Application of time to emesis data for primary triage of radiation accident victims

Relevance. The relevance of the study is due to the risk of developing large-scale radiation accidents with a large number of victims, who will need primary medical triage and early prediction of the severity of injury for correct routing from the source of sanitary losses.Intention. Validation of the method of estimating dose by time-to-emesis under various exposure conditions for pre-hospital triage of victims.Methodology. The object of the study is the data from State Research Center – Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency (Moscow) database of acute radiation injuries.Results and Discussion: We have analyzed individual data for the victims of the 1986 Chernobyl disaster (114 persons) with a separate analysis of the irradiation conditions (short-term exposure for less than 20 minutes and prolonged exposure in selected groups), as well as the data from victims of other radiation accidents in the former USSR (26 persons) and 8 patients with total body radiotherapy without the use of antiemetics. It was shown that for the equal time-to-emesis intervals, predicted radiation injury is more severe in case of prolonged exposure vs short-term exposure. This may be due to varying rate of dose accumulation and so-called “unnecessary dose” effect – when the biological mechanism of vomiting has already been triggered against ongoing exposure. Results are presented as interval estimates of radiation injury severity by time-to-emesis for both short-term and prolonged exposures. We also have formulated two criteria for primary triage purposes in case of moderate or large numbers of victims due to large-scale radiation accidents.Conclusion. Recommendations for pre-hospital triage of victims are proposed.

Ambulance dispatch of older patients following primary and secondary telephone triage in metropolitan Melbourne, Australia: a retrospective cohort study

BackgroundMost calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary telephone triage. Ambulance Victoria uses clinician-led secondary telephone triage for patients identified as low-acuity during primary triage to refer them to alternative care pathways; however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services; however, little is known about the appropriateness of subsequent secondary dispatches.ObjectivesTo examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch.DesignA retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted.SettingThe secondary telephone triage service operated in metropolitan Melbourne, Victoria, Australia during the study period.ParticipantsThere were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses.Main outcome measuresDescriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients.ResultsThe dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51; CI 0.48 to 0.55; p<0.001). Increasing age was associated with decreasing treatment (p<0.005) and increasing transportation rates (p<0.005).ConclusionSecondary triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.

Performance of First Aid Trained Staff using a Modified START Triage Tool at Achieving Appropriate Triage Compared to a Physiology-Based Triage Strategy at Australian Mass Gatherings

Introduction:Triage at mass gatherings in Australia is commonly performed by staff members with first aid training. There have been no evaluations of the performance of first aid staff with respect to diagnostic accuracy or identification of presentations requiring ambulance transport to hospital.Hypothesis:It was hypothesized that triage decisions by first aid staff would be considered correct in at least 61% of presentations.Methods:A retrospective audit of 1,048 presentations to a single supplier of event health care services in Australia was conducted. The presentations were assessed based on the first measured set of physiological parameters, and the primary triage decision was classified as “expected” if the primary and secondary triage classifications were the same or “not expected” if they differed. The performance of the two triage systems was compared using area under the receiver operating characteristic curve (AUROC) analysis.Results:The expected decision was made by first aid staff in 674 (71%) of presentations. Under-triage occurred in 131 (14%) presentations and over-triage in 142 (15%) presentations. The primary triage strategy had an AUROC of 0.7644, while the secondary triage strategy had an AUROC of 0.6280, which was significantly different (P = .0199).Conclusion:The results support the continued use of first aid trained staff members in triage roles at Australian mass gatherings. Triage tools should be simple, and the addition of physiological variables to improve the sensitivity of triage tools is not recommended because such an approach does not improve the discriminatory capacity of the tools.

Patient, hospital and regional characteristics associated with undertriage of injured children in California (2005–2015): a retrospective cohort study

