Comparing the Accuracy of Mass Casualty Triage Systems in a Pediatric Population

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.

Perspective of Emergency Pediatric Nurses Triaging Pediatric Patients in the Emergency Department: A Phenomenographic Study

INTRODUCTION

Triage, a process to determine illness severity, is implemented by emergency nurses to prioritize treatment and provide care for a maximum number of patients using limited resources. The competency of emergency nurses and a highly reliable triage are crucial for the provision of emergency care. Pediatric patients are different from adult patients in certain aspects, such as growth-phase characteristics, communication ability, and the onset of disease; these aspects often pose challenges during their primary triage. This study explored how emergency nurses triage pediatric patients using the Korean Triage and Acuity Scale.

METHODS

Eleven emergency nurses (N = 11) working in the pediatric emergency department of a university hospital in Seoul, South Korea, were recruited using purposive sampling methods. Phenomenography was used to investigate the strategies by which these nurses use the Korean Triage and Acuity Scale to triage pediatric patients.

RESULTS

The findings comprised 2 descriptive categories: 6 approaches on how to triage patients (categories of how) and 3 strategies (categories of what) used by pediatric emergency nurses to triage pediatric patients with the Korean Triage and Acuity Scale.

DISCUSSION

The experience and proficiency of emergency nurses are essential factors for the effective triage of pediatric patients. Our findings qualitatively elucidate different ways of understanding pediatric triage and indicate the need for pediatric triage education programs.

A Scoping Review of Pediatric Mass-Casualty Incident Triage Algorithms

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.

Inter-Rater Reliability and Agreement Among Mass-Casualty Incident Algorithms Using a Pediatric Trauma Dataset: A Pilot Study

INTRODUCTION

Many triage algorithms exist for use in mass-casualty incidents (MCIs) involving pediatric patients. Most of these algorithms have not been validated for reliability across users.

STUDY OBJECTIVE

Investigators sought to compare inter-rater reliability (IRR) and agreement among five MCI algorithms used in the pediatric population.

METHODS

A dataset of 253 pediatric (<14 years of age) trauma activations from a Level I trauma center was used to obtain prehospital information and demographics. Three raters were trained on five MCI triage algorithms: Simple Triage and Rapid Treatment (START) and JumpSTART, as appropriate for age (combined as J-START); Sort Assess Life-Saving Intervention Treatment (SALT); Pediatric Triage Tape (PTT); CareFlight (CF); and Sacco Triage Method (STM). Patient outcomes were collected but not available to raters. Each rater triaged the full set of patients into Green, Yellow, Red, or Black categories with each of the five MCI algorithms. The IRR was reported as weighted kappa scores with 95% confidence intervals (CI). Descriptive statistics were used to describe inter-rater and inter-MCI algorithm agreement.

RESULTS

Of the 253 patients, 247 had complete triage assignments among the five algorithms and were included in the study. The IRR was excellent for a majority of the algorithms; however, J-START and CF had the highest reliability with a kappa 0.94 or higher (0.9-1.0, 95% CI for overall weighted kappa). The greatest variability was in SALT among Green and Yellow patients. Overall, J-START and CF had the highest inter-rater and inter-MCI algorithm agreements.

CONCLUSION

The IRR was excellent for a majority of the algorithms. The SALT algorithm, which contains subjective components, had the lowest IRR when applied to this dataset of pediatric trauma patients. Both J-START and CF demonstrated the best overall reliability and agreement.

The First 15 Minutes: A Novel Disaster Simulation Exercise

OBJECTIVE

The objective was to describe a feasible, multidisciplinary pediatric mass casualty event (MCE) simulation format that was less than 2 h within emergency department space and equipment constraints.

METHODS

This was a prospective cohort study of an MCE in situ simulation program from June-October 2019. Participants rotated through 3 modules: (1) triage, (2) caring for a critical patient in an MCE setting, and (3) being in a disaster leadership role. Triage accuracy, knowledge, self-evaluation of preparedness, and MCE skills by means of pre- and post-test surveys were measured. Wilcoxon matched pairs signed rank test scores and McNemar's matched pair chi-squared test were performed to evaluate for statistically significant differences.

