracy of Personnel Using START in Disaster Triage: A Scoping Review

Background

Mass casualty incidents (MCIs) can occur as a consequence of a wide variety of events and often require overwhelming prehospital and emergency support and coordinated emergency response. A variety of disaster triage systems have been developed to assist health care providers in making difficult choices with regards to prioritization of victim treatment. The simple triage and rapid treatment (START) triage system is one of the most widely used triage algorithms; however, the research literature addressing real-world or simulation studies documenting the classification accuracy of personnel using START is lacking.

Aims and Objectives

To explore the existing literature related to the current state of knowledge about studies assessing the classification accuracy of the START triage system.

Design

Scoping review based on Arksey and O'Malley's methodological framework and narrative synthesis based on methods described by Popay and colleagues were performed.

Results

The literature search identified 1,820 citations, of which 32 studies met the inclusion criteria. Thirty were peer-reviewed articles and 28 published in the last 10 years (i.e., 2010 and onward). Primary research studies originated in 13 countries and included 3,706 participants conducting triaging assessments involving 2,950 victims. Included studies consisted of five randomized controlled trials, 17 non-randomized controlled studies, eight descriptive studies, and two mixed-method studies. Simulation techniques, mode of delivery, contextual features, and participants' required skills varied among studies. Overall, there was no consistent reporting of outcomes across studies and results were heterogeneous. Data were extracted from the included studies and categorized into two themes: (1) typology of simulations and (2) START system in MCIs simulations. Each theme contains sub-themes regarding the development of simulation employing START as a system for improving individuals' preparedness. These include types of simulation training, settings, and technologies. Other sub-themes include outcome measures and reference standards.

Conclusion

This review demonstrates a variety of factors impacting the development and implementation of simulation to assess characteristics of the START system. To further improve simulation-based assessment of triage systems, we recommend the use of reporting guidelines specifically designed for health care simulation research. In particular, reporting of reference standards and test characteristics need to improve in future studies.