Mass Casualty Triage Research Articles

Mass Casualty Triage: An Evaluation of the Science and Refinement of a National Guideline

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

‘Just send them all to a burn centre’: Managing burn resources in a mass casualty incident

Burn experts estimate that 20–30 per cent of injuries from mass casualty events result in serious burns, many requiring specialised care only available at burn centres. Yet, in the USA there are less then 1,850 burn beds available to provide such a level and quality of care. To address this concern, burn centres are beginning to put into practice new mass casualty triage and transport guidelines that must coordinate with local, regional and federal response plans, while still adhering to an accepted standard of care. This presentation describes how one US burn centre developed and implemented a Homeland Security Exercise and Evaluation Program (HSEEP) designed mass casualty incident (MCI) exercise focused on coordinating ‘the right patient to the right facility at the right time’, based upon acuity and bed availability. Discussion will enable planners to identify methodologies adaptable for incorporation into catastrophic emergency management operations within their regions.

A survey of the practice of nurses’ skills in Wenchuan earthquake disaster sites: implications for disaster training

To determine nursing skills most relevant for nurses participating in disaster response medical teams; make recommendations to enhance training of nurses who will be first responders to a disaster site; to improve the capacity of nurses to prepare and respond to severe natural disasters. Worldwide, nurses play a key role in disaster response teams at disaster sites. They are often not prepared for the challenges of dealing with mass casualties; little research exists into what basic nursing skills are required by nurses who are first responders to a disaster situation. This study assessed the most relevant disaster nursing skills of first responder nurses at the 2008 Wenchuan earthquake disaster site. Data were collected in China in 2008 using a self-designed questionnaire, with 24 participants who had been part of the medical teams that were dispatched to the disaster sites. The top three skills essential for nurses were: intravenous insertion; observation and monitoring; mass casualty triage. The three most frequently used skills were: debridement and dressing; observation and monitoring; intravenous insertion. The three skills performed most proficiently were: intravenous insertion; observation and monitoring; urethral catheterization. The top three ranking skills most important for training were: mass casualty transportation; emergency management; haemostasis, bandaging, fixation, manual handling. The core nursing skills for disaster response training are: mass casualty transportation; emergency management; haemostasis, bandaging, fixation, manual handling; observation and monitoring; mass casualty triage; controlling specific infection; psychological crisis intervention; cardiopulmonary resuscitation; debridement and dressing; central venous catheter insertion; patient care recording.

(P2-93) Triage During a Mass Casualty Incident: The 2009 Turkish Airlines Crash in Amsterdam

IntroductionTriage is an important aspect of the management of mass-casualty incidents (MCIs). This study evaluates triage after the Turkish Airlines aircraft crash near Amsterdam in 2009. What were the results of triage? What were the injuries of priority 3, and of “walking” casualties? Did the mechanism of trauma have a factor in this mass-casualty triage? How does this affect spinal immobilization rate during transport?MethodsA retrospective analysis of investigational reports, ambulance forms, and medical charts of survivors of the crash was performed. Outcomes included triage classification, type of injury, Abbreviated Injury Scale (AIS) score, Injury Severity Scale (ISS) score, need for emergency intervention according to the “Baxt criteria”, and spinal immobilization during transport.ResultsThere was minimal documentation of prehospital triage. According to the in-hospital triage, 28% of patients were priority 1, 10% had an ISS score ≥ 16, and 3% met the Baxt criteria for emergency intervention. Forty percent were priority 3, 72% had an ISS score ≤ 8, and 63% were discharged from the emergency department. Approximately 83% were over-triaged, and the critical mortality rate was 0%. Nine percent of priority 3 casualties. and 17% of “walking” casualties had serious injuries. Twenty-five percent of all casualties were transported with spinal immobilization; 22% of patients with diagnosed spinal injury were not transported with spinal immobilization.ConclusionsAfter the Turkish Airlines crash, documentation of triage was minimal. According to the Baxt criteria, there was a great amount of over-triage. Possible injuries sustained by plane crash survivors that seem minimally harmed (P3) must not be underestimated. Considering spinal immobilization, Not insufficient consideration given the high-energy trauma mechanism.

