TY - JOUR
AU - MD, David J. Prezant,
AB - Abstract We sought to evaluate the accuracy and speed for the triage of multiple patients during a disaster drill by Emergency Medical Service (EMS) personnel. During a disaster drill (train collision with blast injury and chemical release), the accuracy and speed of triage of 130 patient-actors by the Fire Department of New York City (FDNY) EMS personnel was evaluated using the Simple Triage and Rapid Treatment (START) triage system. All EMS personnel had been previously trained in START, but refresher training was not administered before the drill. Overall triage accuracy was 78%. In patients that had additional changes in their status during the triage process (injects), 62% were retriaged appropriately. Because of security and decontamination procedures, triage at the triage/treatment area began 40 minutes after the drill commenced. It took 2 hours and 38 minutes to completely clear the scene of all patients. On average, the time from the start of triage to transport was 1 hour and 2 minutes. Despite the fact that triage is a skill practiced by every EMS system in the country on a daily basis, few studies regarding triage accuracy are available. Limited data suggest that the triage accuracy rates using different triage strategy algorithms are approximately 45% to 55%. During this drill, FDNY-EMS triage accuracy using the START system exceeded these expectations. This study provides insight as to the triage experience of a large urban EMS system operating at a disaster drill. A multiple casualty incident (MCI) is any situation or event that places a significant demand on medical equipment and personnel resources.1 By this definition, multiple casualty incidents are experienced by Emergency Medical Service (EMS) systems across the country on a daily basis. The number of patients that may overwhelm a system varies from jurisdiction to jurisdiction as the result of varying resources and availability of staffing. Smaller systems may categorize an incident as an MCI when two vehicles each carrying three passengers collide, whereas other systems may not consider an incident as an MCI until at least 10 to 15 patients are generated.2 When EMS systems are overwhelmed, triage becomes necessary. In today's climate with the potential for terrorist attacks, triage scenarios must also consider the added challenges of secondary explosive devices, contaminated scenes, large numbers of the worried-well, and the confusion inherent in ongoing and unstable situations involving scenes of great destruction. Worldwide, there are many triage strategies used, including the Triage Sieve and Sort, the Careflight method, the Sacco triage, and the Simple Triage and Rapid Treatment (START) system. A commonly used system in the United States is the START triage system, which was developed by the Newport Beach Fire Department and Hoag Hospital in California in 1983 and updated in 1994.3 Despite the almost-daily use of some type of triage system by EMS systems nationwide, there has been little written regarding triage accuracy and time to transport. What little literature exists suggests that EMS systems do an ineffectual job of accurately triaging multiple patients during a MCI.4 Two separate studies report that the overall accuracy rate of triage by prehospital personnel is no better than by chance (approximately 45–55%).5 The Fire Department of the City of New York (FDNY) EMS currently uses the START triage algorithm, which allows responders to prioritize patients into categories in an effort to best use potentially limited resources, maximize survivability for victims, and provide the most good to the most patients. On the basis of this philosophy, expectant patients (not likely to survive) who would be normally treated and transported in a non-MCI situation may be left at the scene of an MCI if the Incident Commander determines that resources are overwhelmed. START triage uses five physiologic criteria to classify patients into one of four possible categories (Figure 1). Green-tag patients are those who are the walking wounded. Yellow tag patients cannot ambulate, have radial pulses present, have respiratory rates of less than 30 breaths per minute, and are able to follow simple commands. Red tag patients are those who either do not have palpable radial pulses, have respiratory rates greater than 30 breaths per minute or who cannot follow simple commands. Black tag patients are those who are dead or expectant. It is important to note that START is a trauma-based algorithm. This system, unless vital signs are severely altered, does not allow for “UP-triaging” to a higher patient care category for medical conditions such as myocardial infarction or asthma attack, which occur with frequency in disaster victims. Similar to trauma patients, survivability in these cases depends upon rapid stabilization and transport. Figure 1. View largeDownload slide START triage algorithm designed for use in a trauma incident to rapidly determine patient category as follows: minor (green), delayed priority (yellow), immediate (red), and deceased/expectant (black). Figure 1. View largeDownload slide START triage algorithm designed for use in a trauma incident to rapidly determine patient category as follows: minor (green), delayed priority (yellow), immediate (red), and deceased/expectant (black). With the attacks on the World Trade Center in 1993 and 2001, New York City is no stranger to MCI of enormous proportions. Patient lives depend on well-planned evacuations, accurate triage, rapid transport off-scene, and appropriate hospital dispositions. These themes are common to all disasters, large or small, human-made or natural. Our current study was primarily designed to assess the ability of FDNY-EMS personnel to accurately use the START triage system during an MCI drill in which large numbers of patients were exposed to blast injury, burns, and an industrial chemical. All personnel involved had been previously trained in the START system. To