Prehospital Emergency Care
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Development of a Pediatric Mass Casualty Triage Algorithm Validation Tool J. Joelle Donofrio DO, Amy H. Kaji MD, PhD, Ilene A. Claudius MD, Todd P. Chang MD, MAcM, Genevieve Santillanes, Mark X. Cicero MD, Saranya Srinivasan MD, Alexis Perez-Rogers BS & Marianne Gausche-Hill MD To cite this article: J. Joelle Donofrio DO, Amy H. Kaji MD, PhD, Ilene A. Claudius MD, Todd P. Chang MD, MAcM, Genevieve Santillanes, Mark X. Cicero MD, Saranya Srinivasan MD, Alexis Perez-Rogers BS & Marianne Gausche-Hill MD (2016): Development of a Pediatric Mass Casualty Triage Algorithm Validation Tool, Prehospital Emergency Care, DOI: 10.3109/10903127.2015.1111476 To link to this article: http://dx.doi.org/10.3109/10903127.2015.1111476
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Date: 28 January 2016, At: 03:41
DEVELOPMENT OF A PEDIATRIC MASS CASUALTY TRIAGE ALGORITHM VALIDATION TOOL J. Joelle Donofrio, DO, Amy H. Kaji, MD, PhD, Ilene A. Claudius, MD, Todd P. Chang, MD, MAcM, Genevieve Santillanes, Mark X. Cicero, MD, Saranya Srinivasan, MD, Alexis Perez-Rogers, BS, Marianne Gausche-Hill, MD
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Abstract
status compromise needing intervention, Yellow - stable cardiopulmonary status but may require life or limb therapy, Green - minimally injured, and Black - deceased or likely to die given the circumstances. Using an anatomic approach, a list of criteria were defined and a modified-Delphi approach was used to create a summative COT that was reviewed by the American Academy of Pediatrics Disaster Preparedness Advisory Council. The resulting COT was independently applied to a weighted retrospective cohort of 25 pediatric victims from a single Level I trauma center by two reviewers to determine reproducibility. Results: We created a Criteria Outcomes Tool (COT) with 47 outcomes and interventions to validate an MCI algorithm’s triage designation. When the COT was applied to a cohort of 25 weighted pediatric charts, we identified the following resource utilization and outcome based triage designations: six Red, six Yellow, six Green, and seven Black triage outcomes. The 100% agreement was obtained between the two reviewers in each of the four categories. Conclusions: We designed an outcomes and resource utilization tool, the COT, to evaluate the ability of an MCI algorithm to correctly triage pediatric patients. Our tool has good reproducibility on initial study. Key words: pediatric; disaster; validation tools; triage algorithms; emergency
Background: Rapid, accurate evaluation and sorting of victims in a mass casualty incident (MCI) is crucial, as overtriage of victims may overwhelm a trauma system and under-triage may lead to an increase in morbidity and mortality. At this time, there is no validation tool specifically developed for the pediatric population to test an MCI algorithm’s inherent capabilities to correctly triage children. Objective: To develop a set of criteria for outcomes and interventions to be used as a validation tool for testing an MCI algorithm’s ability to correctly triage patients from a cohort of pediatric trauma patients. Methods: Expert opinion and literature review was used to formulate an initial Criteria Outcomes Tool (COT) that retrospectively categorizes pediatric (≤14 years of age) MCI victims based on resource utilization and clinical outcomes using the classic Red to Black MCI triage designations: Red - cardiopulmonary or mental
Received May 1, 2015 from UCSD and Rady Children’s Hospital of San Diego, Emergency Medicine, San Diego, California (JJD); Harbor UCLA Medical Center, Emergency Medicine, Torrance, California (AHK); USC, Keck School of Medicine, Emergency Medicine, Los Angeles, California (IAC); Children’s Hospital Los Angeles, Emergency Medicine, Los Angeles, California (TPC, SS); USC Medical Center, Emergency Medicine, Los Angeles, California (GS); Yale Pediatric Emergency Medicine, Pediatrics, New Haven, Connecticut (MXC); Keck School of Medicine of University of Southern California, Los Angeles, California (AP-R); Los Angeles County EMS Agency, Santa Fe Springs, California (MG-H). Revision received October 2, 2015; accepted for publication October 6, 2015.
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INTRODUCTION Rapid, accurate evaluation and sorting of victims in a mass casualty incident (MCI) is crucial, as overtriage of victims may overwhelm a trauma system and under-triage may lead to an increase in morbidity and mortality.1 Multiple algorithms have been created to assist prehospital providers in optimizing care while guiding allocation of resources in MCI settings. The majority of MCI triage algorithms divide patients into four main groups: Red, Yellow, Green, and Black. Red implies a first priority victim who requires a life saving intervention (LSI) or has an unstable mental status, respiratory, or cardiovascular system. Yellow implies a stable airway and cardiovascular system is present at the time of triage, but a life or limb treatment may be needed. Green is the least injured patient, often labeled the “walking wounded,” who is not expected to need hospital-based treatment. Black implies death or imminent death and the first responder should leave the victim to find and care for victims who are more likely to survive.2 Many authors have written about the dearth of evidence regarding triage algorithm validation.3,4 In 2011,
Author Contributions: All authors assisted with the development of the criteria outcomes tool and revision of the manuscript. The abstract was presented at the 2015 Pediatric Academic Societies meeting (April 2015, San Diego, CA) and the 2015 Annual Society of Academic Medicine meeting (May 2015, San Diego, CA). The authors of this manuscript have no sources of support or conflicts of interest to disclose. IRB Approval was obtained from LABiomed, Torrance, California. Guynell Miller and the Division of Trauma Surgery, Department of Surgery, Harbor-UCLA Medical Center, are acknowledged for the use of their trauma database and the American Academy of Pediatrics Disaster Preparedness Advisory Council for reviewing our criteria outcomes. Address correspondence to Dr. J. Joelle Donofrio, DO, UCSD and Rady Children’s Hospital of San Diego, Emergency Medicine, 3020 Children’s Way, MC-5075, San Diego, 92123 CA, USA. E-mail: [email protected] doi: 10.3109/10903127.2015.1111476
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2 the task force for pediatric emergency mass critical care explicitly cited the need to develop pediatric validated scoring system to predict benefit and resource utilization.5 To date, there are no definitive data on which MCI algorithm is the most efficient and useful in the pediatric population.6 Thus far, the ability of MCI algorithms to correctly triage patients has been studied using the Injury Severity Scale (ISS), the Baxt and modified Baxt (Garner) outcomes criteria, and length of stay (LOS) as gold standard outcomes. The ISS, an anatomical scoring system for multiply injured patients, provides a score from 0 to 75 and has been found to correlate with mortality, morbidity, and hospital stay.7 Baxt et al. assessed whether the ISS correlated with death or significant resource utiliation in Red patients. In patients with ISS greater than 15, 17% had no resource utilization, while 20% of patients with ISS less than 10 required resource utilization. He concluded that use of ISS to validate prehospital triage could lead to inaccurate triage rules.8 Garner et al. modifed Baxt’s resource criteria in 2001 for use in the adult (greater than 14 years old) population.9 These modified Baxt criteria have been used in multiple studies to validate MCI triage algorithms’ categorization of adult Red victims and have been further adapted for use in the pediatric population.4,10–12 Despite Baxt’s findings, the ISS is widely used to validate MCI algorithms. As the modified Baxt criteria only designates Red and does not distinguish between Yellow, Green, and Black categories, many studies have used an ISS higher than 15 to define a Red victim, ISS 9-15 with admission for Yellow, and ISS less than 9 for Green.11–14 These studies often cite lack of validated standards as reasoning for the use of ISS and agree that ISS is not an optimal choice to screen for resource utililization. Length of stay (LOS) has also been used in differentiating Yellow from Green. Cross et al. included LOS, death, and a stay greater than two days as serious outcomes while others included LOS > 24 h as a Yellow criterion.8,13,15 In 2010, Newgard et al. assessed LOS as a surrogate measure for injury severity (ISS higher than 15) and resource use (major surgery, ventilation more than 96 h, or blood transfusion) in trauma patients and concluded that while LOS may be a good proxy as an outcome in adults, it may be less accurate in children.15 While the benefit of ISS and LOS includes ease of availablility and objectivity of data, they are less accurate than thorough chart review. Several barriers make accurate triage more difficult in children.16 Over-triage occurs frequently due to the emotional stress of caring for injured or deceased children, unfamiliarity with children—particularily those with special needs—and age-related variations in physiologic variables.11,16,17 In a 2013 trial comparing pediatric triage algorithms, many participating
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paramedics stated that they upgraded a triage category just because the patient was a child.18 It is unclear how EMS providers can best train for disaster care involving children.19 Kilner et al.’s 2011 review of MCI triage algorithms identified the lack of standardized outcomes to compare MCI algorithms.20 We also identified a need for a method of comparing the accuracies of pediatric MCI algorithms for pediatric disaster research. Our objective was to develop a Criteria Outcomes Tool (COT) for MCI algorithm validation based on resource utilitzation and clinical outcomes in the pediatric population.
METHODS This study used 3 distinct phases using a modern validity framework: 1) Systematic Review; 2) Expert Panel modified Delphi process; and 3) National Expert Feedback.21 This study was approved by the Institutional Review Board of the Los Angeles Biomedical Research Institute at Harbor-UCLA.
PHASE 1- LITERATURE REVIEW In the first phase, a systematic review of the literature was conducted to identify outcomes utilized in validation of MCI triage algorithms. In August 2012, we searched the medical databases Pubmed and Google Scholar from 1990 to 2012 for articles written with the following terms: “pediatric triage,” “mass casualty incident triage,” “pediatric MCI,” “pediatric disaster triage,” “disaster triage,” and “MCI triage.” Studies that assessed the specificity, sensitivity, over-triage, and under-triage of an MCI algorithm were included. Initial literature review found 23 papers assessing MCI triage tools, MCI use in pediatric population, MCI simulations, and triage physiology of which 10 assessed sensitivity and specificity of the triage algorithms. A list of this literature review is available in the Supplemental Material section. Of these 10, two used mortality,13,22 six used mean Injury Severity Score (ISS),4,9,11–14 and four8,9,11,12 used derivations of the outcomes from one original paper by Baxt et al.8 We excluded ISS as criterion due to its poor ability to predict resource utilization. Our exclusion of ISS will also allow direct comparison of our COT to ISS in future studies.
