Paramedic Accuracy Using SALT Triage After a Brief Initial Training

Abstract

Objective. To determine paramedics’ understanding of and accuracy using SALT (sort–assess–lifesaving interventions–treatment/transport) triage, a proposed national guideline for primary triage during mass-casualty incidents, immediately and four months after training. Methods. A 20-minute lecture on SALT triage was provided to all paramedics (n = 320) from a single county during mandatory continuing education. Triage concepts were reemphasized during a 10-minute small-group lecture throughout the study period as part of standard refresher training. After the initial training, all paramedics were asked to complete a posttest consisting of three general knowledge questions about SALT triage and 10 patient scenarios in which they had to assign a triage category. The same test was administered four months after the original educational session. Demographic and job experience information was also obtained. Responses were scored and matched for each paramedic and compared using paired t-test. Results. A total of 290 (91%) paramedics completed the initial posttest. They correctly answered an average (± standard deviation) of 10.7 ± 2.3 of the 13 questions (82%). For the 10 patient scenarios, they correctly triaged an average of 8.1 ± 2.0 patients. A total of 159 paramedics completed both tests. Sixty-seven percent had more than 10 years of emergency medical services (EMS) experience; 72% had prior mass-casualty drill experience; 51% had prior actual mass-casualty experience; and 23% had heard of SALT triage prior to the training. There were no statistically significant differences in initial test scores for any of these demographic groups. For those subjects who completed both tests, the mean overall score for the initial test was 10.9 ± 1.9 (84%) and for the later test was 11.0 ± 1.9 (85%) (p < 0.770; 95% confidence interval [CI] –0.3 to 0.3). For the 10 patient scenarios, the paramedics correctly triaged an average of 8.3 ± 1.7 patients on the initial test and 8.3 ±1.4 patients on the later test (p < 0.565; 95% CI –0.4 to 0.2). Conclusion. Following a short didactic course, paramedics were able to accurately perform SALT triage during a written scenario. Four months after the training, they had retained their understanding of and accuracy using SALT triage. It appears that a brief educational tool was effective for training EMS providers in SALT triage.     

Pilot Test of a Proposed Chemical/Biological/Radiation/ Nuclear-Capable Mass Casualty Triage System

Introduction. Existing mass casualty triage systems do not consider the possibility of chemical, biological, or radiologic/nuclear (CBRN) contamination of the injured patients. A system that can triage injured patients who are or may be contaminated by CBRN material, developed through expert opinion, was pilot-tested at an airport disaster drill. The study objective was to determine the system's speed andaccuracy. Methods. For a drill involving a plane crash with release of organophosphate material from the cargo hold, 56 patient scenarios were generated, with some involving signs andsymptoms of organophosphate toxicity in addition to physical trauma. Prior to the drill, the investigators examined each scenario to determine the “correct” triage categorization, assuming proper application of the proposed system, andtrained the paramedics who were expected to serve as triage officers at the drill. During the drill, the medics used the CBRN triage system to triage the 56 patients, with two observers timing andrecording the events of the triage process. The IRB deemed the study exempt from full review. Results. The two triage officers applied the CBRN system correctly to 49 of the 56 patients (87.5% accuracy). One patient intended to be T2 (yellow) was triaged as T1 (red), for an over-triage rate of 1.8%. Five patients intended to be T1 were triaged as T2, andone patient intended to be T2 was triaged as T3 (green), for an under-triage rate of 10.7%. All six under-triage cases were due to failure to recognize or account for signs of organophosphate toxidrome in applying the triage system. For the 27 patients for whom times were recorded, triage was accomplished in a mean of 19 seconds (range 4-37, median 17). Conclusions. The chemical algorithm of the proposed CBRN-capable mass casualty triage system can be applied rapidly by trained paramedics, but a significant under-triage rate (10.7%) was seen in this pilot test. Further refinement andtesting are needed, andeffect on outcome must be studied.     

Remote Scene Size-up Using an Unmanned Aerial Vehicle in a Simulated Mass Casualty Incident

Introduction: The scene-size-up is a crucial first step in the response to a mass casualty incident (MCI). Unmanned aerial vehicles (UAV) may potentially enhance the scene-size-up with real-time visual feedback during chaotic, evolving or inaccessible events. We performed this study to test the feasibility of paramedics using UAV video from a simulated MCI to identify scene hazards, initiate patient triage, and designate key operational locations.