minimize bias, refresher training was not provided before this drill. Additional outcomes for analysis were the impact of additional “clinical injects,” or change of patient status on triage accuracy and the time required to successfully perform triage operations. METHODS A drill scenario was performed during daylight hours with excellent weather conditions. One hundred twelve FDNY-EMS personnel were involved (including officers, EMTs, and paramedics), but the actual number responsible for triage decisions was approximately 40, with the remainder responsible for supervisory, HAZTAC (EMS units trained and equipped to medically care for contaminated patients), transport, and other support responsibilities. The simulation was based on an explosion on a chemical transport train as it passed alongside a passenger train. A gas, later identified as arsenic trichloride, was released at the time of detonation. Early reports in the scenario were only that there were numerous victims affected. The START triage system was used to assess patients during this drill. The simulated patients were police department cadets (n = 99) and mannequins (n = 31). The patients were prepared with moulage make-up and were given information cards that contained the visible presenting problem, pulse rate, respiratory rate, and mental status. These “symptom tags” also contained a unique identification number for data-collection purposes. The symptom tags were designed by the EMS Office of Medical Affairs to represent both blast-type injuries and chemical exposure. These patients, if properly triaged according to the START system and the symptom tags provided, would consist of 51 patients with minor injury (green tag), 16 patients of delayed priority (yellow tag), 30 patients in the immediate category (red tag), and 33 expectant or deceased patients (black tag). Data collection was designed to capture the endpoints of accuracy and timing and was accomplished through the use of checkpoints and evaluators throughout the drill process. The evaluators logged the accuracy of the initial triage, kept track of changes to patient triage status, and recorded the timeline of events. As anticipated for this scenario, patients were removed from the immediate area after simulated decontamination and then directed or carried to an adjacent triage/treatment area for transport. Some patients were triaged before decontamination and all patients were retriaged in the triage/treatment area. After triage classification occurred, additional symptom cards were injected into the scenario to simulate changes in patient status over time. Some of these “inject cards” indicated deterioration, thus changing the patients' triage category, whereas others provided extraneous information. The triage/treatment area evaluators transcribed the patient's symptom tag number to the triage tag and to the tracking form and documented the initial triage category and time of triage. As the patients left the treatment area for transport or disposition, exit time and triage category was again recorded on the tracking sheet. When inject cards were used to simulate changes in status, patients were monitored by inject controllers. The inject controllers gave patients in the triage/treatment area an inject card approximately 5 minutes after their arrival. They indicated the patients' symptom tag number on the inject card. Most of the inject cards called for no additional action by FDNY-EMS personnel. However, a percentage of the inject cards called for the provider to “up-triage” and document accordingly. If an inject was not recognized in a timely manner, the patients were to visibly act out until FDNY-EMS personnel approached the patient again. The inject controller recorded the time, symptom tag number, and triage color. A total of 47 patients were given inject cards. Upon conclusion of the drill, evaluators collected the triage tags as well as all inject cards, to assure that all were identifiable by patient symptom tag number. The time points of drill start time, time at the “IN-Gate” (entry to the triage/treatment area), and time at the “OUT-Gate” (transport start-time) were recorded by the triage/treatment area evaluators. The collected data was then entered into a Microsoft Access™ database and analyzed using SPSS version 13 statistical software (SPSS, Inc., Chicago, IL). RESULTS As the drill began, the initial responding unit, an ambulance unit staffed by two EMTs, responded directly to the explosion site. This unit became exposed to the chemical released and was contaminated. Before exhibiting the signs and symptoms of the chemical exposure, they triaged 20 patients who approached their vehicle. Thirteen of the 20 were triaged correctly (65%). Green patients showed the highest accuracy rate, with 10 of the 11 green patients (91%), triaged correctly. One of the four yellow patients (25%) and two of the five red tag patients (40%) were triaged correctly (Table 1). Table 1. Accuracy of triage by the first responding ambulance View Large Table 1. Accuracy of triage by the first responding ambulance View Large Accuracy of triage within the triage/treatment area was based on the final triage tag color as compared to the known key color (Table 2). Of the 101 patients who were logged as exiting the treatment area, 72 were correctly triaged (71%). Forty-two of the 51 green-tag patients were properly tagged (82%). The yellow and red tag patients were triaged with an accuracy rate of 7/16 (44%) and 20/30 (67%), respectively. The overall triage accuracy rate was 78% (Figure 2), including all of the black tag patients, most appropriately recognized and not removed from the scene. Table 2. Final accuracy at triage/treatment area View Large Table 2. Final accuracy at triage/treatment area View Large Figure 2. View largeDownload slide Final triage accuracy rates at the triage/treatment center grouped by category and expressed as a percent of total patients. Figure 2. View largeDownload slide Final triage accuracy