RESULTS

Forty-six physicians (MD), 1 physician's assistant (PA), and 22 nurses participated over 4 simulation d. Among the MD/PA group, there was a statistically significant 7% knowledge increase (95% confidence interval [CI], 3%-11%). Nurses did not show a statistically significant knowledge difference (0.04, 95% CI, 0.04%, 14%). There was a statistically significant increase in triage and resource use preparedness (P < 0.01) for all participants.

CONCLUSION

This efficient, feasible model for a multidisciplinary ED disaster drill provides a multi-modular exposure while improving both MD and PA knowledge and all staff preparedness for MCE.

JumpSTART Triage Protocol in Disaster Pediatric Patients: A Systematic Literature Review

INTRODUCTION

In a mass-casualty incident (MCI) involving children, there is a need to apply accurate triage tools in order to help those who require important care, and at the same time, to avoid unnecessary use of resources. Thus, it is discussed which would be the best triage device to use in these situations. One of the most used is a modification of Simple Triage and Rapid Treatment, JumpSTART, whose performative quality this review focuses on.

STUDY OBJECTIVE

This review sought to compare the performance parameters of JumpSTART with other triage algorithms used in pediatric disaster victims.

METHODS

This systematic review was performed according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and registered with the PROSPERO database of systematic reviews with the number CRD42021258415. The last update of the search in the databases was on August 12, 2021 and resulted in six documents to be analyzed. The inclusion criteria included the peer-reviewed academic papers in English, Portuguese, Spanish, and Italian languages, and the databases used were PubMed, Scopus, MEDLINE/Bireme (Virtual Library of Health), Web of Science, and CINAHL, which executes the query on the topic, keywords, or abstracts. Also to be included, documents that were available with full-text access through CAPES, Google, or Google Scholar. Books, non-academic research, and content in languages other than the presented ones were represented as exclusion criteria. The Joanna Briggs Institute (JBI) checklists were used to evaluate the methodological quality of the retrieved studies. The results were presented through narrative synthesis. This review was not funded.

RESULTS

Of the collected publications, five articles were used to carry out this review, with the addition of an extra article captured by citation tracking. The findings from the obtained results were that JumpSTART was the preferred tool and presented the fastest speed of use. Only one of the five studies that dealt with accuracy showed JumpSTART as the most accurate algorithm, while three of the other four showed its inferiority in most aspects. In one study, no significant difference was observed amongst the chosen protocols.

CONCLUSIONS

There is insufficient evidence to validate JumpSTART as a universal triage tool, given the disparities in the results obtained from the comparisons. No tool performed satisfactorily well, therefore there is an urgent need to create a reliable algorithm.

Comparison of prehospital professional accuracy, speed, and interrater reliability of six pediatric triage algorithms

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.

Paediatric patients in mass casualty incidents: a comprehensive review and call to action

The paediatric population is disproportionately affected during mass casualty incidents (MCIs). Several unique characteristics of children merit special attention during natural and man-made disasters because of their age, physiology, and vulnerability. Paediatric anaesthesiologists play a critical part of MCI care for this population, yet there is a deficit of publications within the anaesthesia literature addressing paediatric-specific MCI concerns. This narrative review article analyses paediatric MCI considerations and compares differing aspects between care provision in Australia, the UK, and the USA. We integrate some of the potential roles for anaesthesiologists with paediatric experience, which include preparation, command consultation, in-field care, pre-hospital transport duties, and emergency department, operating theatre, and ICU opportunities. Finally, we propose several methods by which anaesthesiologists can improve their contribution to paediatric MCI care through personal education, training, and institutional involvement.

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.