PHASE 2: EXPERT PANEL MODIFIED DELPHI PROCESS AND ANATOMICAL CATEGORIZATION An eight-member panel including six experts and two pediatric emergency fellows was convened. The experts included: one pediatric emergency medicine
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TABLE 1.
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Registry data provided to reviewers
Arrival Time Gender Age Weight Height Broselow Tape Color Trama Tier Level Criteria for Trauma Activation Mechanism of Injury Ability to Walk Neurologic Status Field Vitals ED∗ vitals IV∗ fluids given in field IV fluids given in ED Paramedic exam and treatments ED exam and treatments ED disposition ED LOS∗ Hospital LOS Time to OR∗ Central line/intraosseous lines placed in ED Blood given in field Blood given in ED All imaging results Procedure performed and the location the procedure was performed Days in ICU∗ ICD-9∗ Codes ISS∗ Scores- calculated by department of trauma surgery ED: emergency department; IV: intravenous; LOS: length of stay; OR: operating room; ICU: intensive care unit; ICD-9: the international classification of diseases, 9th revision; ISS: injury severity scale.
physician board certified in both pediatrics and emergency medicine with extensive publications in the disaster field; three academic pediatricians with pediatric emergency fellowship training, including two with extensive disaster research; and two emergency medicine physicians, one with pediatric emergency medicine fellowship training and extensive pediatric prehospital and disaster experience and the other with a doctoral thesis in disaster medicine. Inclusion and exclusion criteria for the use of the COT were defined. Inclusions were trauma patients less than or equal to 14 years of age. Exclusion criteria were all trauma transfers, deaths from medical (iatrogenic) error, and acute psychiatric illness as a result of trauma. An initial round of expert consensus with literature review was performed to identify outcomes and interventions in each of the Red to Black triage categories. The COT was then expanded into a comprehensive table including 10 anatomic systems: head/neck, airway/breathing, circulation/cardiac, chest, abdomen, back/spine, genitourinary, extremities, skin, and other. We captured injuries, interventions, and outcomes that could occur in each system that would lead to a Red, Yellow, Green, or Black designation. The following definitions of outcomes were devised to clearly delineate outcomes: Red - victim required
lifesaving treatment; Yellow - victim required operative repair/reduction during stay to preserve function (e.g., vision and mobility) and limb preservation; Green - no disability nor need for treatment to preserve normal function; and Black – did not survive despite interventions. After the draft COT was completed, the working group had six conference calls to discuss, revise, and refine the indicators and specifications. Prioritization was given to outcomes/interventions that would fit the triage definitions defined by the group, were easily identifiable on chart outcome, and would apply to MCI scenarios.
PHASE 3: NATIONAL FEEDBACK FROM AMERICAN ACADEMY OF PEDIATRICS DISASTER PREPAREDNESS ADVISORY COUNCIL (AAP DPAC) The COT was sent electronically to the AAP DPAC committee for review in October 2013.
PHASE 4 - SPECIFICATION OF CATEGORIES After review by the AAP DPAC, the Working Group then had two further conference calls. Phase 4 resulted in the final COT.
PHASE 5 - RELIABILITY TESTING Two reviewers (AHK and JJD) individually applied the COT to a retrospective cohort of 25 pediatric trauma cases. Only two reviewers were chosen due to the time constraints of a thorough chart review. Reviewer 1 was an emergency medicine physician with a doctoral thesis in disaster medicine and reviewer 2 was a pediatric emergency medicine fellow with prior disaster education and experience. From our existing level I trauma surgery database, 668 cases ≤14 years of age with complete prehospital data from 8/22/2010 to 11/25/2013 were available for review. This hospital has a pediatric emergency department (ED) volume of 23,000 visits per year. A weighted sample of 25 cases was selected to obtain inter-rater reliability of chart data extraction by the reviewers in each of the four triage categories. We reviewed the trauma database beginning with the most recent visits to identify: seven patients in whom the outcome was death, five patients with ISS > 24, four patients with ISS < 25 but with chesttube and/or intubation in the ED (timing of procedure not considered on initial selection), and nine other patients not meeting any of those criteria. The chart was heavily weighted towards the more injured patients as we wanted to ensure adequate inclusion in the Black and Red triage categories. The two reviewers independently reviewed electronic health records to select the
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COT triage (Red to Black) for each patient. Patient data provided to the reviewers in addition to their chart review is included in Table 1. Paramedic, ED, consultant, and all inpatient records were available to the reviewers via chart review as well. Retrospective patient data were collected and stored on Microsoft Excel for Mac 2011 version 14.1.4. Interrater reliability was determined by percentage agreement between two reviewers in each triage category and overall. Median age and median ISS were calculated for the entire retrospective pediatric cohort using Microsoft Excel. Median ISS, 25–75% interquartile ranges (IQR), and the range of ISS numbers were determined for the cohort of patients in each triage category, Red to Black.
RESULTS Initial expert consensus created a COT with 24 outcomes in the four triage categories (Appendix 1). First revision to an anatomical systems-based chart led to an increase from 24 to 59 criteria (Appendix 2). The post modified Delphi COT sent to DPAC for review contained 58 items. Three members of the committee provided specific feedback, including a recommendation to utilize a pediatric trauma activation study reference as well as to change the optimal time to operating room (OR) for a Red outcome from < 6 h to < 90 min and to combine all non-orthopedic Red OR outcomes.23 After their review, the final COT included 47 outcomes: 15 Red, 23 Yellow, one Green, and eight Black criteria (Table 2). The twenty-five patients used for reliability testing had a median age of 8 years (IQR: 4 – 12 years) and a median ISS of 19 (IQR: 4 to 35). There were seven females and 18 males. After completion of the COT, the weighted sample of 25 pediatric trauma patients showed a 100% concordance between the two reviewers in all four categories. There was no need to reach consensus, as independent application of the COT yielded the same findings. There were six Red, six Yellow, six Green, and seven Black COT patient outcomes. Table 3 describes the patients and their outcomes. Table 4 describes the median ISS of each triage category with the 25–75% IQR and range of ISS found in each group. The Red and Yellow groups had similar ISS numbers, with each group including patients with an ISS > 25.
DISCUSSION We have created a COT using patient outcomes and resource utilization to validate MCI algorithms for use in the pediatric population with high inter-rater reliability. We used a novel approach to assess the accuracy of MCI triage algorithms by directly comparing the
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predicted triage level to the outcomes-based triage level. During the development of the COT, we adopted an anatomical approach to selection of criteria. By approaching each anatomic region to determine which interventions and outcomes would specifically fall into a Red to Black category, it allowed us to add criteria we had not previously considered (e.g., treatment of compartment syndrome). Additionally, the COT addresses each of the triage categories. In contrast, the modified Baxt criteria designates only Red patients, the ISS categories were arbitrarily designated with no validation, and there is no tool to test the Black triage category. As opposed to the Baxt and modified Baxt criteria, the COT was developed with the specific intention to validate MCI algorithms; it encompasses each anatomic system, and is designed for the pediatric population.8,9 The criteria specified in the COT were specifically chosen to determine which clinical outcomes and resources would be significant in a medical system overwhelmed by an MCI. In 2015, after our development but prior to our publication of the COT, Lerner et al. created a gold standard definition for each mass casualty triage category using a modified Delphi survey.24 This tool was created to study outcomes data in adults and children, similar to the COT. Although they do have many similarities, especially in the Black and Red categorization of victims, they differ in several ways. 1) Our tool was designed for the pediatric population by pediatric disaster specialists. 2) We have specific criteria to be classifed yellow as pediatric patients are often overtriaged and single trauma patients tend to be hospitalized frequently for relatively minor injuries or observation, but might not require hospitalization in a MCI environment (e.g., a victim with an overnight intensive care stay for observation who received no interventions and had no significant injuries would be considered a Green victim in a MCI scenario based on the COT). We wanted to ensure that when considering a MCI scenario, victims who were designated Yellow truly needed to go to the hospital and victims triaged Green would have had no functional harm if they did not go to the hospital. 3) Our criteria were developed to minimize subjective interpretation to allow consistent data extraction (e.g., requiring capillary refill >3 seconds, tachycardia and hypotension corrected for age when describing poor perfusion). This likely led to a more time intensive chart review, but with the goal of better appreciation of the inherent sensitivity and specificity of the MCI triage algorithm. Neither Lerner et al. nor our COT take resource limitations into account. This may lead to some complications when applying the tools to the Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) algorithm.24
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TABLE 2.