Background/objectiveTrauma centers save lives, but they are scarce and concentrated in urban settings. The population of severely injured children in California who do not receive trauma center care (undertriage) is not well understood.MethodsRetrospective observational study of all children (0–17 years) hospitalized for severe trauma in California (2005–2015). We used the California Office of Statewide Health Planning and Development linked Emergency Department and Inpatient Discharge data sets. Logistic regression models were created to analyze characteristics associated with undertriage. The model was clustered on differential distance between distance from residence to primary triage hospital and distance from residence to nearest trauma center. We controlled for body part injured, injury type, intent and year. The a priori hypothesis was that uninsured and publicly insured children and hospitals and regions with limited resources would be associated with undertriage.ResultsTwelve percent (1866/15 656) of children with severe injury experienced undertriage. Children aged >14 years compared with 0–13 years had more than 2.5 times the odds of undertriage (OR 2.58; 95% CI 2.1 to 3.16). Children with private Health Maintenance Organization (HMO) insurance compared with public insurance had 13 times the odds of undertriage (OR 12.62; 95% CI 8.95 to 17.79). Hospitals with >400 compared with <200 beds had more than three times the odds of undertriage (OR 3.64; 95% CI 2.6 to 5.11). Urban versus suburban residence had 1.3 times increased odds of undertriage (OR 1.31; 95% CI 1.02 to 1.67) Undertriage volume was largest in urban areas.ConclusionUndertriage is associated with private HMO insurance, primary triage to large hospitals and urban residence. Understanding the characteristics associated with undertriage can help improve trauma systems.Level of evidenceLevel III (non-experimental retrospective observational study).

Major incident triage and the evaluation of the Triage Sort as a secondary triage method

IntroductionA key principle in the effective management of major incidents is triage, the process of prioritising patients on the basis of their clinical acuity. In many countries including the UK, a two-stage approach to triage is practised, with primary triage at the scene followed by a more detailed assessment using a secondary triage process, the Triage Sort. To date, no studies have analysed the performance of the Triage Sort in the civilian setting. The primary aim of this study was to determine the performance of the Triage Sort at predicting the need for life-saving intervention (LSI).MethodsUsing the Trauma Audit Research Network (TARN) database for all adult patients (>18 years) between 2006 and 2014, we determined which patients received one or more LSIs using a previously defined list. The first recorded hospital physiology was used to categorise patient priority using the Triage Sort, National Ambulance Resilience Unit (NARU) Sieve and the Modified Physiological Triage Tool-24 (MPTT-24). Performance characteristics were evaluated using sensitivity and specificity with statistical analysis using a McNemar’s test.Results127 233patients (58.1%) had complete data and were included: 55.6% men, aged 61.4 (IQR 43.1–80.0 years), ISS 9 (IQR 9–16), with 24 791 (19.5%) receiving at least one LSI (priority 1). The Triage Sort demonstrated the lowest accuracy of all triage tools at identifying the need for LSI (sensitivity 15.7% (95% CI 15.2 to 16.2) correlating with the highest rate of under-triage (84.3% (95% CI 83.8 to 84.8), but it had the greatest specificity (98.7% (95% CI 98.6 to 98.8).ConclusionWithin a civilian trauma registry population, the Triage Sort demonstrated the poorest performance at identifying patients in need of LSI. Its use as a secondary triage tool should be reviewed, with an urgent need for further research to determine the optimum method of secondary triage.

Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach

BACKGROUND: Injuries caused by emergencies and accidents are increasing in the world. To prioritise patients to provide them with proper services and to optimally use the resources and facilities of the medical centres during accidents, the use of triage systems, which are one of the key principles of accident management, seems essential. AIM: This study is an attempt to identify available triage systems and compare the differences and similarities of the standards of these systems during emergencies and disasters through a review study. METHODS: This study was conducted through a review of the triage systems used in emergencies and disasters throughout the world. Accordingly, all articles published between 1990 and 2018 in both English and Persian journals were searched based on several keywords including Triage, Disaster, Mass Casualty Incidents, in the Medlib, Scopus, Web of Science, Pubmed, Cochrane Library, Science Direct, Google scholar, Irandoc, Magiran, Iranmedex, and SID databases in isolation and in combination using both and/ or conjunctions. RESULTS: Based on the search done in these databases, twenty different systems were identified in the primary adult triage field including START, Homebush triage Standard, Sieve, Care Flight, STM, Military, CESIRA Protocol, MASS, Revers, CBRN Triage, Burn Triage, META Triage, Mass Gathering Triage, SwiFT Triage, MPTT, TEWS Triage, Medical Triage, SALT, mSTART and ASAV. There were two primary triage systems including Jump START and PTT for children, and also two secondary triage systems encompassing SAVE and Sort identified in this respect. ESI and CRAMS were two other cases distinguished for hospital triage systems. CONCLUSION: There are divergent triage systems in the world, but there is no general and universal agreement on how patients and injured people should be triaged. Accordingly, these systems may be designed based on such criteria as vital signs, patient's major problems, or the resources and facilities needed to respond to patients’ needs. To date, no triage system has been known as superior, specifically about the patients’ clinical outcomes, improvement of the scene management or allocation of the resources compared to other systems. Thus, it is recommended that different countries such as Iran design their triage model for emergencies and disasters by their native conditions, resources and relief forces.