Standardizing Prehospital Triage Decision-Making Systems in Mass
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Khorram‑Manesh et al. Scand J Trauma Resusc Emerg Med (2021) 29:119 https://doi.org/10.1186/s13049‑021‑00932‑z ORIGINAL RESEARCH Open Access A translational triage research development tool: standardizing prehospital triage decision‑making systems in mass casualty incidents Amir Khorram‑Manesh1,2,3* , Johan Nordling1, Eric Carlström2,4,5, Krzysztof Goniewicz6, Roberto Faccincani7 and Frederick M. Burkle8 Abstract Background: There is no global consensus on the use of prehospital triage system in mass casualty incidents. The purpose of this study was to evaluate the most commonly used pre‑existing prehospital triage systems for the pos‑ sibility of creating one universal translational triage tool. Methods: The Rapid Evidence Review consisted of (1) a systematic literature review (2) merging and content analysis of the studies focusing on similarities and diferences between systems and (3) development of a universal system. Results: There were 17 triage systems described in 31 eligible articles out of 797 identifed initially. Seven of the systems met the predesignated criteria and were selected for further analysis. The criteria from the fnal seven systems were compiled, translated and counted for in means of 1/7’s. As a product, a universal system was created of the majority criteria. Conclusions: This study does not create a new triage system itself but rather identifes the possibility to convert vari‑ ous prehospital triage systems into one by using a triage translational tool. Future research should examine the tool and its diferent decision‑making steps either by using simulations or by experts’ evaluation to ensure its feasibility in terms of speed, continuity, simplicity, sensitivity and specifcity, before fnal evaluation at prehospital level. Keywords: Mass casualty incident, Prehospital, Tool, Trauma, Triage Background resources in mind [1–3]. Since WWI, utilitarianism has Mass casualty incidents (MCI), generate more casual- become a part of the triage systems in MCI. Basic utilitar- ties at one time than the locally available resources can ianism states that an action is morally right if it produces manage using the routine procedures, highlighting that maximal happiness or well-being for everyone afected by resource scarcity becomes a critical decision-making [4, 5]. Terefore, predetermined modern triage systems issue. MCI triage aims to prioritize casualties according may unknowingly allow for the loss of a severely injured to the severity of their injuries, often keeping available casualty’s life to provide treatment or evacuation to a greater number of casualties with lesser injuries [6]. Tis concept is equally used in hospital triage to justify which *Correspondence: amir.khorram‑[email protected] patients should receive treatment before others accord- 1 Institute of Clinical Sciences, Department of Surgery, Sahlgrenska ing to the alleged beneft of treatment [5–7]. Since 1964, Academy, Gothenburg University, 413 45 Gothenburg, Sweden Full list of author information is available at the end of the article when the frst record of emergency department (ED) © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Khorram‑Manesh et al. Scand J Trauma Resusc Emerg Med (2021) 29:119 Page 2 of 13 triage was described [8], the concept of triage has evolved mechanisms of injury and available resources [6, 9, 11, into an even broader terminology, such as primary, sec- 13, 17]. Tis heterogeneity constitutes a particular threat ondary and tertiary triage, which can be subcategorized in the event of an MCI, which often involves rescue per- in diverse ways depending on a dynamic process where sonnel from diferent organizations, or across-the-globe the patient’s vital signs can deteriorate over time [1, 9]. In allies, and may create unnecessary discussion between general, triage categories can be expressed as a Descrip- EMS-personnel on the scene, haltering the time-crit- tion (immediate; Urgent; Delayed; Expectant), Priority ical management, timely triage decisions and evacua- (1 to 4), or Color (Red, Yellow, Green, Blue), respectively, tion of the victims [2, 18, 19]. Te problem of variability where Immediate category equals Priority 1 and Red has proven to be contentious and unsolvable often both color [1, 2]. immediately and for the long-term. Tere have been sev- Te distinction between the ordinary sorting and pri- eral attempts to achieve a global or even national consen- oritizing of patients at a hospital ED from the more sus in a number of cases without fruition due to a lack utilitarian prehospital triage of casualties from a natu- of actual research behind the origin or refnements of the ral disaster scene lies on the diferences in available various systems. When proposing a modern system for resources in the feld versus that of a fully stafed hospital universal consideration there has often not been much and may explain the notable variance seen between dif- more than anecdotal evidence to its efcacy, making it ferent, modern triage systems [1, 2, 5, 6, 9–11]. However, hard to choose one over the other [15, 17, 20–23]. both hospital and prehospital triage systems may rely on Diverse triage exist which leads to confusion. Tere- four essential factors: speed, precision, fairness and com- fore, a translational tool that combines criteria from dif- patibility [10]. For prehospital triage systems (especially ferent system is needed. Tis paper aims to take the frst in MCI), the element of speed of decision-making is of step in a multistep procedure to evaluate the possibility importance, since there are more casualties than the res- of creating a translational triage tool. Te proposed tool, cue staf can manage, and the post-incident environment using criteria used in most common pre-existing pre- might not be secure. Both hospital and prehospital triage hospital triage systems, represents an applicable frame- also beneft from a fast, simple system that quickly identi- work for a proposed unifed global system. Tis approach fes the patients or casualties that require an immediate acknowledges that existing systems are similar in terms intervention/evacuation [2, 5]. Te element of speed can- of speed, precision and fairness and thereby tackles the not come at a too big of a sacrifce of precision, though. compatibility element of triage. Te majority criteria will Generally, the more hastily the triage, the bigger the risk refect the intrinsic uniformity of present systems, high- of faulty categorization. Under-triage increases the mor- lighting the point in time whereby a global, translational tality among casualties because of a prolonged time to system is accepted as the appropriate combination solu- establish the accurate diagnosis and to provide proper tion at the time. interventions. Over-triage could lead to unnecessary consumption of resources, leading to increased morbid- Methods ity and mortality [2, 11–17]. Tis rapid evidence review is the product of a qualitative Prehospital systems allow for a more limited precision meta-analysis of a number of identifed triage systems since speed remains frequently a priority while hospital [24]. Te method consists of (1) a systematic literature triage can often sacrifce time to maximize precision. review [25], (2) merging and content analysis of the stud- Fairness in triage is a matter of assessing patients objec- ies focusing on similarities and diferences between sys- tively according to a set of parameters of vital signs or tems using the Constant Targeted Comparison process mechanisms of injury, and not discriminating in terms [26], and (3) the development of a universal operational of age, gender, nationality, religion or any other indi- system format/model. To avoid selection and opinion vidual aspect [1, 2]. Compatibility is applicable to triage bias, each step of the methodology and decision-making systems being translational across agencies and to pre- was discussed, according to Nominal Group Technique hospital systems being able to integrate seamlessly with (NGT) [27], in a group of three people (JN, EC, AK). AK its hospital counterparts in terms of categorization, etc. and EC had extensive scientifc and feld experience (over [1, 2, 10, 15, 16]. Since its entry on the civilian stage in 20 years) in both prehospital and hospital triage. JN was the 1960s, the area of triage has generated a plethora of newly graduated physician, with no previous experience diverse systems designed for equally as many situations, in triage systems. locations, nations and even within separate emergency Initially, a Preferred Reporting Items for Systematic medical services (EMS). Tese systems range from fast, Reviews and Meta-Analysis (PRISMA)-style literature crude algorithms and fowcharts to complex scoring sys- search was conducted to identify the most frequently tems requiring exact information on vital parameters, mentioned prehospital triage systems designed for use in Khorram‑Manesh et al. Scand J Trauma Resusc Emerg Med (2021) 29:119 Page 3 of 13 MCIs [25].