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Category
∗
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Criteria outcomes tool Intervention/Outcome
Red
1. ICH∗ requiring immediate surgical intervention, invasive ICP∗ monitoring or mannitol/3% Saline in ED∗ 2. OR∗ < 90 minutes 3. Intubation in ED 4. Requires supportive ventilation with palpable pulse in ED: e.g., BVM∗ , intubation, extraglottic, supraglottic, and surgical airway 5. Noninvasive ventilation in ED: e.g., CPAP∗ , BiPAP ∗ 6. Emergent removal of an airway foreign body 7. More than 60 mL/kg NS∗ bolus for shock∗∗ 8. Vasopressors required in ED 9. Blood given in ED 10. Cardiac intervention with documented poor perfusion∗ : e.g., cardioversion, pacing, pharmacologic interventions 11. Chest tube/needle decompression within 2 h 12. Pericardiocentesis 13. Thoracotomy in the ED 14. Burn requiring escharotomy of chest/abdomen or airway protection 15. Administered antidote/counter measure for a life-threatening chemical or toxin exposure
Yellow
1. Ophthomology intervention other than laceration repair or OR repair within 24 h to preserve vision: e.g., lateral cathotomy or globe rupture repair 2. ENT/OMFS∗ surgical intervention (bedside or OR) to preserve functional outcome 3. Spinal injury with neurologic findings not requiring immediate operative interention (e.g., paralysis, weakness) 4. Supplemental oxygen for oxygen saturation < 94%, respiratory distress, or simple pneumothorax 5. Four or more nebulized treatments or continuous treatments 6. Cardiopulmonary monitored (e.g., ICU∗ or step down admission) bed admission for greater than 48 h 7. Two saline boluses needed: 40 mL/kg in < 6 h no matter where they are 8. Cardioversion without poor perfusion∗∗ : e.g., tachycardia unresponsive to adenosine 9. Chest tube placed after 2 h: e.g., non-tension pneumothorax 10. Go to OR in > 90 min for abdominal injury 11. Monitored bed admission for documented intra-abdominal organ injury 12. Placement of stabilization device: e.g., thoracolumbosacral orthosis or halo placement 13. Go to OR in > 90 min for spinal injury 14. Extraperitoneal bladder rupture, ureteral, or urethral injury 15. Positive cysturethrogram 16. Any genitourinary injury requiring OR repair 17. Fracture requiring closed reduction or ORIF∗ 18. Vascular injury requiring compression only 19. OR or bedside fasciotomy/escharotomy in > 90 min for limb threat from neuro vascular injury (6P’s∗ ): e.g., compartment syndrome, arterial bleeding, nerve injury 20. Open fracture requiring wash out 21. Transfer to burn center for meeting national burn center criteria 22. Hyperbaric therapy or 100% oxygen required for carbon monoxide poisoning 23. Admission for IV∗ pain control and monitoring of neurovascular status
Green
1. No poor outcome without treatment
Black
1. Decapitation 2. Brain exposed 3. Cervical spine fracture above fourth cervical vertebrae with respiratory failure 4. Apnea despite two rescue breaths 5. No pulse 6. Defibrillation 7. Transection through a non-extremity 8. Died in ED∗
ED: emergency department; ICH: intracranial hemorrhage; ICP: intracranial pressure; OR: operating room; BVM: bag valve mask; CPAP: continuous positive airway pressure; BiPAP: bilevel positive airway pressure; NS: normal saline; ENT/OMFS: otolaryngology/oral maxillary facial surgeons; ICU: intensive care unit; ORIF: open reduction internal fixation; 6P’s: pulselessness/pallor/pain out of proportion/paresthesis/paralysis/poikilothermia; IV: intravenous ∗∗ Poor perfusion/shock/hemodynamic compromise: cool mottled extremities, capillary refill > 3 sec, tachycardia > 95%, and/or hypotensive for age.
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TABLE 3.
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Patient outcome designations
Patient Number
Outcome Chart Designation
Red Category Intubated for ICH. Not apneic in field. Intubated in ED Intubated in ED for ICH. Not apneic in field Intubation for ICH. Not apneic in field. Mannitol, intubation, and OR < 90 min required for head injury with mass effect. Not apneic in field. Received blood in ED for hemorrhagic shock from liver laceration
74 135 193 165 124 109
4 31
Yellow Category 2 boluses, PICU∗ stay > 48 h, respiratory distress with hypoxia, monitored bed for documented grade 5 liver lac Chest tube placed after 2 h, PICU stay > 48 h ORIF∗ femur fracture, PICU stay > 48 h PICU stay > 48 h, admit for monitoring of splenic laceration, oxygen given in PICU for pneumothoraxes Required closed reduction of wrist to regain pulses ORIF femur fracture, ED traction
1, 2, 3, 5, 6, 40
Green Category No treatments to preserve limb or function
15 127 20 36
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Black Category Apneic and hypoxemic in field requiring BVM∗ . Declared brain dead in 29 h Apneic and pulseless despite BVM, declared dead in ED∗ Apneic and pulseless in field, defibrillated in OR∗ . Died within 10 minutes of arrival to OR and within 2 h of arrival Head injury, cardiac arrest in in ED (pulseless VT∗ ), required chest compressions, defibrillation x 3 No pulse, apneic in field. Declared dead in ED Pulseless and apneic in field. Declared dead in ED Pulseless in field. In ED ROSC∗ but apneic. Declared brain dead same day
672 280 308 120 122 728 536 ∗
BVM: Bag Valve Mask, OR: Operating Room, ED: Emergency Department, VT: Ventricular Tachycardia, ROSC: Return of Spontaneous Circulation, ICH: Intracranial Hemorrhage, PICU: Pediatric Intensive Care Unit, ORIF: Open reduction Internal Fixation
The COT was developed for a direct comparison of MCI algorithms using retrospective trauma cases to identify the inherent ability of an MCI algorithm to correctly triage patients in the pediatric population. Thus far, there have been two studies comparing MCI algorithm use in the pediatric population using retrospective trauma cases.11,25 In 2006, Wallis et al. compared four MCI algorithms (Pediatric Triage Tape, Careflight, Simple Triage and Rapid Treatment, and JumpSTART systems) in children less than 13 years of age who were triaged and treated by the Red Cross Children’s Hospital in Cape Town, South Africa.11 This study applied the Garner criteria, the ISS, and the New ISS (NISS) as gold standard outcomes and found the Garner criteria to be a better measure than ISS/NISS in the Red category.
TABLE 4.
They found an ISS higher than 15 correlated well to serious injury, but commented on the lack of ability to appropriately distinguish between Yellow and Green. They did not specifically study victims with Black triage designation as many of their patients had long travel times and would have died on the way to the hospital if they were designated Black in an MCI. In 2013, Cross et al. compared six algorithms in the pediatric, adult, and geriatric population using the National Trauma Data Base to compare MCI algorithm triage assignment to mortality at discharge.25 In addition to mortality at discharge, they assessed death in the ED, use of a ventilator during hospitalization, lengths of stay in ED and hospital, and ISS. As only 10% of deaths were in the ED and there was no adjust-
Retrospective Pediatric Trauma ISS scores
Triage Category
n
Median ISS
ISS IQR
ISS Range
Red Yellow Green Black
6 6 6 7
18 19 3 43
12 to 24 13 to 25 1 to 4 40 to 55
9 to 34 10 to 34 1 to 3 25 to 57
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ment for comorbidities or age, it is difficult to discern whether the deaths after hospitalization were related to co-morbidities, such as hospital aquired pneumonia in an elderly patient. Additionally, although they assessed any ventilator use during hospitalization, they did not specifically assess ventilator use in the ED. MCI triage algorithms need to be repeatedly applied and a patient who is initially triaged as a Yellow may deteriorate into a Red status. Comparing resource utilization later in the hospital course can make MCI algorithms appear to inappropriately under-triage victims. It is not clear whether these mortalities and interventions are applicable to MCI scenarios or whether they apply to the pediatric population which has fewer comorbidities and more physiologic reserves. These difficulties are common with database extraction and it is possible that we will encounter similar difficulties when the COT is used as the gold standard to test MCI algorithms.
Future Directions Further studies are needed for validation of this tool that compare reliability across novice and non-trained users and using a greater number of patients. Further application of the COT with feasability studies may lead to a more refined and simplified tool. Application of this tool as a gold standard outcome to compare the available MCI algorithms is our next step. Additionally, the COT may be adapted for use in evaluating adult MCI triage methods.
LIMITATIONS At this time, the COT: 1) contains data that are not readily available from the trauma registry and 2) requires chart review. It is possible that future studies using retrospective chart review of pediatric trauma patients may lead to further refinement of the COT. Although the COT does require chart review, it was created in a systems-based fashion with expert opinion, using clear definitions. The COT was designed to determine an appropriate triage category based on the ultimate clinical outcome and resource utilization of the victim and not the initial triage presentation. Initial triage tools may not be able to identify all injuries, which is an inherent limitation of triage itself. Patient sample number was low and data collected were retrospective with isolated, non-MCI trauma cases. Reliability may change with larger numbers of patients and with differing disaster scenarios (e.g., involving biological or chemical exposures). The COT working group was not blinded during the revisions of indicators and specifications. This may have created a bias as members of the group knew who made each recommendation which may have re-
sulted in unintended influence on criteria selection. However, the lack of blinding led to in-depth discussions about which injuries and treatments were appropriate in each anatomical and triage designation, which would not have taken place if panel members were blinded. Additionally, both reviewers who performed the inter-rater reliability testing had prior training in disaster and triage. Thus, use of the COT by non-trained individuals may lead to lower inter-rater reliability. We found the Black triage category lent itself to subjective interpretation on chart review. Certain MCI algorithms use “apnea despite two breaths” to designate a Black patient. In non-MCI scenarios, any patient who is not breathing automatically receives bag mask ventilation and the respiratory effort is not reassessed after two breaths. We assumed that patients requiring continuous positive pressure bag valve mask ventilation in the field were apneic. Additionally, during our retrospective chart review, we noted that for some patients the paramedic information recorded in the trauma data base was incorrect. For example, one patient was apneic and pulseless in the field on EMS arrival but vital signs were still recorded. The documented vital signs were likely the compression and bagging rate. In Sundermann et al.’s 2015 study evaluting the accuracy of pre-hospital patient care reports for identification of critical resuscitation events, they found EMS patient care reports to be an inaccurate source of information for out-of-hospital cardiac arrest data.26 Furthermore, it must be taken into account that field vitals often differ greatly from the vitals upon arrival. A 2013 study of the decision making process by EMS found that estimates of vital signs such as blood pressure were inferred by EMS because many prehospital providers stated that taking vital signs is often not feasible until the patient is stabilized and a destination hospital has been selected.27 Thorough chart review of the EMS documentation allowed us to discover issues which could be lost with large scale database interpretation. This validation tool does not take into account an MCI algorithm’s ease of use or the ability of the prehospital provider to use the algorithm correctly.
