A better START for low-acuity victims: data-driven refinement of mass casualty triage

Computer-assisted diagnostics

Healthcare is at the edge of a profound renovation or collapse due to the rapid inflow of machine learning protocols and procedures able to optimize several processes. Clinical trials are key for the progress of science and the correct interpretation of data. Rickard et al., in this journal, report that data on misidentification rates in medical trials are scarce. In five trials involving more than 800 blood or histology specimens examined, data clarification forms (DCFs) were issued for 21% of instances, and 67% were related to sample identification. The authors suggest that a suitable number of de- recognized data points is critical. Moreover, a formalized process involving the specimen accession employed in routine care is key to mitigate recognition errors and their potential profound impact on clinical research and outcome. We fully agree with the authors and their report is highly relevant today that we face transformation in healthcare. We suggest that 3D barcoding may mitigate several issues on misidentification.

Tradeoffs in Triage of Motor Vehicle Trauma by Rural 911 Emergency Medical Services Practitioners

PURPOSE

Identification and triage of severely injured patients to trauma centers is paramount to survival. Many patients are undertriaged in rural areas and do not receive proper care. The decision-making processes involved in triage are not well understood and should be assessed to improve the triage process and outcomes.

METHODS

Triage decision-making processes were explored through emergency medical services (EMS) practitioner focus groups and a discrete choice experiment (DCE). Attributes of trauma determined from focus groups and the literature included patient demography, injury mechanism, and trauma center distance. DCE data were analyzed using mixed logit models.

RESULTS

High-risk mechanism, decreased age, multiple comorbidities, and pregnancy were found to increase the preference for triage. Greater trauma center distance was found to decrease preference for triage, but practitioners were willing to trade off up to 2 h of travel time to transport a third-trimester pregnancy and 48 min of travel time to transport a 25-y-old than they would a 50-y-old with the same comorbidities, injuries, and stability.

CONCLUSIONS

Our findings suggest that current forms of EMS protocols may not be appropriately tailored to support the mechanisms underlying practitioner decision making. Public health professionals and researchers should consider using DCEs to better understand EMS practitioner decision making and identify structures and incentives that may improve patient outcomes and optimally guide appropriate triage decisions.

HIGHLIGHTS

Discrete choice experiments are an effective method to elicit prehospital practitioners' preferences around transport of the traumatized patient.Practitioner biases observed in EMS transport data are recovered in stated preference models incorporating individual preference heterogeneity.There is a discrepancy between the triage priorities recommended by protocol and those measured from prehospital practitioners' decisions-this may have implications in over- and undertriage rates and prehospital protocol design.

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.

Comparison of Outcome Tools Used to Test Mass-Casualty Algorithms in the Pediatric Population

INTRODUCTION

Mass-casualty incident (MCI) algorithms are used to sort large numbers of patients rapidly into four basic categories based on severity. To date, there is no consensus on the best method to test the accuracy of an MCI algorithm in the pediatric population, nor on the agreement between different tools designed for this purpose.

STUDY OBJECTIVE

This study is to compare agreement between the Criteria Outcomes Tool (COT) to previously published outcomes tools in assessing the triage category applied to a simulated set of pediatric MCI patients.

METHODS

An MCI triage category (black, red, yellow, and green) was applied to patients from a pre-collected retrospective cohort of pediatric patients under 14 years of age brought in as a trauma activation to a Level I trauma center from July 2010 through November 2013 using each of the following outcome measures: COT, modified Baxt score, modified Baxt combined with mortality and/or length-of-stay (LOS), ambulatory status, mortality alone, and Injury Severity Score (ISS). Descriptive statistics were applied to determine agreement between tools.

RESULTS

A total of 247 patients were included, ranging from 25 days to 13 years of age. The outcome of mortality had 100% agreement with the COT black. The "modified Baxt positive and alive" outcome had the highest agreement with COT red (65%). All yellow outcomes had 47%-53% agreement with COT yellow. "Modified Baxt negative and <24 hours LOS" had the highest agreement with the COT green at 89%.

