COMMENTARY

Mass-casualty Triage Systems: A Hint of Science

When a mass-casualty incident (MCI) or disaster(however these are defined1) strikes, the first thingthat emergency medical services (EMS) personnel aretrained to do, after ensuring scene safety as best aspossible, is to provide triage, sorting patients intogroups based on apparent priority. Roughly halfa dozen mass-casualty triage systems have been de-veloped and are in use around the world for thispurpose, and most sort patients into the familiarimmediate, delayed, minimal, and expectant cate-gories. Surprisingly, there has been very little researchvalidating or even evaluating these systems. Wesimply have no idea whether any of them actuallywork as intended, or have any effect on patientoutcome even if used as designed.The most commonly used system in the United

States is probably the Simple Triage And RapidTreatment (START) system, developed by the New-port Beach Fire Department and Hoag Hospital inCalifornia in 1983 after three emergency department(ED) staff members noted what they believed was in-efficient field triage at a school bus crash exercise. Thesystem was updated in 1994, and its primary intent isto identify three problems that will lead to deathwithin one hour if untreated: impaired breathing,head injury, and significant hemorrhage. Despiteclaims that it is the most effective triage program,and that trained rescuers can use it to triage patientsin 60 seconds or less2 or even 30 seconds or less,3 therehas been almost no scientific evaluation of the STARTsystem. To the best of our knowledge, only one suchstudy has been reported: in 2001, Risavi and col-leagues examined the performance of 109 EMS per-sonnel on a written test taken before and again after atwo-hour video and slide presentation describing theSTART program.4 The mean postintervention score(75%) was significantly better than the mean prein-tervention score (55%, p , 0.001), but it is importantto recognize that the meaning of high scores on awritten test such as this one has not been evaluated interms of predicting actual provider performance inthe field, or effect on patient outcomes.A pediatric version of START, called JumpSTART,

was developed in 1995, and modified in 2001.5 It is notknown how widespread this system is in terms offield personnel training or actual use. One recentarticle in the literature evaluated the effect of Jump-START training on the ability of 24 EMS providersand eight school nurses to triage 12 children withsimulated injuries into the ‘‘correct’’ categories, asdetermined by the authors.6 As with the Risavi study,there is no way to know whether ‘‘correct’’ triage has

any meaning in terms of improved scene operationsor outcomes.

We are aware of only one article in the literaturecomparing mass-casualty triage schemes. This 2001paper examined START, a modification of START(substituting palpation of the radial pulse for assess-ment of capillary refill), the British ‘‘Triage Sieve,’’ amodification of the Triage Sieve (same substitution),and the home-grown system of the Australian med-ical retrieval service that conducted the study (‘‘Care-Flight Triage’’). The systems were used to categorize asample of 1,144 adult trauma patients from a traumadatabase. The differences in sensitivities and specific-ities were minimal, but the authors postulated that theCareFlight Triage system, because it seems to be thefastest to apply to each patient, would likely performthe best in the field.7 We are aware of no studies of theapplication of mass-casualty triage systems in thesetting of an actual disaster, or even drills, or that haveexamined the outcomes of patients triaged to differentcategories.

This issue of Academic Emergency Medicine containswhat appears to be the first attempt to scientificallydevelop and evaluate a new mass-casualty triagesystem.8 The authors are to be applauded for puttinga tremendous amount of effort into developing thecomplex mathematical models needed to create, andthen assess, this system. No existing system appearsto have had the benefit of a scientific approach to itsdevelopment, or any real attempt at validation. Thepaper suggests two significant benefits to the Saccotriage method (STM): a physiologic score that appearsto cluster patients into more clinically homogeneousgroups than does START, and a computer algorithmto assist with transport prioritization, timing, anddestination selection. While these are potentially im-portant advances, several cautions are in order.

First, it is important to recognize that many of theassumptions that underlie the background work andthe development of the STM have no scientific sup-port, at least in part due to the general lack of researchin this area. Examining the background work first, oneof the authors’ criticisms of START is that victimprognosis is not considered by START; however, thepurpose of the START ‘‘expectant’’ category is toeliminate from further consideration those patientswhose prognosis is grim, even with maximal resusci-tative efforts—efforts that cannot reasonably be deliv-ered in a mass-casualty setting. The authors also statethat infrequent use of the START protocol makesaccurate field use unlikely in an MCI. There are nodata in the literature to either support or refute this