CONCLUSION We created a COT based on clinical outcomes and resource utilization for use in validation of MCI algorithms in the pediatric population. Our study found a high inter-rater reliabilty for all four triage categories: Red, Yellow, Green, and Black. Additionally, we explicitly describe clear definitions for each triage designation. This tool may lead to improved scientific testing of existing and novel MCI algorithms.
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References 1. Aitken P, FitzGerald G. Disaster triage: evidence, consistency and standard practice. Emerg Med Australas. 2012 Jun;24(3):222–4. 2. Cone DC, Serra J, Burns K, MacMillan DS, Kurland L, Van Gelder C. Pilot test of the SALT Mass Casualty Triage System. Prehosp Emerg Care. 2009;13(4):536–40. 3. Cone DC. Mass-casualty Triage systems: a hint of science. Acad Emerg Med. 2005;12(8):739–41. 4. Kahn CA, Schultz CH, Miller KT, Anderson CL. Does START Triage work? an outcomes assessment after a disaster. Ann Emer Med. 2009;54(3):424–30.e1. 5. Antommaria AHM, Powell T, Miller JE, Christian MD. Ethical issues in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(Supplement):S163–8. 6. Lee CH. Clinical Pearl. Disaster and Mass Casualty Triage. Virtual Mentor. 2010;12(6):466–70. 7. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187–96. 8. Baxt WG, Upenieks V. The lack of full correlation between the Injury Severity Score and the resource needs of injured patients. Ann Emerg Med. 1990;19(12):1396–400. 9. Garner A, Lee A, Harrison K, Schultz CH. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001;38(5):541–8. 10. Challen K, Walter D. Major incident triage: Comparative validation using data from 7th July bombings. Injury, Int. J. Care Injured. 2012;44(5):629–33. 11. Wallis LA, Carley S. Comparison of paediatric major incident primary triage tools. Emerg Med J. 2006;23(6):475–8. 12. Wallis LA, Carley S. Validation of the Paediatric Triage Tape. Emerg Med J. 2006;23(1):47–50. 13. Cross KP, Cicero MX. Independent application of the Sacco disaster triage method to pediatric trauma patients. Prehosp Disaster Med. 2012;27(4):1–6. ¨ 14. Aylwin CJ, Konig TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet. 2006;368(9554):2219–25. 15. Newgard C, Fleischman R, Choo E, Ma OJ, Hedges JR, McConnell KJ. Validation of length of hospital stay as a surrogate
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measure for injury severity and resource use among injury survivors. Acad Emerg Med. 2010;17:142–50. Koziel J, Meckler, Brown L, et al. Barriers to pediatric disaster triage: a qualitative investigation. Prehosp Emerg Care. 2015;19(2):279–86. Gausche-Hill M. Pediatric disaster preparedness: are we really prepared? J Trauma. 2009;67(2):S73–6. Jones N, White ML, Tofil N, et al. Randomized trial comparing two mass casualty triage systems (JumpSTART versus SALT) in a pediatric simulated mass casualty event. Prehosp Emerg Care. 2014;18(3):417–23. Cicero MX, Brown L, Overly F, et al. Creation and Delphimethod Refinement of Pediatric Disaster Triage Simulations. Prehosp Emerg Care. 2014;18(2):282–9. Kilner TM, Brace SJ, Cooke MW, Stallard N, Bleetman A, Perkins GD. In “big bang” major incidents do triage tools accurately predict clinical priority?: a systematic review of the literature. Injury, Int. J. Care Injured. 2011;42(5):460– 8. Lindsay P, Schull M, Bronskill S, Anderson G. The development of indicators to measure the quality of clinical care in emergency departments following a modified-delphi approach. Acad Emerg Med. 2002;9(11):1131–9. Gebhart ME, Pence R. START triage: Does it work? Disaster Manag Response. 2007;5(3):68–73. Falcone RA Jr., Haas L, King E, et al. A multicenter prospective analysis of pediatric trauma activation criteria routinely used in addition to the six criteria of the American College of Surgeons. J Trauma Acute Care Surg. 2012;73(2):377–84. Lerner EB, McKee CH, Cady CE, et al. A consensus-based gold standard for the evaulation of mass casualty triage systems. Prehosp Emerg Care. 2015;19(2):267–71. Cross KP, Cicero MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61(6):668–76.e7. Sundermann ML, Salcido DD, Koller AC, Menegazzi JJ. Inaccuracy of patient care reports for identification of critical resuscitation events during out-of-hospital cardiac arrest. Am J of Emerg Med. 2015;33(1):95–99. Jones CM, Cushman JT, Lerner EB, et al. Prehospital trauma triage decision making: A model of what happens between the 9-1-1 call and the hospital. Prehosp Emerg Care. Published Online: May 27, 2015 (doi: 10.3109/10903127.2015.102 5157)
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APPENDIX 1. Initial Expert Derived Criteria Red
Non-orthopedic OR∗ within 6 h
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IVF∗ > 40 mL/kg to keep SBP∗ > 90 (or 2xage + 70) Intracranial hemorrhage Assisted ventilation or procedure to maintain airway Relief of tension pneumothorax
Acute hemorrhage with tourniquet or suture placed Cyanide antidote given Hyperbaric therapy initiated Burn > 20% TBSA ∗
Yellow
Hospitalized but not fulfilling and intermediate criteria (not including purely social admissions) Non ortho OR∗ > 6 h
Green
Black
Ambulatory at scene
Pulselessness
No hospitalization required
Rigor/lividity
Ortho OR < 6 h More than 1 h oxygen required
Burn > 90% TBSA∗ Died in ED∗
Parental medication in ED in excess of single dose of pain medication or vaccination More than 1 nebulized medication More than 24 h IVF
ISS∗ > 25
Decapitation/transection through torso
IVF Intravenous fluid, SBP systolic blood pressure, ortho orthopedic, OR operating room, TBSA total body surface area, ISS Injury Severity Score
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APPENDIX 2. Initial systems based categorization
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Red
Yellow
Green
Black
Body part
Life Saving Intervention/outcome
Intervention/ outcome
Intervention/ Outcome
Injury
Head/Neck
• ICH∗ requiring immediate OR∗ intervention, ICP∗ monitoring or mannitol/3% NS∗ in ED∗ • OR required < 6 h for pending airway/lifesaving: e.g., Le Fort 3 • Intubation
• Ophthomology intervention
• Nothing
• Decapitation
• ENT/OMFS∗ surgical intervention (bedside or OR)
• Topical tx
• Brain exposed
• Thoracic or lumbar spine injury with neurologic findings (e.g., paralysis, weakness)
• Torsion of neck (deformity incompatible with life)
• Requires supportive ventilation with palpable pulse: extraglottic, supraglottic, and surgical airway • OR in < 6 h for potential life/airway saving intervention: vascular injury, airway compromise • Emergent removal of a foreign body
• Nonrebreather
• Apnea despite two rescue breaths
• NS∗ bolus and documented hypotension corrected for age
• Cardiopulmonary monitored (e.g., ICU∗ or step down admission) bed admission for greater than 48 h • 3 NS boluses needed: 60 mL/kg in less than 6 h no matter where they are • Cardioversion without poor perfusion
• Cervical spine injury with neurologic findings (e.g/ paralysis, weakness) Airway/Breathing
Circulation/Cardiac
• Pressors required • Blood in ED • Measures required to stop life/limb threatening bleed: e.g., pressure, tourniquet, surgery, sutures • Cardiac intervention with documented poor perfusions (decreased cap refill, decreased pulses, altered mental status): e.g., cardioversion, pacing, atropine, adenosine Chest
• Chest needle decompression • Chest tube placed within 2 h • Pericardiocentesis • Thoracotomy in the emergency department • Intubation • OR < 6 h
• NC∗ O2
• > 1 nebulized treatment • Nonsupportive ventilation: CPAP∗ , BiPAP∗
• Admit IV∗ pain control and monitoring • Chest tube placed after 2h
• No pulse
• Defibrillation
• Transection through torso
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APPENDIX 2. Initial systems based categorization Red
Abdomen
• OR < 6 h (organ injury scaling 3 or higher)
Yellow
• Go to OR > 6 h
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• Receive blood in the ED∗
Green
• Repair by ED not requiring procedural sedation • Admit for monitoring
Back/spine
• OR < 6 h
GU
• OR < 6 h for intraperitoneal injury (eg bladder rupture, grade 5 renal injury)
• Extraperitoneal bladder rupture, ureteral, or urethral injury
• Measures required to stop life/limb threatening bleed: e.g., pressure, tourniquet, surgery, sutures • Blood in ED
• Reduction in ED
• Casting in ED → home
• Orthopedic OR
• Reduced in ED → home • Repair by ED doc
Extremities
Others
∗
• Burn requiring escharotomy or airway protection • Cyanide antidote given
• Transection
• Positive cysturethrogram • OR surgery > 6 h
• OR or bedside fasciotomy or escharotomy < 6 h for limb threat from neuro vascular injury (6P’s∗ ): e.g., compartment syndrome, arterial bleeding, nerve injury Skin
Black
• Transfer to burn center or clinic • Procedural sedation
• Died in ED
• Hyperbaric therapy required
• ISS∗ > 24 • Transferred to OR within 2 h and died in OR
ICH: intracranial hemorrhage, OR: operating room, ICP: intracranial pressure, NS: normal saline, ED: emergency department, ENT/OMFS: otolaryngology/oral maxillary facial surgeons, NC: nasal canula, CPAP: continuous positive airway pressure, BiPAP: bilevel positive airway pressure, ICU: intensive care unit, IV: intravenous, 6P’s: pulselessness/pallor/pain out of proportion/paresthesis/paralysis/poikilothermia, ISS: injury severity scale
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Development of a Pediatric Mass Casualty Triage Algorithm Validation Tool J. Joelle Donofrio DO, Amy H. Kaji MD, PhD, Ilene A. Claudius MD, Todd P. Chang MD, MAcM, Genevieve Santillanes, Mark X. Cicero MD, Saranya Srinivasan MD, Alexis Perez-Rogers BS & Marianne Gausche-Hill MD To cite this article: J. Joelle Donofrio DO, Amy H. Kaji MD, PhD, Ilene A. Claudius MD, Todd P. Chang MD, MAcM, Genevieve Santillanes, Mark X. Cicero MD, Saranya Srinivasan MD, Alexis Perez-Rogers BS & Marianne Gausche-Hill MD (2016): Development of a Pediatric Mass Casualty Triage Algorithm Validation Tool, Prehospital Emergency Care, DOI: 10.3109/10903127.2015.1111476 To link to this article: http://dx.doi.org/10.3109/10903127.2015.1111476
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Date: 28 January 2016, At: 03:41
DEVELOPMENT OF A PEDIATRIC MASS CASUALTY TRIAGE ALGORITHM VALIDATION TOOL J. Joelle Donofrio, DO, Amy H. Kaji, MD, PhD, Ilene A. Claudius, MD, Todd P. Chang, MD, MAcM, Genevieve Santillanes, Mark X. Cicero, MD, Saranya Srinivasan, MD, Alexis Perez-Rogers, BS, Marianne Gausche-Hill, MD