rates at the triage/treatment center grouped by category and expressed as a percent of total patients. Inject cards were given to 47 patients (Table 3). Of these, 34 cards offered additional information but did not require a change in the triage category, whereas 13 required that EMS personnel recognize a worsening condition and assign a higher priority category (“up-triage”). Overall 29, of the 47 patients were managed appropriately (62%). Individually, the 34 “stable” patients were properly reassessed with 59% accuracy, and the 13 “unstable” patients were reassessed with 69% accuracy. Of the “stable” inject patient group, 13 of 34 were incorrectly up-triaged according to START criteria. Six of the 13 had medical inject information indicating a possible myocardial infarction or an asthma attack, with palpable pulse and a respiratory rate less than 30 breaths per minute. Up-triage of these patients was appropriate on a clinical basis, demonstrating the limitations of a triage system designed primarily for assessment of traumatic injury. Table 3. Injected patient status changes View Large Table 3. Injected patient status changes View Large The drill began at 10 am. The first patients to be triaged at the triage/treatment area occurred at 10:40 am. The maximum time needed from the start of the drill to completion of triage was 1 hour and 48 minutes. On average, 57 minutes were required for triage to occur (Table 4). Table 4. Time to triage from beginning of drill View Large Table 4. Time to triage from beginning of drill View Large The time from triage to transport was reviewed for the different triage categories (Table 5). Overall, the average time from triage to transport was 1 hour and 2 minutes. Green patients had a minimum time from triage to transport of 9 minutes, a maximum time of 2 hours and 30 minutes, and an average time of 1 hour and 6 minutes. Yellow patients also had a minimum time from triage to transport of 9 minutes with a maximum time of 1 hour and 58 minutes and an average time of 1 hour and 5 minutes. Finally, red patients, (the most critical), had a minimum time from triage to transport of 8 minutes, a maximum time of 2 hours and 38 minutes and an average time of 57 minutes. The differences in these groups were not statistically significant. Table 5. Time from triage to transport View Large Table 5. Time from triage to transport View Large DISCUSSION FDNY-EMS personnel, without refresher training before the drill, performed with a 78% accuracy rate in correctly triaging patients using the START triage system. This triage accuracy rate well exceeded the rates of 45% to 55% that have been previously reported.5,6 No system aims for minimum standards, and our goal is to achieve accuracy rates as close to 100% as possible. This exercise demonstrated that, although accuracy rates were greater than average, improvements can be made that would substantially impact triage and transport decisions. Triage accuracy rates generated during a drill situation may not truly reflect what would occur during an actual emergency. Any study evaluating accuracy in a controlled environment, including our own, must be reviewed with this in mind. Many factors might have influenced our accuracy rates. During the initial phase of the drill, a number of patients were classified into the green category because they were walking. However, some of the actors did not completely understand their triage category and inappropriately became ambulatory on their own. Although this is a flaw in our drill execution, it mirrors what happens in real life. A total of 6 of 30 red tag patients (20%) ambulating on their own were misclassified in this manner. Suggestions to improve triage accuracy include the daily use of triage algorithms in all patient encounters to maintain familiarity and comfort with the algorithms by prehospital personnel. Other strategies suggest conducting more-frequent, small-scale tabletop and survey-type drills of the triage algorithms, to keep the concepts fresh in the minds of providers. Development of an improved triage algorithm would be worthwhile, and a complete overhaul of the triage system has been advocated. In particular, the use of the START system has been questioned,7 although other triage algorithms presently available have not been proven to increase accuracy rates in triaging multiple patients. The START triage system may not fully address the needs of certain populations. For example, many pediatricians believe that the START triage system is inappropriate for use with children. Because of the physiological differences between adults and children in heart and respiratory rates, many children would automatically be triaged into the immediate (red tag) category on these indices alone. Others feel that an up-triage of pediatric patients to a more immediate/emergent level is not a detriment but rather a benefit. For pediatric trauma victims, it has been suggested that the addition of a few forced breaths be considered as part of the initial management before categorization of children as expectant. In response to the specialized needs of children, a JUMP START triage algorithm has been developed specifically for the pediatric population.7,8 Because the present drill did not include pediatric patients, evaluation of the START algorithm for the pediatric population was not performed. The START triage system also lacks the ability to up-triage, or prioritize, the acuity of patients based upon medical illness. The stress of a disaster can easily result in the onset of a myocardial infraction or an acute asthma attack in victims with preexisting cardiopulmonary disease. Such victims who remain ambulatory at the scene would be prioritized as green-tag and those with similar conditions who are nonambulatory but with stable vital signs (palpable pulse and respiratory rate less than 30 breaths per minute) would be prioritized as yellow-tag. In both instances, patient priority, need for rapid transportation, and need for immediate