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assumption, and anecdotally we are aware of a num-ber of EMS systems that use the START system andtriage tags on all patients seen on certain days (often‘‘Triage Tuesday’’), to maintain the familiarity of bothEMS and ED personnel with the system. Finally, theauthors’ assumption that patients might have theirairways opened or bleeding controlled, but be givenno intravenous fluids, may not hold in certain MCIswhere the constrained resource is transport, not scenetreatment.9

Turning to the development of the STM, it is statedthat STM is applied only to patients who are notdeemed ‘‘ambulatory’’ or ‘‘expectant,’’ but it is notindicated how this initial determination is made. Sincethe ‘‘ambulatory’’ patients would not be subjected tothe Sacco algorithm, they would receive no moreassessment than would patients triaged to the ‘‘ambu-latory’’ category in START. In the example given in thepaper’s introduction, patients with an expected sur-vival of 0.10 are used to illustrate START’s ‘‘immedi-ate’’ patients. However, in an MCI where resources aresignificantly outstripped, such patients should be cat-egorized as ‘‘expectant,’’ and thus not be subjected tothe algorithm. Admittedly, START does a poor job ofthis, as it classifies as ‘‘expectant’’ only those patientswho are not breathing after one attempt at reposition-ing the airway. It is not clear whether such patientswould be subject to the STM algorithm, or if theywould be deemed ‘‘expectant’’ and thus excluded.Regardless, the 0.10 example given may not be the bestillustration of the mathematics involved, and a sensi-tivity analysis might be helpful both here and else-where in the paper.

Some readers may be concerned about the makeupof the Delphi group, which seems quite small, andwhich includedneither emergencyphysicians nor EMSphysicians. The authors acknowledge among theirlimitations that the absence of an emergency physicianwas an oversight. We believe that input from addi-tional personnel with field experience would alsohave been helpful. The estimates of deterioration gene-rated by the Delphi group require validation, though,as the authors point out, such data are not readilyavailable. This is one example of the several limitationsthat were forced by the limitations of disaster re-search.10 As another example, it would have beenpreferable to use data from actual disaster/MCIvictims in the design and test sets, instead of patientsfrom the general trauma population, most of whom (asnoted by the authors) were treated under non-MCIconditions, and received much more field care thanwould be typical in anMCI.However, suchdata simplydo not exist.11

OPERATIONAL ISSUES

Readers with significant field experience will have avariety of questions regarding the actual implemen-

tation of this system in the field, and perhaps thedisaster medicine forest has been obscured by themathematical modeling trees. While the authors indi-cate that the process of communicating and inputtingof scores, performing calculations, and communicat-ing the results back to the scene takes under a minute,this seems improbable in large events, such as ahypothetical 300-patient passenger train crash. Inaddition, once the system assigns priorities based onscores, how does one locate patients with certainscores on the battlefield? Does the system use tags ofsome sort? Is searching among the 300 victims for thelast two top-priority patients, or physically organizingthe patients into the three RPM (respiratory rate,pulse rate, and motor response) groups at the scene,a reasonable use of scarce personnel time?

Additional information is also needed regardinghow the personnel performing triage operations enterthe data. It appears that the system described assumesa fully operational incident command system, withthe logistics and communication capabilities such asystem may bring to bear. These capabilities are oftennot available in the first hours of an event. If cellularcommunications are required during an event withwide geographic coverage, areas of limited coverageor system failure may prevent transmission of triagedata to the computer performing the calculations.What is also not clear is how the results will betransmitted to the triage, treatment, and transportofficers for implementation. Beta testing this system inseveral large-scale events and drills may help answerthese questions. We encourage the authors to publishtheir findings from their initial field tests, and to workwith other researchers to test and refine the system.

It is our belief that the biggest potential benefit ofSTM comes in the area of transport logistics. Byintegrating pre-assessed capacities and capabilitiesof surrounding hospitals into the system, automaticdistribution of patients to these facilities seems tooffer tremendous benefits. Neither the transportofficer nor the dispatcher will need to handle thecomplexities of patient destination selection. Integrat-ing STM with one of the several real-time EMS andhospital resource tracking systems currently availablemight further enhance medical communications andlogistics. We urge the authors and others to explorethis possibility.