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Abstract
status compromise needing intervention, Yellow - stable cardiopulmonary status but may require life or limb therapy, Green - minimally injured, and Black - deceased or likely to die given the circumstances. Using an anatomic approach, a list of criteria were defined and a modified-Delphi approach was used to create a summative COT that was reviewed by the American Academy of Pediatrics Disaster Preparedness Advisory Council. The resulting COT was independently applied to a weighted retrospective cohort of 25 pediatric victims from a single Level I trauma center by two reviewers to determine reproducibility. Results: We created a Criteria Outcomes Tool (COT) with 47 outcomes and interventions to validate an MCI algorithm’s triage designation. When the COT was applied to a cohort of 25 weighted pediatric charts, we identified the following resource utilization and outcome based triage designations: six Red, six Yellow, six Green, and seven Black triage outcomes. The 100% agreement was obtained between the two reviewers in each of the four categories. Conclusions: We designed an outcomes and resource utilization tool, the COT, to evaluate the ability of an MCI algorithm to correctly triage pediatric patients. Our tool has good reproducibility on initial study. Key words: pediatric; disaster; validation tools; triage algorithms; emergency
Background: Rapid, accurate evaluation and sorting of victims in a mass casualty incident (MCI) is crucial, as overtriage of victims may overwhelm a trauma system and under-triage may lead to an increase in morbidity and mortality. At this time, there is no validation tool specifically developed for the pediatric population to test an MCI algorithm’s inherent capabilities to correctly triage children. Objective: To develop a set of criteria for outcomes and interventions to be used as a validation tool for testing an MCI algorithm’s ability to correctly triage patients from a cohort of pediatric trauma patients. Methods: Expert opinion and literature review was used to formulate an initial Criteria Outcomes Tool (COT) that retrospectively categorizes pediatric (≤14 years of age) MCI victims based on resource utilization and clinical outcomes using the classic Red to Black MCI triage designations: Red - cardiopulmonary or mental
Received May 1, 2015 from UCSD and Rady Children’s Hospital of San Diego, Emergency Medicine, San Diego, California (JJD); Harbor UCLA Medical Center, Emergency Medicine, Torrance, California (AHK); USC, Keck School of Medicine, Emergency Medicine, Los Angeles, California (IAC); Children’s Hospital Los Angeles, Emergency Medicine, Los Angeles, California (TPC, SS); USC Medical Center, Emergency Medicine, Los Angeles, California (GS); Yale Pediatric Emergency Medicine, Pediatrics, New Haven, Connecticut (MXC); Keck School of Medicine of University of Southern California, Los Angeles, California (AP-R); Los Angeles County EMS Agency, Santa Fe Springs, California (MG-H). Revision received October 2, 2015; accepted for publication October 6, 2015.
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INTRODUCTION Rapid, accurate evaluation and sorting of victims in a mass casualty incident (MCI) is crucial, as overtriage of victims may overwhelm a trauma system and under-triage may lead to an increase in morbidity and mortality.1 Multiple algorithms have been created to assist prehospital providers in optimizing care while guiding allocation of resources in MCI settings. The majority of MCI triage algorithms divide patients into four main groups: Red, Yellow, Green, and Black. Red implies a first priority victim who requires a life saving intervention (LSI) or has an unstable mental status, respiratory, or cardiovascular system. Yellow implies a stable airway and cardiovascular system is present at the time of triage, but a life or limb treatment may be needed. Green is the least injured patient, often labeled the “walking wounded,” who is not expected to need hospital-based treatment. Black implies death or imminent death and the first responder should leave the victim to find and care for victims who are more likely to survive.2 Many authors have written about the dearth of evidence regarding triage algorithm validation.3,4 In 2011,
Author Contributions: All authors assisted with the development of the criteria outcomes tool and revision of the manuscript. The abstract was presented at the 2015 Pediatric Academic Societies meeting (April 2015, San Diego, CA) and the 2015 Annual Society of Academic Medicine meeting (May 2015, San Diego, CA). The authors of this manuscript have no sources of support or conflicts of interest to disclose. IRB Approval was obtained from LABiomed, Torrance, California. Guynell Miller and the Division of Trauma Surgery, Department of Surgery, Harbor-UCLA Medical Center, are acknowledged for the use of their trauma database and the American Academy of Pediatrics Disaster Preparedness Advisory Council for reviewing our criteria outcomes. Address correspondence to Dr. J. Joelle Donofrio, DO, UCSD and Rady Children’s Hospital of San Diego, Emergency Medicine, 3020 Children’s Way, MC-5075, San Diego, 92123 CA, USA. E-mail: [email protected] doi: 10.3109/10903127.2015.1111476
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2 the task force for pediatric emergency mass critical care explicitly cited the need to develop pediatric validated scoring system to predict benefit and resource utilization.5 To date, there are no definitive data on which MCI algorithm is the most efficient and useful in the pediatric population.6 Thus far, the ability of MCI algorithms to correctly triage patients has been studied using the Injury Severity Scale (ISS), the Baxt and modified Baxt (Garner) outcomes criteria, and length of stay (LOS) as gold standard outcomes. The ISS, an anatomical scoring system for multiply injured patients, provides a score from 0 to 75 and has been found to correlate with mortality, morbidity, and hospital stay.7 Baxt et al. assessed whether the ISS correlated with death or significant resource utiliation in Red patients. In patients with ISS greater than 15, 17% had no resource utilization, while 20% of patients with ISS less than 10 required resource utilization. He concluded that use of ISS to validate prehospital triage could lead to inaccurate triage rules.8 Garner et al. modifed Baxt’s resource criteria in 2001 for use in the adult (greater than 14 years old) population.9 These modified Baxt criteria have been used in multiple studies to validate MCI triage algorithms’ categorization of adult Red victims and have been further adapted for use in the pediatric population.4,10–12 Despite Baxt’s findings, the ISS is widely used to validate MCI algorithms. As the modified Baxt criteria only designates Red and does not distinguish between Yellow, Green, and Black categories, many studies have used an ISS higher than 15 to define a Red victim, ISS 9-15 with admission for Yellow, and ISS less than 9 for Green.11–14 These studies often cite lack of validated standards as reasoning for the use of ISS and agree that ISS is not an optimal choice to screen for resource utililization. Length of stay (LOS) has also been used in differentiating Yellow from Green. Cross et al. included LOS, death, and a stay greater than two days as serious outcomes while others included LOS > 24 h as a Yellow criterion.8,13,15 In 2010, Newgard et al. assessed LOS as a surrogate measure for injury severity (ISS higher than 15) and resource use (major surgery, ventilation more than 96 h, or blood transfusion) in trauma patients and concluded that while LOS may be a good proxy as an outcome in adults, it may be less accurate in children.15 While the benefit of ISS and LOS includes ease of availablility and objectivity of data, they are less accurate than thorough chart review. Several barriers make accurate triage more difficult in children.16 Over-triage occurs frequently due to the emotional stress of caring for injured or deceased children, unfamiliarity with children—particularily those with special needs—and age-related variations in physiologic variables.11,16,17 In a 2013 trial comparing pediatric triage algorithms, many participating
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paramedics stated that they upgraded a triage category just because the patient was a child.18 It is unclear how EMS providers can best train for disaster care involving children.19 Kilner et al.’s 2011 review of MCI triage algorithms identified the lack of standardized outcomes to compare MCI algorithms.20 We also identified a need for a method of comparing the accuracies of pediatric MCI algorithms for pediatric disaster research. Our objective was to develop a Criteria Outcomes Tool (COT) for MCI algorithm validation based on resource utilitzation and clinical outcomes in the pediatric population.
METHODS This study used 3 distinct phases using a modern validity framework: 1) Systematic Review; 2) Expert Panel modified Delphi process; and 3) National Expert Feedback.21 This study was approved by the Institutional Review Board of the Los Angeles Biomedical Research Institute at Harbor-UCLA.
PHASE 1- LITERATURE REVIEW In the first phase, a systematic review of the literature was conducted to identify outcomes utilized in validation of MCI triage algorithms. In August 2012, we searched the medical databases Pubmed and Google Scholar from 1990 to 2012 for articles written with the following terms: “pediatric triage,” “mass casualty incident triage,” “pediatric MCI,” “pediatric disaster triage,” “disaster triage,” and “MCI triage.” Studies that assessed the specificity, sensitivity, over-triage, and under-triage of an MCI algorithm were included. Initial literature review found 23 papers assessing MCI triage tools, MCI use in pediatric population, MCI simulations, and triage physiology of which 10 assessed sensitivity and specificity of the triage algorithms. A list of this literature review is available in the Supplemental Material section. Of these 10, two used mortality,13,22 six used mean Injury Severity Score (ISS),4,9,11–14 and four8,9,11,12 used derivations of the outcomes from one original paper by Baxt et al.8 We excluded ISS as criterion due to its poor ability to predict resource utilization. Our exclusion of ISS will also allow direct comparison of our COT to ISS in future studies.