Methods: We simulated an MCI, including 15 patients plus 4 hazards, on a college campus. A UAV surveyed the scene, capturing video of all patients, hazards, surrounding buildings and streets. We invited attendees of a provincial paramedic meeting to participate. Participants received a lecture on Sort-Assess-Lifesaving Interventions-Treatment/Transport (SALT) Triage and MCI scene management principles. Next, they watched the UAV video footage. We directed participants to sort patients according to SALT Triage Step One, identify injuries, and to localize the patients within the campus. Additionally, we asked them to select a start point for SALT Triage Step Two, identify and locate hazards, and designate locations for an Incident Command Post, Treatment Area, Transport Area and Access/Egress routes. The primary outcome was the number of correctly allocated triage scores.

Results: Ninety-six individuals participated. Mean age was 35 years (SD 11); 46% (44) were female and 49% (47) were Primary Care Paramedics. Most participants (79; 82%) correctly sorted at least 12 of 15 patients. Increased age was associated with decreased triage accuracy [?0.04(?0.07, ?0.01); p?=?0.031]. Fifty-two (54%) correctly localized 12 or more patients to a 27?×?20m grid area. Advanced paramedic certification, and local residency were associated with improved patient localization [2.47(0.23,4.72); p?=?0.031], [3.36(1.10,5.61); p?=?0.004]. The majority of participants (70; 81%) chose an acceptable location to start SALT Triage Step Two and 75 (78%) identified at least 3 of 4 hazards. Approximately half (53; 56%) of participants appropriately designated 4 or more of 5 key operational areas.

Conclusion: This study demonstrates the ability of UAV technology to remotely facilitate the scene size-up in an MCI. Additional research is required to further investigate optimal strategies to deploy UAVs in this context.     

Effects of a Triage Process Conversion on the Triage of High‐risk Presentations

Objectives: The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time‐sensitive therapy. Methods: The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time‐sensitive care. Results: There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain. Conclusions: Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time‐sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored.     

FAST Ultrasound as an Adjunct to Triage Using the START Mass Casualty Triage System:

Objective. To determine whether the FAST examination might be a useful adjunct to simple triage andrapid treatment (START) in the secondary triage of mass-casualty victims already classified as delayed (Yellow). Methods. A retrospective chart review was conducted of all adult trauma patients evaluated by the trauma surgery service at a level 1 trauma center between January 1 andDecember 31, 2003. Patients were retrospectively triaged to one of three START categories: immediate (Red), delayed (Yellow), or expectant (Black). The FAST results were obtained from the medical records. Results. FAST results were available for 359 patients, of which 27 were classified as positive. Twenty (6.9%) of 286 patients retrospectively triaged as delayed (Yellow) had positive FAST studies. Of these, six underwent operative intervention within 24 hours of arrival. A total of 232 patients had both FAST andcomputed tomography (CT) studies performed, of which 19 FAST studies were inconclusive. In the remaining 213 patients, six of 27 had falsely positive studies, while 24 of 186 had falsely negative studies. Conclusions. Portable ultrasound technology might have identified 20 delayed (Yellow) patients with evidence of hemoperitoneum, thereby expediting evacuation to definitive care. However, only 30% of these patients subsequently underwent an operative intervention within 24 hours of arrival. Both over- andundertriage were significant problems. As such, the current study does not support the routine use of FAST ultrasound as a secondary triage tool.     

Teaching Resource for Instructors in Prehospital Pediatrics (TRIPP): Basic Life Support,Second Edition

Abstract

Introduction. Accuracy and effectiveness analyses of mass casualty triage systems are limited because there are no gold standard definitions for each of the triage categories. Until there is agreement on which patients should be identified by each triage category, it will be impossible to calculate sensitivity and specificity or to compare accuracy between triage systems. Objective. To develop a consensus-based, functional gold standard definition for each mass casualty triage category. Methods. National experts were recruited through the lead investigators’ contacts and their suggested contacts. Key informant interviews were conducted to develop a list of potential criteria for defining each triage category. Panelists were interviewed in order of their availability until redundancy of themes was achieved. Panelists were blinded to each other's responses during the interviews. A modified Delphi survey was developed with the potential criteria identified during the interview and delivered to all recruited experts. In the early rounds, panelists could add, remove, or modify criteria. In the final rounds edits were made to the criteria until at least 80% agreement was achieved. Results. Thirteen national and local experts were recruited to participate in the project. Six interviews were conducted. Three rounds of voting were performed, with 12 panelists participating in the first round, 12 in the second round, and 13 in the third round. After the first two rounds, the criteria were modified according to respondent suggestions. In the final round, over 90% agreement was achieved for all but one criterion. A single e-mail vote was conducted on edits to the final criterion and consensus was achieved. Conclusion. A consensus-based, functional gold standard definition for each mass casualty triage category was developed. These gold standard definitions can be used to evaluate the accuracy of mass casualty triage systems after an actual incident, during training, or for research.     