attention on hospital arrival would be underestimated. Although modification of the START system for medical illness is desirable, in practice, this exercise demonstrated that such up-triaging is already occurring in a nonstandardized way. In our drill, the ambulance crews took initiative and up-triaged some of the patients with injects describing a myocardial infarction. Although this sample was a very small one, it is an indication as to the thought process of the field personnel who responded appropriately to medical changes. Unfortunately, for the purposes of drill design, these patients were recorded as triage errors because based on START alone, their category should not have changed. If START system had incorporated this medical up-triage strategy into the standard algorithms, then the patients who received injects would have been counted as correctly triaged and an accuracy rate of 74% rather than 59% would have been obtained. Contrary to expectations, the triage to transport times for the green-, yellow-, and red-tag patients was similar. It is important to note that for our scenario decontamination was required by protocol but was only simulated for drill purposes. If decontamination had actually been performed, the amount of time needed to remove victims from the scene would have been greater than reported. To improve resource use, the walking-wounded (green tags), after being grossly decontaminated, could be removed expeditiously from the scene via a mass transport vehicle (public transit bus, train, or emergency vehicle). Also, if enough transport resources are available on the scene, the remaining patients (yellow and red tags) could be transported immediately after decontamination on a first-come, first-serve basis rather than prioritizing transport according to their triage category. Hospital destinations could then be chosen according to triage category while en route. A final controversy is the management of red-tagged (immediate priority) patients who are contaminated. Currently, these patients are required to go through a thorough decontamination before medical care. In an actual incident, this decontamination would take a significant amount of time, and some patients would deteriorate or die during the decontamination process. From a medical standpoint, treatment of the most critical patients must be viewed as equally important to decontamination. Perhaps, similar to the military, specialized hazardous materials units should be performing advanced medical care during the decontamination process. This activity would require a large commitment to training and to the cost of additional resources. An alternative would be to remove these patients directly to the hospital before decontamination. This step would provide more rapid treatment but has the great disadvantage of contamination of EMS and hospital personnel and resources, which might then become unavailable for further use at the incident. For this reason and others, FDNY is training its entire EMS pre-hospital care workforce to a higher level of hazardous materials certification (HAZMAT Medical Technician Level II) and has already deployed additional HAZ-TAC EMS ambulances. Besides the standard basic life support or advanced life support equipment, these ambulances are equipped with Level A Tychem 10000 suits (Lakeland Industries, Inc., Ronkonkoma, NY), breathing apparatus, and supplies for medical decontamination. Members of these specialized units receive 80 additional hours of HAZMAT training. To date, FDNY-EMS deployed 35 HAZTAC ambulances, a 3.5-fold increase from just 2 years ago. CONCLUSIONS The data from a disaster drill conducted in our EMS system showed the accuracy rates of triage using the START triage system to be better than those reported nationally. Because of the unfortunate fact that multiple casualty incidents occur on a daily basis, one would expect the availability of triage accuracy studies from real events. This is not the case. Although our accuracy rates from this experience were significantly greater than those reported in the literature from other drill scenarios, a future study defining the accuracy in real events should be conducted. Also, as we look to the future, triage systems that account for acute medical conditions as well as extended decontamination times should be explored, designed and implemented. REFERENCES 1. Noji EK Disaster medical services. Tintinalli JE, Ruiz E, Krome RL Emergency Medicine: A Comprehensive Study Guide. 5th ed.  New York: McGraw-Hill; 2000; 22– 31. 2. Asaeda G The Day that the START Triage System Came to a STOP: Observations from the World Trade Center Disaster. Acad Emerg Med  2002; 9: 255– 66. Google Scholar CrossRef Search ADS PubMed  3. Cone D Mass-casualty triage systems: a hint of science. Acad Emerg Med  2005; 12: 739– 41. Google Scholar CrossRef Search ADS PubMed  4. Wallis L START is not the best triage strategy. Br J Sports Med  2002; 36: 473. Google Scholar CrossRef Search ADS PubMed  5. Chen K The role tabletop exercise using START in improving triage ability in disaster medical assistance team. Ann Disaster Med  2003; 1: 79– 83. 6. Risavi B A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehospital Emerg Care  2001; 5: 197– 9. Google Scholar CrossRef Search ADS   7. Garner A Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med  2001; 38: 541– 8. Google Scholar CrossRef Search ADS PubMed  8. Romig L. JumpSTART Pediatric Multiple Casualty Incident Triage. Available at: http://JumpStarttriage.com; Internet; accessed July 27, 2006. Copyright © 2006 by the American Burn Association
TI - Triage Accuracy at a Multiple Casualty Incident Disaster Drill: The Emergency Medical Service, Fire Department of New York City Experience
JO - Journal of Burn Care & Research
DO - 10.1097/01.BCR.0000235450.12988.27
DA - 2006-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/triage-accuracy-at-a-multiple-casualty-incident-disaster-drill-the-RNAb60a1zT
SP - 570
EP - 575
VL - 27
IS - 5
DP - DeepDyve
ER -