CONCLUSIONS

Assessment of algorithms for triaging pediatric MCI patients is complicated by the lack of a gold standard outcome tool and variability between existing measures.

Prehospital Disaster Triage Does Not Predict Pediatric Outcomes: Comparing the Criteria Outcomes Tool to Three Mass-Casualty Incident Triage Algorithms

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.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

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.

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

Promptly reporting of critical laboratory values in pediatrics: A work in progress

In the 21^st century, the determination of alert thresholds remains the most challenging and controversial issue in clinical pediatrics. Pre-analytical, analytical, and post-analytical matters will consolidate or undermine the fate of any laboratory process. Pre-analytical issues need to be cleared off before the laboratory physician can dispatch the result to the pediatrician in charge. Once it is cleared off, the classification of essential laboratory results is paramount. It is more than an academic exercise and may be subdivided in the order of priority we handle it to inform promptly and safely the primary physicians. Currently, we are applying new modes of making sure relevant information is transmitted without interrupting the standard workflow of the primary physicians in charge for the child, who eventually need a fast line of action for results that may be life-threatening.

Paramedic Application of a Triage Sieve: A Paper-Based Exercise

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.

Emergency imaging after a mass casualty incident: role of the radiology department during training for and activation of a disaster management plan

In the setting of mass casualty incidents (MCIs), hospitals need to divert from normal routine to delivering the best possible care to the largest number of victims. This should be accomplished by activating an established hospital disaster management plan (DMP) known to all staff through prior training drills. Over the recent decades, imaging has increasingly been used to evaluate critically ill patients. It can also be used to increase the accuracy of triaging MCI victims, since overtriage (falsely higher triage category) and undertriage (falsely lower triage category) can severely impact resource availability and mortality rates, respectively. This article emphasizes the importance of including the radiology department in hospital preparations for a MCI and highlights factors expected to influence performance during hospital DMP activation including issues pertinent to effective simulation, such as establishing proper learning objectives. After-action reviews including performance evaluation and debriefing on issues are invaluable following simulation drills and DMP activation, in order to improve subsequent preparedness. Historically, most hospital DMPs have not adequately included radiology department operations, and they have not or to a little extent been integrated in the DMP activation simulation. This article aims to increase awareness of the need for radiology department engagement in order to increase radiology department preparedness for DMP activation after a MCI occurs.

Simple Triage Algorithm and Rapid Treatment and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation mass casualty triage methods for sensitivity, specificity, and predictive values

OBJECTIVE

Two common mass casualty triage algorithms are Simple Triage Algorithm and Rapid Treatment (START) and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation (SALT). We sought to determine the START and SALT efficacy in predicting clinical outcome by appropriate triage.

METHODS

We performed a retrospective chart review of trauma registry of patients from our emergency department (ED). We applied the triage algorithms to 100 patient charts. The end points categories were defined by patient outcomes and the need for intervention: minor/green, discharged without intervention other than minor ED procedure; delayed/yellow, patients get an intervention more than 12 hours after arrival to the ED; immediate/red, patients get an intervention less than 12 hours after arrival; dead/expectant/black, patients die within 48 hours after arrival.

RESULTS

The mean age was 47 years (range, 17-92 years), and 72% were male. The mechanism of injury was 41% motor vehicle collision, 32% fall, and 16% penetrating trauma. Hospital outcome was 60% minor/green, 5% delayed/yellow, 29% immediate/red, and 6% dead/black. The SALT method resulted in 5 patients overtriaged (95% confidence interval [CI], 1.6-11.2), 30 undertriaged (95% CI, 21.2-40), and 65 met triage level (95% CI, 54.8-74.3). The START method resulted in 12 overtriage (95% CI, 6.4-20), 33 undertriaged (95% CI, 23.9-43.1), and 55 at triage level (95% CI, 44.7-65). Within triage levels, sensitivity ranged from 0% to 92%, specificity from 55% to 100%, positive predictive values from 10% to 100%, and negative predictive value from 65% to 97%.

CONCLUSION

Overall, neither SALT nor START was sensitive or specific for predicting clinical outcome.