PHASE 2: EXPERT PANEL MODIFIED DELPHI PROCESS AND ANATOMICAL CATEGORIZATION An eight-member panel including six experts and two pediatric emergency fellows was convened. The experts included: one pediatric emergency medicine
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TABLE 1.
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Registry data provided to reviewers
Arrival Time Gender Age Weight Height Broselow Tape Color Trama Tier Level Criteria for Trauma Activation Mechanism of Injury Ability to Walk Neurologic Status Field Vitals ED∗ vitals IV∗ fluids given in field IV fluids given in ED Paramedic exam and treatments ED exam and treatments ED disposition ED LOS∗ Hospital LOS Time to OR∗ Central line/intraosseous lines placed in ED Blood given in field Blood given in ED All imaging results Procedure performed and the location the procedure was performed Days in ICU∗ ICD-9∗ Codes ISS∗ Scores- calculated by department of trauma surgery ED: emergency department; IV: intravenous; LOS: length of stay; OR: operating room; ICU: intensive care unit; ICD-9: the international classification of diseases, 9th revision; ISS: injury severity scale.
physician board certified in both pediatrics and emergency medicine with extensive publications in the disaster field; three academic pediatricians with pediatric emergency fellowship training, including two with extensive disaster research; and two emergency medicine physicians, one with pediatric emergency medicine fellowship training and extensive pediatric prehospital and disaster experience and the other with a doctoral thesis in disaster medicine. Inclusion and exclusion criteria for the use of the COT were defined. Inclusions were trauma patients less than or equal to 14 years of age. Exclusion criteria were all trauma transfers, deaths from medical (iatrogenic) error, and acute psychiatric illness as a result of trauma. An initial round of expert consensus with literature review was performed to identify outcomes and interventions in each of the Red to Black triage categories. The COT was then expanded into a comprehensive table including 10 anatomic systems: head/neck, airway/breathing, circulation/cardiac, chest, abdomen, back/spine, genitourinary, extremities, skin, and other. We captured injuries, interventions, and outcomes that could occur in each system that would lead to a Red, Yellow, Green, or Black designation. The following definitions of outcomes were devised to clearly delineate outcomes: Red - victim required
lifesaving treatment; Yellow - victim required operative repair/reduction during stay to preserve function (e.g., vision and mobility) and limb preservation; Green - no disability nor need for treatment to preserve normal function; and Black – did not survive despite interventions. After the draft COT was completed, the working group had six conference calls to discuss, revise, and refine the indicators and specifications. Prioritization was given to outcomes/interventions that would fit the triage definitions defined by the group, were easily identifiable on chart outcome, and would apply to MCI scenarios.
PHASE 3: NATIONAL FEEDBACK FROM AMERICAN ACADEMY OF PEDIATRICS DISASTER PREPAREDNESS ADVISORY COUNCIL (AAP DPAC) The COT was sent electronically to the AAP DPAC committee for review in October 2013.
PHASE 4 - SPECIFICATION OF CATEGORIES After review by the AAP DPAC, the Working Group then had two further conference calls. Phase 4 resulted in the final COT.
PHASE 5 - RELIABILITY TESTING Two reviewers (AHK and JJD) individually applied the COT to a retrospective cohort of 25 pediatric trauma cases. Only two reviewers were chosen due to the time constraints of a thorough chart review. Reviewer 1 was an emergency medicine physician with a doctoral thesis in disaster medicine and reviewer 2 was a pediatric emergency medicine fellow with prior disaster education and experience. From our existing level I trauma surgery database, 668 cases ≤14 years of age with complete prehospital data from 8/22/2010 to 11/25/2013 were available for review. This hospital has a pediatric emergency department (ED) volume of 23,000 visits per year. A weighted sample of 25 cases was selected to obtain inter-rater reliability of chart data extraction by the reviewers in each of the four triage categories. We reviewed the trauma database beginning with the most recent visits to identify: seven patients in whom the outcome was death, five patients with ISS > 24, four patients with ISS < 25 but with chesttube and/or intubation in the ED (timing of procedure not considered on initial selection), and nine other patients not meeting any of those criteria. The chart was heavily weighted towards the more injured patients as we wanted to ensure adequate inclusion in the Black and Red triage categories. The two reviewers independently reviewed electronic health records to select the
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COT triage (Red to Black) for each patient. Patient data provided to the reviewers in addition to their chart review is included in Table 1. Paramedic, ED, consultant, and all inpatient records were available to the reviewers via chart review as well. Retrospective patient data were collected and stored on Microsoft Excel for Mac 2011 version 14.1.4. Interrater reliability was determined by percentage agreement between two reviewers in each triage category and overall. Median age and median ISS were calculated for the entire retrospective pediatric cohort using Microsoft Excel. Median ISS, 25–75% interquartile ranges (IQR), and the range of ISS numbers were determined for the cohort of patients in each triage category, Red to Black.
RESULTS Initial expert consensus created a COT with 24 outcomes in the four triage categories (Appendix 1). First revision to an anatomical systems-based chart led to an increase from 24 to 59 criteria (Appendix 2). The post modified Delphi COT sent to DPAC for review contained 58 items. Three members of the committee provided specific feedback, including a recommendation to utilize a pediatric trauma activation study reference as well as to change the optimal time to operating room (OR) for a Red outcome from < 6 h to < 90 min and to combine all non-orthopedic Red OR outcomes.23 After their review, the final COT included 47 outcomes: 15 Red, 23 Yellow, one Green, and eight Black criteria (Table 2). The twenty-five patients used for reliability testing had a median age of 8 years (IQR: 4 – 12 years) and a median ISS of 19 (IQR: 4 to 35). There were seven females and 18 males. After completion of the COT, the weighted sample of 25 pediatric trauma patients showed a 100% concordance between the two reviewers in all four categories. There was no need to reach consensus, as independent application of the COT yielded the same findings. There were six Red, six Yellow, six Green, and seven Black COT patient outcomes. Table 3 describes the patients and their outcomes. Table 4 describes the median ISS of each triage category with the 25–75% IQR and range of ISS found in each group. The Red and Yellow groups had similar ISS numbers, with each group including patients with an ISS > 25.
DISCUSSION We have created a COT using patient outcomes and resource utilization to validate MCI algorithms for use in the pediatric population with high inter-rater reliability. We used a novel approach to assess the accuracy of MCI triage algorithms by directly comparing the
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predicted triage level to the outcomes-based triage level. During the development of the COT, we adopted an anatomical approach to selection of criteria. By approaching each anatomic region to determine which interventions and outcomes would specifically fall into a Red to Black category, it allowed us to add criteria we had not previously considered (e.g., treatment of compartment syndrome). Additionally, the COT addresses each of the triage categories. In contrast, the modified Baxt criteria designates only Red patients, the ISS categories were arbitrarily designated with no validation, and there is no tool to test the Black triage category. As opposed to the Baxt and modified Baxt criteria, the COT was developed with the specific intention to validate MCI algorithms; it encompasses each anatomic system, and is designed for the pediatric population.8,9 The criteria specified in the COT were specifically chosen to determine which clinical outcomes and resources would be significant in a medical system overwhelmed by an MCI. In 2015, after our development but prior to our publication of the COT, Lerner et al. created a gold standard definition for each mass casualty triage category using a modified Delphi survey.24 This tool was created to study outcomes data in adults and children, similar to the COT. Although they do have many similarities, especially in the Black and Red categorization of victims, they differ in several ways. 1) Our tool was designed for the pediatric population by pediatric disaster specialists. 2) We have specific criteria to be classifed yellow as pediatric patients are often overtriaged and single trauma patients tend to be hospitalized frequently for relatively minor injuries or observation, but might not require hospitalization in a MCI environment (e.g., a victim with an overnight intensive care stay for observation who received no interventions and had no significant injuries would be considered a Green victim in a MCI scenario based on the COT). We wanted to ensure that when considering a MCI scenario, victims who were designated Yellow truly needed to go to the hospital and victims triaged Green would have had no functional harm if they did not go to the hospital. 3) Our criteria were developed to minimize subjective interpretation to allow consistent data extraction (e.g., requiring capillary refill >3 seconds, tachycardia and hypotension corrected for age when describing poor perfusion). This likely led to a more time intensive chart review, but with the goal of better appreciation of the inherent sensitivity and specificity of the MCI triage algorithm. Neither Lerner et al. nor our COT take resource limitations into account. This may lead to some complications when applying the tools to the Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) algorithm.24
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TABLE 2.
