Precision of In-Hospital Triage in Mass-Casualty Incidents after Terror Attacks

Abstract

Introduction:Proper management of mass-casualty incidents (MCIs) relies on triage as a critical component of the disaster plan.Objective:The objective of this study was to assess the precision of triage in mass-casualty incidents.Methods:The precision of decisions made by two experienced triage officers was examined in two large MCIs. These decisions were compared to the real severity of injury as defined by the Israeli Defence Forces (IDF) classification of severity of injuries and the Injury Severity Score (ISS).Results:Two experienced trauma physicians triaged a total of 94 casualties into 77 mild, seven moderate, and 10 severe casualties. Based on the IDF criteria, there were 74 mild, five moderate, and 15 severe casualties. Based on ISS scoring, there were 78 mild (ISS <9), five moderate (9 ≤ISS<16), and 11 severe (ISS < 16) casualties. Of 15 severely injured victims defined by the IDF classification of injury severity, the triage officers identified only seven (47%).Conclusion:Primary triage, even when carried out by experienced trauma physicians, can be unreliable in a MCI.

Usefulness of the Shock Index as a secondary triage tool

“…Clinical acumen alone has been shown to be insensitive at predicting serious injury—potentially as low as 47% 22. The TSO (widely used in the UK for second-line triage at casualty clearing stations and hospitals) only has a sensitivity of 59% for those patients needing LSI in this military population.…”

Can teaching methods based on pattern recognition skill development optimise triage in mass-casualty incidents?

“…Whatever the system used, healthcare professionals’ performance in triage is poor,5 even when it is carried out by experienced doctors 6. Undertriage, which consists in missing important patients’ injuries, leads to the inefficient use of available human and material resources.…”

“…Performing triage during an MCI ideally requires to assess in a very short time the number of critically injured patients and the availability of treatment resources 1 22. Students’ high performance must be relativised because they were not asked to make triage considering human and material resources and no maximum execution time was allotted.…”

Triage in the Defence Medical Services

“…The US SALT triage system attempts to address this by describing injuries as minor or unlikely to be survivable, given the available resources 16. While anatomical triage has been out of favour because of its poor reproducibility, low sensitivity in isolation, and impracticality (it involves the need to undress),11 this may be a very sensible course—Israeli experience after bombings showed that while rapid senior clinician assessment alone had sensitivity of only 60%, it had a specificity of over 80% 17. It may be that combining optimised physiological parameters with a senior clinician making an early on-scene assessment, and downgrading where appropriate, may improve the sensitivity without vastly diluting the specificity.…”