While we hope that the transport logistics benefitsare as great as the authors anticipate, a number ofoperational questions need to be addressed regardingthis portion of the system, such as how changes in thepriorities of transport will be communicated andintegrated as transport units become available ordepleted, as patient condition changes, or as otherpatients are discovered. This raises the question ofwhen to rerun the algorithm. Does one rerun it as eachindividual asset arrives, or does one wait until a‘‘significant’’ number have arrived on scene before

740 Cone and MacMillan d MASS CASUALTY TRIAGE SYSTEMS

rerunning it? The effect of adding a small number oftransport units in a moderate-sized incident will begreater than in a large incident—how does one decidewhen the parameters have changed enough to warrantrepeating the calculations? Is the system capable oftracking which patients have left the scene, so thetransport priorities can be adjusted as numbers re-maining on scene dwindle? Unless there is real-timeconnectivity into an EMS resource tracking system,how will the system track individual units arrivingand leaving in a staggeredmanner, as they typically doin an MCI? Is there a component to the algorithm thatincorporates the distance and/or transport time fromthe scene to each receiving facility? Evenwith the sameset of available destinations, transport decisions willvary based on the location of the event.Finally, the reader needs to be aware that the STM is

a proprietary system. Unlike all of the other mass-casualty triage systems currently available, the detailsneeded for actual implementation of the computeralgorithm are not freely available, and it is unclearwhether the need to pay for the system will inhibitwidespread implementation. We are aware of an EastCoast multicounty EMS system that had consideredimplementing STM, but recently abandoned theseplans because of a combination of cost considerationsand logistics. We believe that a greater concern lies inthe availability of the system for external validationby independent researchers. The system needs to betested in a wide variety of disaster and MCI scenarios(both drills and, ultimately, actual events), and it isour hope that the authors will make the entire systemfreely available to those who wish to pursue suchresearch.Despite the cautions we have raised here, the paper

by Sacco et al. is an important step toward applyingscience to the process of mass-casualty triage. Clearly,additional work is needed in a number of areas, per-haps most importantly in determining whether patientoutcome is (or can be) improved through effectiveuse of any system of field triage. Thus far, there are nodata to show whether correctly sorting the patientsinto the categories set forth by any particular triagesystem results in improved outcomes, either foran individual patient or for the group of patients as awhole. Somemay ask whywe are expending energy to

develop a ‘‘better’’ triage system when we don’t knowwhat ‘‘better’’ means, and don’t even really knowwhatbenefit (if any) we get from the systems we have now.We believe that the authors have made a reasonablecase that these questions can be studied, and thatscience can be applied to the concept of mass-casualtytriage, but we also believe that a large number ofquestions remain. We urge the authors to work withthe rest of the EMSanddisastermedicine community toanswer these questions.—David C. Cone, MD (david.cone@yale.edu), Senior Associate Editor, Academic Emer-gency Medicine; Section of Emergency Medicine, Yale Univer-sity School of Medicine, New Haven, CT; and Donald S.MacMillan, MA, PA, EMT-P, Section of Emergency Medicine,Yale University School of Medicine, New Haven, CTdoi:10.1197/j.aem.2005.04.001

References

1. Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature—afunctional impact approach: the PICE system. Acad EmergMed. 1996; 3:723–7.

2. START Triage. Available at: www.start-triage.com/start_triage_faq_.htm. Accessed Mar 25, 2005.

3. START triage plan for disaster scenarios. ED Manag. 1996;8(9 suppl 101):103–4.

4. Risavi BL, Salen PN, Heller MB, Arcona S. A two-hourintervention using START improves prehospital triage ofmass-casualty incidents. Prehosp Emerg Care. 2001; 5:197–9.

5. Romig LE. Pediatric triage. A system to JumpSTART yourtriage of young patients at MCIs. J Emerg Med Serv. 2002;27(7):52–8, 60–3.

6. Sanddal TL, Loyacono T, Sanddal ND. Effect of JumpSTARTtraining on immediate and short-term pediatric triageperformance. Pediatr Emerg Care. 2004; 20:749–53.

7. Garner A, Lee A, Harrison K, Schultz CH. Comparativeanalysis of multiple-casualty incident triage algorithms.Ann Emerg Med. 2001; 38:541–8.

8. Sacco WJ, Navin DM, Fieldler KE, Waddell RK, Long WB,Buckman RF. Precise formulation and evidence-basedapplication of resource-constrained triage. Acad Emerg Med.2005; 12:759–70.

9. Benson M, Koenig KL, Schultz CH. Disaster triage: START,then SAVE—a new method of dynamic triage for victims ofa catastrophic earthquake. Prehosp Disaster Med. 1996; 11:117–24.

10. Noji EK. Disaster epidemiology. Emerg Med Clin North Am.1996; 14:289–300.

11. Chan TC, Killeen J, Griswold W, Lenert L. Informationtechnology and emergency medical care during disasters.Acad Emerg Med. 2004; 11:1229–36.

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