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Category
∗
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Criteria outcomes tool Intervention/Outcome
Red
1. ICH∗ requiring immediate surgical intervention, invasive ICP∗ monitoring or mannitol/3% Saline in ED∗ 2. OR∗ < 90 minutes 3. Intubation in ED 4. Requires supportive ventilation with palpable pulse in ED: e.g., BVM∗ , intubation, extraglottic, supraglottic, and surgical airway 5. Noninvasive ventilation in ED: e.g., CPAP∗ , BiPAP ∗ 6. Emergent removal of an airway foreign body 7. More than 60 mL/kg NS∗ bolus for shock∗∗ 8. Vasopressors required in ED 9. Blood given in ED 10. Cardiac intervention with documented poor perfusion∗ : e.g., cardioversion, pacing, pharmacologic interventions 11. Chest tube/needle decompression within 2 h 12. Pericardiocentesis 13. Thoracotomy in the ED 14. Burn requiring escharotomy of chest/abdomen or airway protection 15. Administered antidote/counter measure for a life-threatening chemical or toxin exposure
Yellow
1. Ophthomology intervention other than laceration repair or OR repair within 24 h to preserve vision: e.g., lateral cathotomy or globe rupture repair 2. ENT/OMFS∗ surgical intervention (bedside or OR) to preserve functional outcome 3. Spinal injury with neurologic findings not requiring immediate operative interention (e.g., paralysis, weakness) 4. Supplemental oxygen for oxygen saturation < 94%, respiratory distress, or simple pneumothorax 5. Four or more nebulized treatments or continuous treatments 6. Cardiopulmonary monitored (e.g., ICU∗ or step down admission) bed admission for greater than 48 h 7. Two saline boluses needed: 40 mL/kg in < 6 h no matter where they are 8. Cardioversion without poor perfusion∗∗ : e.g., tachycardia unresponsive to adenosine 9. Chest tube placed after 2 h: e.g., non-tension pneumothorax 10. Go to OR in > 90 min for abdominal injury 11. Monitored bed admission for documented intra-abdominal organ injury 12. Placement of stabilization device: e.g., thoracolumbosacral orthosis or halo placement 13. Go to OR in > 90 min for spinal injury 14. Extraperitoneal bladder rupture, ureteral, or urethral injury 15. Positive cysturethrogram 16. Any genitourinary injury requiring OR repair 17. Fracture requiring closed reduction or ORIF∗ 18. Vascular injury requiring compression only 19. OR or bedside fasciotomy/escharotomy in > 90 min for limb threat from neuro vascular injury (6P’s∗ ): e.g., compartment syndrome, arterial bleeding, nerve injury 20. Open fracture requiring wash out 21. Transfer to burn center for meeting national burn center criteria 22. Hyperbaric therapy or 100% oxygen required for carbon monoxide poisoning 23. Admission for IV∗ pain control and monitoring of neurovascular status
Green
1. No poor outcome without treatment
Black
1. Decapitation 2. Brain exposed 3. Cervical spine fracture above fourth cervical vertebrae with respiratory failure 4. Apnea despite two rescue breaths 5. No pulse 6. Defibrillation 7. Transection through a non-extremity 8. Died in ED∗
ED: emergency department; ICH: intracranial hemorrhage; ICP: intracranial pressure; OR: operating room; BVM: bag valve mask; CPAP: continuous positive airway pressure; BiPAP: bilevel positive airway pressure; NS: normal saline; ENT/OMFS: otolaryngology/oral maxillary facial surgeons; ICU: intensive care unit; ORIF: open reduction internal fixation; 6P’s: pulselessness/pallor/pain out of proportion/paresthesis/paralysis/poikilothermia; IV: intravenous ∗∗ Poor perfusion/shock/hemodynamic compromise: cool mottled extremities, capillary refill > 3 sec, tachycardia > 95%, and/or hypotensive for age.
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TABLE 3.
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Patient outcome designations
Patient Number
Outcome Chart Designation
Red Category Intubated for ICH. Not apneic in field. Intubated in ED Intubated in ED for ICH. Not apneic in field Intubation for ICH. Not apneic in field. Mannitol, intubation, and OR < 90 min required for head injury with mass effect. Not apneic in field. Received blood in ED for hemorrhagic shock from liver laceration
74 135 193 165 124 109
4 31
Yellow Category 2 boluses, PICU∗ stay > 48 h, respiratory distress with hypoxia, monitored bed for documented grade 5 liver lac Chest tube placed after 2 h, PICU stay > 48 h ORIF∗ femur fracture, PICU stay > 48 h PICU stay > 48 h, admit for monitoring of splenic laceration, oxygen given in PICU for pneumothoraxes Required closed reduction of wrist to regain pulses ORIF femur fracture, ED traction
1, 2, 3, 5, 6, 40
Green Category No treatments to preserve limb or function
15 127 20 36
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2016
Black Category Apneic and hypoxemic in field requiring BVM∗ . Declared brain dead in 29 h Apneic and pulseless despite BVM, declared dead in ED∗ Apneic and pulseless in field, defibrillated in OR∗ . Died within 10 minutes of arrival to OR and within 2 h of arrival Head injury, cardiac arrest in in ED (pulseless VT∗ ), required chest compressions, defibrillation x 3 No pulse, apneic in field. Declared dead in ED Pulseless and apneic in field. Declared dead in ED Pulseless in field. In ED ROSC∗ but apneic. Declared brain dead same day
672 280 308 120 122 728 536 ∗
BVM: Bag Valve Mask, OR: Operating Room, ED: Emergency Department, VT: Ventricular Tachycardia, ROSC: Return of Spontaneous Circulation, ICH: Intracranial Hemorrhage, PICU: Pediatric Intensive Care Unit, ORIF: Open reduction Internal Fixation
The COT was developed for a direct comparison of MCI algorithms using retrospective trauma cases to identify the inherent ability of an MCI algorithm to correctly triage patients in the pediatric population. Thus far, there have been two studies comparing MCI algorithm use in the pediatric population using retrospective trauma cases.11,25 In 2006, Wallis et al. compared four MCI algorithms (Pediatric Triage Tape, Careflight, Simple Triage and Rapid Treatment, and JumpSTART systems) in children less than 13 years of age who were triaged and treated by the Red Cross Children’s Hospital in Cape Town, South Africa.11 This study applied the Garner criteria, the ISS, and the New ISS (NISS) as gold standard outcomes and found the Garner criteria to be a better measure than ISS/NISS in the Red category.
TABLE 4.
They found an ISS higher than 15 correlated well to serious injury, but commented on the lack of ability to appropriately distinguish between Yellow and Green. They did not specifically study victims with Black triage designation as many of their patients had long travel times and would have died on the way to the hospital if they were designated Black in an MCI. In 2013, Cross et al. compared six algorithms in the pediatric, adult, and geriatric population using the National Trauma Data Base to compare MCI algorithm triage assignment to mortality at discharge.25 In addition to mortality at discharge, they assessed death in the ED, use of a ventilator during hospitalization, lengths of stay in ED and hospital, and ISS. As only 10% of deaths were in the ED and there was no adjust-
Retrospective Pediatric Trauma ISS scores
Triage Category
n
Median ISS
ISS IQR
ISS Range
Red Yellow Green Black
6 6 6 7
18 19 3 43
12 to 24 13 to 25 1 to 4 40 to 55
9 to 34 10 to 34 1 to 3 25 to 57
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ment for comorbidities or age, it is difficult to discern whether the deaths after hospitalization were related to co-morbidities, such as hospital aquired pneumonia in an elderly patient. Additionally, although they assessed any ventilator use during hospitalization, they did not specifically assess ventilator use in the ED. MCI triage algorithms need to be repeatedly applied and a patient who is initially triaged as a Yellow may deteriorate into a Red status. Comparing resource utilization later in the hospital course can make MCI algorithms appear to inappropriately under-triage victims. It is not clear whether these mortalities and interventions are applicable to MCI scenarios or whether they apply to the pediatric population which has fewer comorbidities and more physiologic reserves. These difficulties are common with database extraction and it is possible that we will encounter similar difficulties when the COT is used as the gold standard to test MCI algorithms.
Future Directions Further studies are needed for validation of this tool that compare reliability across novice and non-trained users and using a greater number of patients. Further application of the COT with feasability studies may lead to a more refined and simplified tool. Application of this tool as a gold standard outcome to compare the available MCI algorithms is our next step. Additionally, the COT may be adapted for use in evaluating adult MCI triage methods.
LIMITATIONS At this time, the COT: 1) contains data that are not readily available from the trauma registry and 2) requires chart review. It is possible that future studies using retrospective chart review of pediatric trauma patients may lead to further refinement of the COT. Although the COT does require chart review, it was created in a systems-based fashion with expert opinion, using clear definitions. The COT was designed to determine an appropriate triage category based on the ultimate clinical outcome and resource utilization of the victim and not the initial triage presentation. Initial triage tools may not be able to identify all injuries, which is an inherent limitation of triage itself. Patient sample number was low and data collected were retrospective with isolated, non-MCI trauma cases. Reliability may change with larger numbers of patients and with differing disaster scenarios (e.g., involving biological or chemical exposures). The COT working group was not blinded during the revisions of indicators and specifications. This may have created a bias as members of the group knew who made each recommendation which may have re-
sulted in unintended influence on criteria selection. However, the lack of blinding led to in-depth discussions about which injuries and treatments were appropriate in each anatomical and triage designation, which would not have taken place if panel members were blinded. Additionally, both reviewers who performed the inter-rater reliability testing had prior training in disaster and triage. Thus, use of the COT by non-trained individuals may lead to lower inter-rater reliability. We found the Black triage category lent itself to subjective interpretation on chart review. Certain MCI algorithms use “apnea despite two breaths” to designate a Black patient. In non-MCI scenarios, any patient who is not breathing automatically receives bag mask ventilation and the respiratory effort is not reassessed after two breaths. We assumed that patients requiring continuous positive pressure bag valve mask ventilation in the field were apneic. Additionally, during our retrospective chart review, we noted that for some patients the paramedic information recorded in the trauma data base was incorrect. For example, one patient was apneic and pulseless in the field on EMS arrival but vital signs were still recorded. The documented vital signs were likely the compression and bagging rate. In Sundermann et al.’s 2015 study evaluting the accuracy of pre-hospital patient care reports for identification of critical resuscitation events, they found EMS patient care reports to be an inaccurate source of information for out-of-hospital cardiac arrest data.26 Furthermore, it must be taken into account that field vitals often differ greatly from the vitals upon arrival. A 2013 study of the decision making process by EMS found that estimates of vital signs such as blood pressure were inferred by EMS because many prehospital providers stated that taking vital signs is often not feasible until the patient is stabilized and a destination hospital has been selected.27 Thorough chart review of the EMS documentation allowed us to discover issues which could be lost with large scale database interpretation. This validation tool does not take into account an MCI algorithm’s ease of use or the ability of the prehospital provider to use the algorithm correctly.
