Mass-casualty incidents (MCIs) easily overwhelm a health care facility’s human and material resources through the extraordinary influx of casualties. Efficient and accurate triage of incoming casualties is a critical step in the hospital disaster response.

Traditionally, triage during MCIs has been manually performed using paper cards. This study investigated the use of electronic Simple Triage and Rapid Treatment (START) triage as compared to the manual method.

This observational, crossover study was performed during a live MCI simulation at an urban, Canadian, Level 1 trauma center on May 26, 2016. Health care providers (two medical doctors [MDs], two paramedics [PMs], and two registered nurses [RNs]) each triaged a total of 30 simulated patients - 15 by manual (paper-based) and 15 by electronic (computer-based) START triage. Accuracy of triage categories and time of triage were analyzed. Post-simulation, patients and participating health care providers also completed a feedback form.

There was no difference in accuracy of triage between the electronic and manual methods overall, 83% and 80% (P=1.0), between providers or between triage categories. On average, triage time using the manual method was estimated to be 8.4 seconds faster (P<.001) for PMs; and while small differences in triage times were observed for MDs and RNs, they were not significant. Data from the participant feedback survey showed that the electronic method was preferred by most health care providers. Patients had no preference for either method. However, patients perceived the computer-based method as “less personal” than the manual triage method, but they also perceived the former as “better organized.”

Hospital-based electronic START triage had the same accuracy as hospital-based manual START triage, regardless of triage provider type or acuity of patient presentations. Time of triage results suggest that speed may be related to provider familiarity with a modality rather than the modality itself. Finally, according to patient and provider perceptions, electronic triage is a feasible modality for hospital triage of mass casualties. Further studies are required to assess the performance of electronic hospital triage, in the context of a rapid surge of patients, and should consider additional efficiencies built in to electronic triage systems. This study presents a framework for assessing the accuracy, triage time, and feasibility of digital technologies in live simulation training or actual MCIs.

BolducC, MaghrabyN, FokP, LuongTM, HomierV. Comparison of Electronic Versus Manual Mass-Casualty Incident Triage. Prehosp Disaster Med. 2018;33(3):273–278.

The goal of this search was to review the current literature regarding paramedic triage of primary care patients and the safety of paramedic-initiated non-transport of non-urgent patients.

A narrative literature review was conducted using the Medline (Medline Industries, Inc.; Mundelein, Illinois USA) database and a manual search of Google Scholar (Google; Mountain View, California USA).

Only 11 studies were found investigating paramedic triage and safety of non-transport of non-urgent patients. It was found that triage agreement between paramedic and emergency department staff generally is poor and that paramedics are limited in their abilities to predict the ultimate admission location of their patients. However, these triage decisions and admission predictions are much more accurate when the patient’s condition is the result of trauma and when the patient requires critical care services. Furthermore, the literature provides very limited support for the safety of paramedic triage in the refusal of non-urgent patient transport, especially without physician oversight. Though many non-transported patients are satisfied with the quality of non-urgent treatment that they receive from paramedics, the rates of under-triage and subsequent hospitalization reported in the literature are too high to suggest that this practice can be adopted widely.

There is insufficient evidence to suggest that non-urgent patients can safely be refused transport based on paramedic triage alone. Further attempts to implement paramedic-initiated non-transport of non-urgent patients should be approached with careful triage protocol development, paramedic training, and pilot studies. Future primary research and systematic reviews also are required to build on the currently limited literature.

Fraess-PhillipsAJ. Can Paramedics Safely Refuse Transport of Non-Urgent Patients?Prehosp Disaster Med. 2016;31(6):667–674.

A high influx of patients during a mass-casualty incident (MCI) may disrupt patient flow in an already overcrowded emergency department (ED) that is functioning beyond its operating capacity. This pilot study examined the impact of a two-step ED triage model using Simple Triage and Rapid Treatment (START) for pre-triage, followed by triage with the Canadian Triage and Acuity Scale (CTAS), on patient flow during a MCI simulation exercise.

It was hypothesized that there would be no difference in time intervals nor patient volumes at each patient-flow milestone.

Physicians and nurses participated in a computer-based tabletop disaster simulation exercise. Physicians were randomized into the intervention group using START, then CTAS, or the control group using START alone. Patient-flow milestones including time intervals and patient volumes from ED arrival to triage, ED arrival to bed assignment, ED arrival to physician assessment, and ED arrival to disposition decision were compared. Triage accuracy was compared for secondary purposes.

There were no significant differences in the time interval from ED arrival to triage (mean difference 108 seconds; 95% CI, -353 to 596 seconds; P=1.0), ED arrival to bed assignment (mean difference 362 seconds; 95% CI, -1,269 to 545 seconds; P=1.0), ED arrival to physician assessment (mean difference 31 seconds; 95% CI, -1,104 to 348 seconds; P=0.92), and ED arrival to disposition decision (mean difference 175 seconds; 95% CI, -1,650 to 1,300 seconds; P=1.0) between the two groups. There were no significant differences in the volume of patients to be triaged (32% vs 34%; 95% CI for the difference -16% to 21%; P=1.0), assigned a bed (16% vs 21%; 95% CI for the difference -11% to 20%; P=1.0), assessed by a physician (20% vs 22%; 95% CI for the difference -14% to 19%; P=1.0), and with a disposition decision (20% vs 9%; 95% CI for the difference -25% to 4%; P=.34) between the two groups. The accuracy of triage was similar in both groups (57% vs 70%; 95% CI for the difference -15% to 41%; P=.46).

Experienced triage nurses were able to apply CTAS effectively during a MCI simulation exercise. A two-step ED triage model using START, then CTAS, had similar patient flow and triage accuracy when compared to START alone.