GPS Devices in a Simulated Mass Casualty Event

Objective: The aim of this study was to assess the staff perception of a global positioning system (GPS) as a patient tracking tool at an emergency department (ED) receiving patients from a simulated mass casualty event. Methods: During a regional airport disaster drill a plane crash with 46 pediatric patients was simulated. Personnel from airport fire, municipal fire, law enforcement, emergency medical services, and emergency medicine departments were present. Twenty of the 46 patient actors required transport for medical evaluation, and we affixed GPS devices to 12 of these actors. At the hospital, ED staff including attending physicians, fellows and nurses working in the ED during the time of the drill accessed a map through an application that provided real-time geolocation of these devices. The primary outcome was staff reception of the GPS device as assessed via Likert scale survey after the event. The secondary outcomes were free text feedback from staff and event debriefing observations. Results: Queried registered nurses, attending physicians, and pediatric emergency medicine fellows perceived the GPS device as an advantage for patient care during a disaster. The GPS device allowed multiple-screen real-time tracking and improved situational awareness in cases with and without EMS radio communication prior to arrival at the hospital. Conclusion: ED staff reported that the use of GPS trackers in a disaster improved real-time tracking and could potentially improve patient management during a mass casualty event.     

Reliability of a Computerized Version of the Pediatric Canadian Triage and Acuity Scale

Background: The use of a standardized triage tool allows better comparison of the patients; a computerized version could theoretically improve its reliability.
Objectives: To compare the interrater agreement of the Pediatric Canadian Triage and Acuity Scale (PedCTAS) and a computerized version (Staturg).
Methods: A two-phase experimental study was conducted to compare the interrater agreement between nurses assigning triage level to written case scenarios using either traditional PedCTAS or Staturg. Participants were nurses with at least one year of experience in pediatric emergency medicine and trained at triage. Each of the 54 scenarios was evaluated first by all nurses using either one of the strategies. Four weeks later, they evaluated the same scenarios using the other tool. The primary outcome was the interrater agreement measured using κ score.
Results: Eighteen of the 29 eligible nurses participated in the study. The computerized triage tool showed a better interrater agreement, with a Staturg κ score of 0.55 (95% confidence interval = 0.53 to 0.57) versus a PedCTAS κ score of 0.51 (95% confidence interval = 0.49 to 0.53). The computerized version was also associated with higher agreements for scenarios describing patients with the highest severity of triage (κ score of 0.72 vs. 0.55 for level 1; κ score of 0.70 vs. 0.51 for level 2).
Conclusions: A computerized version of the PedCTAS showed a statistically significant improvement in the interrater agreement for nurses evaluating the triage level of 54 clinical scenarios, but this difference has probably small clinical significance.     

Disaster triage tags: Is one better than another?

Objective: To determine which of the disaster triage tag systems in use in Australia and New Zealand is better in terms of the time taken to complete the triage and the ease of use. Methods: A disaster scenario was created. Mock patients were provided with clinical information to allow them to be triaged in a disaster sieve. Six different triage tag systems available in Australia and New Zealand were trialled. Participants triaged 10 patients with each triage tag system. The 10 patients used were different for each of the tag systems and were standardized for acuity and triage category. The time to complete the triage of the 10 patients with each different tag system was measured. The participants then completed a questionnaire with regards to the ease of use of the different tags and were asked to nominate their most preferred tag. Results: The Victorian cruciate fold up tag was the quickest to complete, with an average of 6.6 min to triage 10 patients, compared with an average time for all systems of 7.8 min. New Zealand tags were found to be the easiest to use, easiest to fill in and were considered the most preferred tag. Conclusion: The Victorian style of tag was found to be the most efficient in terms of the time to complete a triage. The New Zealand tags were the easiest to use, easiest to fill in and the most preferred tag by the participants. We recommend that one of these tags be adapted for use as a nationwide system.     