CONCLUSION We created a COT based on clinical outcomes and resource utilization for use in validation of MCI algorithms in the pediatric population. Our study found a high inter-rater reliabilty for all four triage categories: Red, Yellow, Green, and Black. Additionally, we explicitly describe clear definitions for each triage designation. This tool may lead to improved scientific testing of existing and novel MCI algorithms.
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References 1. Aitken P, FitzGerald G. Disaster triage: evidence, consistency and standard practice. Emerg Med Australas. 2012 Jun;24(3):222–4. 2. Cone DC, Serra J, Burns K, MacMillan DS, Kurland L, Van Gelder C. Pilot test of the SALT Mass Casualty Triage System. Prehosp Emerg Care. 2009;13(4):536–40. 3. Cone DC. Mass-casualty Triage systems: a hint of science. Acad Emerg Med. 2005;12(8):739–41. 4. Kahn CA, Schultz CH, Miller KT, Anderson CL. Does START Triage work? an outcomes assessment after a disaster. Ann Emer Med. 2009;54(3):424–30.e1. 5. Antommaria AHM, Powell T, Miller JE, Christian MD. Ethical issues in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(Supplement):S163–8. 6. Lee CH. Clinical Pearl. Disaster and Mass Casualty Triage. Virtual Mentor. 2010;12(6):466–70. 7. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187–96. 8. Baxt WG, Upenieks V. The lack of full correlation between the Injury Severity Score and the resource needs of injured patients. Ann Emerg Med. 1990;19(12):1396–400. 9. Garner A, Lee A, Harrison K, Schultz CH. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001;38(5):541–8. 10. Challen K, Walter D. Major incident triage: Comparative validation using data from 7th July bombings. Injury, Int. J. Care Injured. 2012;44(5):629–33. 11. Wallis LA, Carley S. Comparison of paediatric major incident primary triage tools. Emerg Med J. 2006;23(6):475–8. 12. Wallis LA, Carley S. Validation of the Paediatric Triage Tape. Emerg Med J. 2006;23(1):47–50. 13. Cross KP, Cicero MX. Independent application of the Sacco disaster triage method to pediatric trauma patients. Prehosp Disaster Med. 2012;27(4):1–6. ¨ 14. Aylwin CJ, Konig TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet. 2006;368(9554):2219–25. 15. Newgard C, Fleischman R, Choo E, Ma OJ, Hedges JR, McConnell KJ. Validation of length of hospital stay as a surrogate
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measure for injury severity and resource use among injury survivors. Acad Emerg Med. 2010;17:142–50. Koziel J, Meckler, Brown L, et al. Barriers to pediatric disaster triage: a qualitative investigation. Prehosp Emerg Care. 2015;19(2):279–86. Gausche-Hill M. Pediatric disaster preparedness: are we really prepared? J Trauma. 2009;67(2):S73–6. Jones N, White ML, Tofil N, et al. Randomized trial comparing two mass casualty triage systems (JumpSTART versus SALT) in a pediatric simulated mass casualty event. Prehosp Emerg Care. 2014;18(3):417–23. Cicero MX, Brown L, Overly F, et al. Creation and Delphimethod Refinement of Pediatric Disaster Triage Simulations. Prehosp Emerg Care. 2014;18(2):282–9. Kilner TM, Brace SJ, Cooke MW, Stallard N, Bleetman A, Perkins GD. In “big bang” major incidents do triage tools accurately predict clinical priority?: a systematic review of the literature. Injury, Int. J. Care Injured. 2011;42(5):460– 8. Lindsay P, Schull M, Bronskill S, Anderson G. The development of indicators to measure the quality of clinical care in emergency departments following a modified-delphi approach. Acad Emerg Med. 2002;9(11):1131–9. Gebhart ME, Pence R. START triage: Does it work? Disaster Manag Response. 2007;5(3):68–73. Falcone RA Jr., Haas L, King E, et al. A multicenter prospective analysis of pediatric trauma activation criteria routinely used in addition to the six criteria of the American College of Surgeons. J Trauma Acute Care Surg. 2012;73(2):377–84. Lerner EB, McKee CH, Cady CE, et al. A consensus-based gold standard for the evaulation of mass casualty triage systems. Prehosp Emerg Care. 2015;19(2):267–71. Cross KP, Cicero MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61(6):668–76.e7. Sundermann ML, Salcido DD, Koller AC, Menegazzi JJ. Inaccuracy of patient care reports for identification of critical resuscitation events during out-of-hospital cardiac arrest. Am J of Emerg Med. 2015;33(1):95–99. Jones CM, Cushman JT, Lerner EB, et al. Prehospital trauma triage decision making: A model of what happens between the 9-1-1 call and the hospital. Prehosp Emerg Care. Published Online: May 27, 2015 (doi: 10.3109/10903127.2015.102 5157)
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APPENDIX 1. Initial Expert Derived Criteria Red
Non-orthopedic OR∗ within 6 h
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IVF∗ > 40 mL/kg to keep SBP∗ > 90 (or 2xage + 70) Intracranial hemorrhage Assisted ventilation or procedure to maintain airway Relief of tension pneumothorax
Acute hemorrhage with tourniquet or suture placed Cyanide antidote given Hyperbaric therapy initiated Burn > 20% TBSA ∗
Yellow
Hospitalized but not fulfilling and intermediate criteria (not including purely social admissions) Non ortho OR∗ > 6 h
Green
Black
Ambulatory at scene
Pulselessness
No hospitalization required
Rigor/lividity
Ortho OR < 6 h More than 1 h oxygen required
Burn > 90% TBSA∗ Died in ED∗
Parental medication in ED in excess of single dose of pain medication or vaccination More than 1 nebulized medication More than 24 h IVF
ISS∗ > 25
Decapitation/transection through torso
IVF Intravenous fluid, SBP systolic blood pressure, ortho orthopedic, OR operating room, TBSA total body surface area, ISS Injury Severity Score
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APPENDIX 2. Initial systems based categorization
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Red
Yellow
Green
Black
Body part
Life Saving Intervention/outcome
Intervention/ outcome
Intervention/ Outcome
Injury
Head/Neck
• ICH∗ requiring immediate OR∗ intervention, ICP∗ monitoring or mannitol/3% NS∗ in ED∗ • OR required < 6 h for pending airway/lifesaving: e.g., Le Fort 3 • Intubation
• Ophthomology intervention
• Nothing
• Decapitation
• ENT/OMFS∗ surgical intervention (bedside or OR)
• Topical tx
• Brain exposed
• Thoracic or lumbar spine injury with neurologic findings (e.g., paralysis, weakness)
• Torsion of neck (deformity incompatible with life)
• Requires supportive ventilation with palpable pulse: extraglottic, supraglottic, and surgical airway • OR in < 6 h for potential life/airway saving intervention: vascular injury, airway compromise • Emergent removal of a foreign body
• Nonrebreather
• Apnea despite two rescue breaths
• NS∗ bolus and documented hypotension corrected for age
• Cardiopulmonary monitored (e.g., ICU∗ or step down admission) bed admission for greater than 48 h • 3 NS boluses needed: 60 mL/kg in less than 6 h no matter where they are • Cardioversion without poor perfusion
• Cervical spine injury with neurologic findings (e.g/ paralysis, weakness) Airway/Breathing
Circulation/Cardiac
• Pressors required • Blood in ED • Measures required to stop life/limb threatening bleed: e.g., pressure, tourniquet, surgery, sutures • Cardiac intervention with documented poor perfusions (decreased cap refill, decreased pulses, altered mental status): e.g., cardioversion, pacing, atropine, adenosine Chest
• Chest needle decompression • Chest tube placed within 2 h • Pericardiocentesis • Thoracotomy in the emergency department • Intubation • OR < 6 h
• NC∗ O2
• > 1 nebulized treatment • Nonsupportive ventilation: CPAP∗ , BiPAP∗
• Admit IV∗ pain control and monitoring • Chest tube placed after 2h
• No pulse
• Defibrillation
• Transection through torso
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APPENDIX 2. Initial systems based categorization Red
Abdomen
• OR < 6 h (organ injury scaling 3 or higher)
Yellow
• Go to OR > 6 h
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• Receive blood in the ED∗
Green
• Repair by ED not requiring procedural sedation • Admit for monitoring
Back/spine
• OR < 6 h
GU
• OR < 6 h for intraperitoneal injury (eg bladder rupture, grade 5 renal injury)
• Extraperitoneal bladder rupture, ureteral, or urethral injury
• Measures required to stop life/limb threatening bleed: e.g., pressure, tourniquet, surgery, sutures • Blood in ED
• Reduction in ED
• Casting in ED → home
• Orthopedic OR
• Reduced in ED → home • Repair by ED doc
Extremities
Others
∗
• Burn requiring escharotomy or airway protection • Cyanide antidote given
• Transection
• Positive cysturethrogram • OR surgery > 6 h
• OR or bedside fasciotomy or escharotomy < 6 h for limb threat from neuro vascular injury (6P’s∗ ): e.g., compartment syndrome, arterial bleeding, nerve injury Skin
Black
• Transfer to burn center or clinic • Procedural sedation
• Died in ED
• Hyperbaric therapy required
• ISS∗ > 24 • Transferred to OR within 2 h and died in OR
ICH: intracranial hemorrhage, OR: operating room, ICP: intracranial pressure, NS: normal saline, ED: emergency department, ENT/OMFS: otolaryngology/oral maxillary facial surgeons, NC: nasal canula, CPAP: continuous positive airway pressure, BiPAP: bilevel positive airway pressure, ICU: intensive care unit, IV: intravenous, 6P’s: pulselessness/pallor/pain out of proportion/paresthesis/paralysis/poikilothermia, ISS: injury severity scale