LeeJS, FrancJM. Impact of a Two-step Emergency Department Triage Model with START, then CTAS, on Patient Flow During a Simulated Mass-casualty Incident. Prehosp Disaster Med. 2015;30(4):1–7.

Surge capacity, or the ability to manage an extraordinary volume of patients, is fundamental for hospital management of mass-casualty incidents. However, quantification of surge capacity is difficult and no universal standard for its measurement has emerged, nor has a standardized statistical method been advocated. As mass-casualty incidents are rare, simulation may represent a viable alternative to measure surge capacity.

The objective of the current study was to develop a statistical method for the quantification of surge capacity using a combination of computer simulation and simple process-control statistical tools. Length-of-stay (LOS) and patient volume (PV) were used as metrics. The use of this method was then demonstrated on a subsequent computer simulation of an emergency department (ED) response to a mass-casualty incident.

In the derivation phase, 357 participants in five countries performed 62 computer simulations of an ED response to a mass-casualty incident. Benchmarks for ED response were derived from these simulations, including LOS and PV metrics for triage, bed assignment, physician assessment, and disposition. In the application phase, 13 students of the European Master in Disaster Medicine (EMDM) program completed the same simulation scenario, and the results were compared to the standards obtained in the derivation phase.

Patient-volume metrics included number of patients to be triaged, assigned to rooms, assessed by a physician, and disposed. Length-of-stay metrics included median time to triage, room assignment, physician assessment, and disposition. Simple graphical methods were used to compare the application phase group to the derived benchmarks using process-control statistical tools. The group in the application phase failed to meet the indicated standard for LOS from admission to disposition decision.

This study demonstrates how simulation software can be used to derive values for objective benchmarks of ED surge capacity using PV and LOS metrics. These objective metrics can then be applied to other simulation groups using simple graphical process-control tools to provide a numeric measure of surge capacity. Repeated use in simulations of actual EDs may represent a potential means of objectively quantifying disaster management surge capacity. It is hoped that the described statistical method, which is simple and reusable, will be useful for investigators in this field to apply to their own research.

FrancJM, IngrassiaPL, VerdeM, ColomboD, Della CorteF. A Simple Graphical Method for Quantification of Disaster Management Surge Capacity Using Computer Simulation and Process-control Tools. Prehosp Disaster Med. 2015;30(1):1-7.

To identify factors known prior to triage that might have predicted hospital admission for patients triaged by the Canadian Triage Acuity Scale (CTAS) as level 5 (CTAS 5, nonurgent) and to determine whether inappropriate triage occurred in the admitted CTAS 5 patients.

We reviewed the triage records of patients triaged as CTAS 5 at the emergency departments (EDs) of three tertiary care hospitals between April 2002 and September 2009. Two triage nurses unaware of the study objective independently assigned the CTAS level in 20% of randomly selected CTAS 5 patients who were admitted. We used the kappa statistic (κ) to measure the agreement among the raters in CTAS level between the assessment of the research nurses and the original triage assessment and regression analysis to identify independent predictors of admission to hospital.

Of the 37,416 CTAS 5 patients included in this study, 587 (1.6%) were admitted. Agreement on CTAS assignment in CTAS 5 patients who were admitted was κ −0.9, (95% confidence interval [CI] 20.96 to 20.84). Age over 65 (odds ratio [OR] 5.46, 95% CI 4.57 to 6.53) and arrival by ambulance (OR 7.42, 95% CI 6.15 to 8.96) predicted hospital admission in CTAS 5 patients.

Most of the CTAS 5 patients who were subsequently admitted to hospital may have qualified for a higher triage category. Two potential modifiers, age over 65 and arrival by ambulance, may have improved the prediction of admission in CTAS 5 patients. However, the consistent application of existing CTAS criteria may also be important to prevent incorrect triage.

In Italy, administration of medications or advanced procedures dictates the prehospital presence of a physician to initiate treatment. Nursing staff is often used as dispatchers in Italian emergency medical ambulance services. There is little data about nursing dispatch performance in detecting high-acuity patients who need prehospital medications and procedures.

To determine the ability of a dispatch center staffed by emergency ambulance nurses to detect prehospital need for physician interventions in the context of a semi-rural area Emergency Medical Services system.

A retrospective analysis of 53,606 calls from the Rovigo Emergency Ambulance Services’ database was undertaken. Physician prehospital interventions were defined as the administration of medications or procedures (advanced airway management and ventilation, pneumothorax decompression, fluid replacement therapy, external defibrillation, cardioversion and pacing). The dispatch codes (assigned by a subjective decision-making process as Red, Yellow, or Green) of all transported prehospital patient calls were matched with an out-of-hospital triage system staffed by clinicians to determine the number of correctly identified prehospital need of physician interventions. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

The sensitivity of subjective experience-based nursing dispatch in detecting the need for physician interventions was 78.0% (95% CI, 76.9%-79.1%), with a PPV of 36.6% (95% CI, 35.8%-37.5%). Specificity was 83.8% (95% CI: 83.4%-84.1%), with an NPV of 96.9% (95% CI, 96.8%-97.1%).

A dispatch center staffed by nurses with six years of experience and three months of training correctly identified when not to send a doctor to the scene in the absence of need for physician interventions, using a subjective decision-making process. The nurses staffing the dispatch center also worked in the field. Dispatch center staff were not able to predict when there was no need for physician interventions in high-acuity dispatch code patients, resulting in an over-triage and use of emergency physicians on scene.

LeopardiM, SommacampagnaM.Emergency Nursing Staff Dispatch: Sensitivity and Specificity in Detecting Prehospital Need for Physician Interventions During Ambulance Transport in Rovigo Emergency Ambulance Service, Italy. Prehosp Disaster Med. 2013;28(5):1-6.