A better START for low-acuity victims: data-driven refinement of mass casualty triage.
Prehospital Emergency Care · 2014-08-25 · Method & validation
Abstract
OBJECTIVE: Methods currently used to triage patients from mass casualty events have a sparse evidence basis. The objective of this project was to assess gaps of the widely used Simple Triage and Rapid Transport (START) algorithm using a large database when it is used to triage low-acuity patients. Subsequently, we developed and tested evidenced-based improvements to START. METHODS: Using the National Trauma Database (NTDB), a large set of trauma victims were assigned START triage levels, which were then compared to recorded patient mortality outcomes using area under the receiver-operator curve (AUC). Subjects assigned to the "Minor/Green" level who nevertheless died prior to hospital discharge were considered mistriaged. Recursive partitioning identified factors associated with of these mistriaged patients. These factors were then used to develop candidate START models of improved triage, whose overall performance was then re-evaluated using data from the NTDB. This process of evaluating performance, identifying errors, and further adjusting candidate models was repeated iteratively. RESULTS: The study included 322,162 subjects assigned to "Minor/Green" of which 2,046 died before hospital discharge. Age was the primary predictor of under-triage by START. Candidate models which re-assigned patients from the "Minor/Green" triage level to the "Delayed/Yellow" triage level based on age (either for patients >60 or >75), reduced mortality in the "Minor/Green" group from 0.6% to 0.1% and 0.3%, respectively. These candidate START models also showed net improvement in the AUC for predicting mortality overall and in select subgroups. CONCLUSION: In this research model using trauma registry data, most START under-triage errors occurred in elderly patients. Overall START accuracy was improved by placing elderly but otherwise minimally injured-mass casualty victims into a higher risk triage level. Alternatively, such patients would be candidates for closer monitoring at the scene or expedited transport ahead of other, younger "Minor/Green" victims.
Abstract © the authors or publisher, via PubMed. Reuse and removal
Tags
Mortality & survival · Older adults · Triage instruments
Related articles
- Pre-hospital triage performance and emergency medical services nurse's field assessment in an unselected patient population attended to by the emergency medical services: a prospective observational study. (Scand J Trauma Resusc Emerg Med, 2020)
- Traumatic Spinal Cord Injury Emergency Service Triage Patterns and the Associated Emergency Department Outcomes. (J Neurotrauma, 2015)
- Evaluating pre-hospital triage and decision-making in patients who died within 30 days post-trauma: A multi-site, multi-center, cohort study. (Injury, 2022)
- Comparison of START triage categories to emergency department triage levels to determine need for urgent care and to predict hospitalization. (Am J Disaster Med, 2015)
- Out-of-Hospital Triage of Older Adults With Head Injury: A Retrospective Study of the Effect of Adding "Anticoagulation or Antiplatelet Medication Use" as a Criterion. (Ann Emerg Med, 2017)
- Development of Data-Driven Triage Systems for Identifying Mortally Wounded Casualties-Implications for Future Large-Scale Combat Operations. (Med J (Ft Sam Houst Tex), 2022)