Sort, Assess, Life-Saving Intervention, Triage With Drone Assistance in Mass Casualty Simulation: Analysis of Educational Efficacy

Introduction

Mass casualty incident (MCI) simulation and triage are educational methods used to provide high fidelity training to first response teams. Simulation and triage need to be as effective as possible to train professionals for true emergencies involving mass casualty. Although MCI simulation and triage have been used in the pre-professional setting (i.e. medical school, nursing school, etc.), more data is required regarding quality improvement of these simulations. This study focuses on quality improvement of MCI simulation and triage in the pre-professional training. In order to evaluate simulation quality to optimize future triage simulations, this study had three specific aims: (1) assess participant accuracy of triage after training in Sort, Assess, Life-Saving Interventions, Triage/Transport (SALT); (2) evaluate the role of stress and confidence in participants of triage simulation; (3) determine trainees’ perception of unmanned aerial vehicles (drones) in the setting of mass casualty simulation.

Methods

A total of 44 attendees of the University of Central Florida (UCF) College of Medicine Global Health Conference participated in this study across three groups. Each group was provided a 15-minute lecture on SALT protocol. After the training, the participants continued to a 30-minute simulation in which they were asked to accurately triage up to 46 patient-actors. Each participants’ triage designations were compared to the previously assigned designations of each patient-actor. Pre- and post-simulation surveys were collected and analyzed using Statistical Package for the Social Sciences (SPSS) (IBM Corp., Chicago, IL). All other data were analyzed using descriptive statistics. 

Results

Qualitative and Likert data for the simulation were collected from 44 participants. Given a total of 1,113 triage scores (average of 25.29 triage designations per person), there was data to support that novice learners in this study tended to under-triage using the SALT protocol after 15-minute SALT training, with an overall accuracy of 52.43%. Survey data showed that confidence in mass casualty triage improved post-simulation, improving from median 3/10 to 5/10. Most participants were unaware of the use of unmanned aerial vehicles in MCI but most had positive opinions of their usefulness in MCI after the simulation, with a median score of 8/10.

Conclusions

Participant accuracy of triage after undergoing a 15-minute training in SALT triage was 52.43%, with a non-statistically significant tendency to under-triage. This accuracy level is consistent with other studies of SALT triage in MCI, but the tendency to undertriage requires further study for validation. Stress levels during the simulation were significantly elevated, while post-simulation confidence increased significantly from pre-simulation. The perception of drone utility in MCI was favorable among participants in this study, indicating drones may be useful for first response teams in future mass casualty simulations.

Tabletop Application of SALT Triage to 10, 100, and 1000 Pediatric Victims

INTRODUCTION

The Sort, Access, Life-saving interventions, Treatment and/or Triage (SALT) mass-casualty incident (MCI) algorithm is unique in that it includes two subjective questions during the triage process: "Is the victim likely to survive given the resources?" and "Is the injury minor?"

HYPOTHESIS/PROBLEM

Given this subjectivity, it was hypothesized that as casualties increase, the inter-rater reliability (IRR) of the tool would decline, due to an increase in the number of patients triaged as Minor and Expectant.

METHODS

A pre-collected dataset of pediatric trauma patients age <14 years from a single Level 1 trauma center was used to generate "patients." Three trained raters triaged each patient using SALT as if they were in each of the following scenarios: 10, 100, and 1,000 victim MCIs. Cohen's kappa test was used to evaluate IRR between the raters in each of the scenarios.

RESULTS

A total of 247 patients were available for triage. The kappas were consistently "poor" to "fair:" 0.37 to 0.59 in the 10-victim scenario; 0.13 to 0.36 in the 100-victim scenario; and 0.05 to 0.36 in the 1,000-victim scenario. There was an increasing percentage of subjects triaged Minor as the number of estimated victims increased: 27.8% increase from 10- to 100-victim scenario and 7.0% increase from 100- to 1,000-victim scenario. Expectant triage categorization of patients remained stable as victim numbers increased.

CONCLUSION

Overall, SALT demonstrated poor IRR in this study of increasing casualty counts while triaging pediatric patients. Increased casualty counts in the scenarios did lead to increased Minor but not Expectant categorizations.

Paediatric major incident triage tools for identifying those in need of life-saving interventions

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.

Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population

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.