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

Abstract

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.

A Scoping Review of Pediatric Mass-Casualty Incident Triage Algorithms

“…22,23 Other studies looked at the providers' perspective and ease of use either in a tabletop or using a Delphi method during a simulation. 20,37 Also, Cross et al retrospectively looked at trauma patients that were hospitalized and compared the outcome (mortality) while applying different triage algorithms upon first presentation to identify the best algorithm with the lowest mortality. 26 JS is the most commonly used system in the USA, 24 and this can be partially due to its derivation from an adult system, START, that is the most widely used system in the USA.…”

“…Due to the heterogenicity of the studies, the most accurate algorithm was not identified. However, CF was found to have a good overall performance in multiple comparative studies, [20][21][22][23] while JS was the most used. 24 SALT was consistently found to have a high over-triage rate when compared to predefined scores meaning that it has high sensitivity but low specificity to high acuity cases and this means that although SALT is less likely to miss more critical patients, using it will probably lead to more resource utilization.…”

“…24 SALT was consistently found to have a high over-triage rate when compared to predefined scores meaning that it has high sensitivity but low specificity to high acuity cases and this means that although SALT is less likely to miss more critical patients, using it will probably lead to more resource utilization. 22,25 Studies analyzing PTT and STM had very controversial and conflicting results: PTT was found to have a low accuracy in 1 study and high performance rate in another study; 20,23 STM on the other hand was found to be highly accurate in 2 studies and to have a high rate of under-triage in another study. 20,22,26 These different and conflicting results highlight once again the issue of defining 'accuracy.'…”

“…22,25 Studies analyzing PTT and STM had very controversial and conflicting results: PTT was found to have a low accuracy in 1 study and high performance rate in another study; 20,23 STM on the other hand was found to be highly accurate in 2 studies and to have a high rate of under-triage in another study. 20,22,26 These different and conflicting results highlight once again the issue of defining 'accuracy.'…”

The number of beds occupied is an independent risk factor for discharge of trauma patients

“…[3,4] Even during routine pre-hospital triage, algorithms have been developed that are subject to constant optimization. [5] The brief physician-patient interaction during emergency triage led to a sensitivity of 74%, and specificity of 84% for predicting admission. [6] Miss-triage might therefore adversely affect the quality of the individual trauma care.…”