Comparison of Triage Assessments among Pediatric Registered Nurses and Pediatric Emergency Physicians

OBJECTIVES: To compare triage level assignments, using simulated written case scenarios, in a pediatric emergency department (ED) among registered nurses (RNs) and pediatric emergency physicians (PEPs) and to compare the triage level assignments among RNs and PEPs with a consensus criterion standard. METHODS: This was a cross-sectional mailed questionnaire survey. The study was conducted at a pediatric tertiary care center with more than 65,000 annual patient visits. Participants were PEPs and RNs working in the ED. Dillman's Total Design Method, with three mailouts, was used for questionnaire construction and implementation. The survey included 55 case scenarios of patients presenting to the ED. Participants were instructed to assign triage level on each case, using the following four-level triage scale: 1 = resuscitation/emergent, 2 = urgent, 3 = less-urgent, and 4 = non-urgent. A priori, all cases were assigned a triage level by consensus agreement of three PEPs, using established triage guidelines from the RNs' teaching manual. Kappa statistics (95% CI) and the mean percentage of correct responses (+/-1 SD) were calculated. RESULTS: There was a 100% response rate (39 RNs, 24 PEPs). The kappa level of agreement (95% CI) was 0.453 (0.447 to 0.459) among the RNs and was 0.419 (0.409 to 0.429) among the PEPs. The mean percentage of correct responses (+/-1 SD) for the RNs was 64.2% (+/-8.0%) and for the PEPs was 53.5% (+/-8.1%, p < 0.01). There was no significant difference within groups by experience level (< 10 vs. > or =10 years) or by the type of work schedule (day vs. evening vs. overnight) or full-time vs. part-time status. CONCLUSIONS: The level of agreement and accuracy of triage assignment was only moderate for both RNs and PEPs. Triage, a crucial step in emergency care, requires improved measurement.     

Trauma Triage: Concepts in Prehospital Trauma Care

This report examines the efficacy of current trauma triage rules to determine the exigency of field care andtransport of severely injured patients from a variety of medical populations.     

Improved Pediatric Patient Flow in a General Emergency Department by Altering Triage Criteria

Objective: To evaluate the effect of altering pediatric triage criteria on ED triage scoring and patient flow.
Methods: A prospective observational study of a pediatric triage modification was performed. Data for all pediatric patients presenting to an urban general ED during a six-month study period were collected. After the first three months, pediatric triage criteria were altered by elevating the acuity of several historical items and specifically listing abnormal signs and symptoms. Outcome measures included triage score assignment, criteria making the patient emergent, proportion of emergent or urgent triage assignments, and times to examination, disposition, and admission.
Results: Altering pediatric triage criteria resulted in a significant (p < 0.05) increase in the number of patients triaged as emergent (2% vs 15%) or urgent (48% vs 55%). In addition, for emergent and urgent patients there was a significant decrease (p < 0.05) in the mean times to ED examination (50 vs 44 min), floor admission (355 vs 245 min), and intensive care unit admission (221 vs 132 min). The triage changes that had a significant impact on these results were a history of color change, decreased activity, and prematurity with complications.
Conclusions: A significant improvement in pediatric patient flow occurred after posting age-specific abnormal signs and symptoms as well as elevating triage acuity for specific historical clues.     

Role of Guideline Adherence in Improving Field Triage

Objective: To compare the sensitivity of current field triage practices for identifying high-risk trauma patients to strict guideline adherence, including changes in triage specificity, ambulance transport patterns, and trauma center volumes. Methods: This was a pre-planned secondary analysis of an out-of-hospital prospective cohort of injured children and adults transported by 44 EMS agencies to 28 trauma and non-trauma hospitals in 7 Northwest U.S. counties from January 1, 2011 through December 31, 2011. Outcomes included Injury Severity Score (ISS) ≥16 (primary) and early critical resource use. Strict adherence of the triage guidelines was based on evidence in the EMS chart for patients meeting any current field triage criteria, calculated with and without strict interpretation of the age criterion (<15 or >55 years). Due to the probability sampling nature of the cohort, strata and weights were included in all analyses. Results: 17,633 injured patients were transported by EMS (weighted to represent 53,487 transported patients), including 3.1% with ISS ≥16 and 1.7% requiring early critical resources. Field triage sensitivity for identifying patients with ISS ≥16 increased from the current 66.2% (95% CI 60.2–71.7%) to 87.3% (95% CI 81.9–91.2%) for strict adherence without age and to 91.0% (95% CI 86.4–94.2%) for strict adherence with age. Specificity decreased with increasing adherence, from 87.8% (current) to 47.6% (strict adherence without age) and 35.8% (strict adherence with age). Areas under the curve (AUC) were 0.78, 0.73, and 0.72, respectively. Results were similar for patients requiring early critical resources. We estimate the number of triage-positive patients transported each year by EMS to an individual major trauma center (on average) to increase from 1,331 (current) to 5,139 (strict adherence without age) and to 6,256 (strict adherence with age). Conclusions: The low sensitivity of current triage practices would be expected to improve with strict adherence to current triage guidelines, with a commensurate decrease in triage specificity and an increase in the number of triage-positive patients transported to major trauma centers.     

Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital

We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.     

Precise Formulation and Evidence-based Application of Resource-constrained Triage

Objectives: To develop a precise mathematical formulation of resource‐constrained triage, denoted the Sacco triage method (STM), to develop an evidence‐based application to blunt trauma, and to compare the STM with the simple triage and rapid treatment (START) method. Methods: Resource‐constrained triage is modeled mathematically as a classic resource allocation problem. The objective is to maximize expected survivors given constraints on the timing and availability of resources. The model incorporates estimates of time‐dependent victim survival probabilities based on an initial assessment and expected deterioration. For application to blunt trauma, an “RPM” score, based on r espiratory rate, p ulse rate, and m otor response, was used to predict survivability. Logistic function‐generated survival probability estimates for scene values of RPM were determined from 76,459 blunt‐injured patients from the Pennsylvania Trauma Outcome Study (PTOS). The Delphi method provided expert consensus on victim deterioration rates, and the model was solved using linear programming. STM was compared with START across various criteria of process and outcome. Outcome was measured by expected number of survivors in simulated resource‐constrained casualty incidents. Results: In this mathematical simulation, RPM was a more accurate predictor of survivability from blunt trauma than the Injury Severity Score and the Revised Trauma Score, as measured by calibration and discrimination statistics. STM resulted in greater expected survivorship than START in all simulations. Conclusions: Resource‐constrained triage is modeled precisely as an evidence‐based, outcome‐driven method that maximizes expected survivors in consideration of resources. The lifesaving potential and operational advantages over current methods warrant scrutiny and further research.     

Implementation of Prehospital Dispatch Protocols That Triage Low-acuity Patients to Advice-line Nurses

Abstract

Introduction. Although EMS agencies have been designed to efficiently provide medical assistance to individuals, the overuse of 9-1-1 as an alternative to primary medical care has resulted in the need for new methods to respond to this increasing demand. Our study analyzes the efficacy of classifying specific low-acuity calls that can be transferred to an advice-line nurse for further medical instruction. The objectives of our study were to analyze the impact of implementing this protocol and resultant patient feedback regarding the transfer to an advice-line nurse. Methods. We collected data for retrospective review from April 2011 to April 2012 from a single municipal EMS agency with an average annual call volume of approximately 90,000. Medical Priority Dispatch System response codes were assigned to calls based on patient acuity. Patients classified under Omega response codes were assessed for eligibility of transfer to nurse advice lines. Exclusion criteria included the following: if the call was placed by a third-party caller; if the patient refused to be transferred to the advice-line nurse; anytime the MPDS system was not used; if the patient was referred from a skilled nursing facility, school, or university nursing office, or physician's office. Telephone surveys were conducted for those patients who spoke to an advice-line nurse and did not receive an ambulance response 24 hours after calling 9-1-1 to obtain patient feedback. Results. The database included 1660 patients initially classified as Omega and eligible for transfer to an advice-line nurse. After applying the exclusion criteria, 329 (19.8%) patients were ultimately transferred to an advice-line nurse and 204 (12.3%) received no ambulance response. Of those patients who were not transported by ambulance 118 (57.8%), patients completed telephone follow-up, with 104 (88.1%) reporting the nontransport option met their health-care needs and 108 (91.5%) responding they would accept the transfer again for a similar complaint. Conclusion. We identified an average of two patients per day as eligible for transfer to the nurse advice line, with less than one patient successfully completing the Omega protocol per day. While impact was limited, there was a decrease in ambulance response.