(A47) Pediatric Mass-Casualty Triage: The New York City Approach

IntroductionA Mass-Casualty Event (MCE) involving pediatric victims could overwhelm existing pediatric resources. Therefore, early recognition of critically ill infants and children is essential for proper distribution among pediatric capable hospitals. However, emergency medical services (EMS) personnel have limited experience with pediatric assessments, and less with pediatric mass-casualty triage (MCT). To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) in collaboration with the Fire Department (FDNY) and Office of Emergency Management, made simple alterations to the START-based NYC-MCT Algorithm that can be rapidly and accurately applied by EMS personnel in the field with minimal additional education and preparation, obviating the requirement for extensive and expensive retraining.MethodsThe PDC includes experts in pediatric emergency preparedness, emergency medicine, critical care, and trauma surgery in NYC, as well as DOHMH, FDNY-OMA, and OEM. Its Triage Subcommittee determined the minimum essential pediatric alterations to the Algorithm, which then was tested by FDNY-EMS.ResultsAfter focused literature review and multiple draft revisions aimed to maximize pediatric benefit yet minimize unnecessary complexity, the Algorithm was modified to ensure that: (1) five rescue breaths will be provided to infants or children prior to being categorized as Dead or Expectant; (2) infants under 12 months old will be categorized as Critical and receive priority transport, and (3) children initially categorized as Delayed or Minor will be uptriaged to a new Urgent (Orange) category to receive such care in a rapid manner. To date, > 3,000 FDNY personnel have been trained in its use, and tested its accuracy using tabletop scenarios. Mean accuracy is 80–90%.ConclusionsThe model is an effective, multidisciplinary approach to planning. Minimum alterations to the Algorithm were adopted by the regional EMS system. The Modified Algorithm improves identification of critically ill infants and children. This approach could be adopted by other large urban centers.

Triage in Mass-Casualty Events: The Haitian Experience

Mass-casualty triage is implemented when available resources are insufficient to meet the needs of all patients in a disaster situation. The basic principle is to do the maximum good for the most casualties with the least amount of resources. There are limited data to support the applicability of this principle in massive disasters such as the January 2010 earthquake in Haiti, in which the number of patients seeking medical attention overwhelmed the local resources. To analyze the application of a triage system developed for use in a mass-casualty setting with limited resources. The system was designed to admit only those patients who had medical conditions requiring urgent treatment that were within the capabilities of the hospital and had a good chance of survival after discharge. Priority was given to those whose treatment could be administered within a short hospital stay. A retrospective, observational review of computerized registration forms of Haitian earthquake victims who sought medical care at a 72-bed field hospital within four to 14 days after the event. An analysis of the efficacy of the triage protocol that was used followed, using length of hospital stay to measure consumption of resources. A total of 1,111 patients were triaged for treatment in the field hospital within 14 days of the earthquake. The median length of stay for all patients for whom data was available was 16 hours (mean = 29.7 hours). The majority of patients (n = 620, 65%) were discharged within 24 hours. Two hundred five patients underwent surgery and were discharged within a median of 39 hours (mean = 52.6 hours); of these, 124 (62%) were discharged within 48 hours. The total mortality of the treated patients was 1.5% (n = 17). Currently accepted triage principles for the most part are appropriate for efficiently providing medical care in a disaster area with extremely limited resources, but require extensive adaptation to local conditions.

Treatment of Earthquake-Related Craniofacial Injuries aboard the USNS Comfort during Operation Unified Response

Craniofacial injuries secondary to earthquake-related trauma are uncommonly reported and can pose a significant reconstructive challenge. The objective of this study is to report and analyze earthquake-related craniofacial injury reconstruction and the disaster relief capabilities of a U.S. Navy hospital ship. A review of earthquake-related injuries treated over 40 days requiring craniofacial reconstruction onboard a U.S. Navy hospital ship was performed. From January 20 to February 28, 2010 (40 days), 869 patients were admitted to the USNS Comfort. Thirty-three patients (4 percent) treated by the craniofacial service underwent 93 craniofacial surgical procedures. Average patient hospitalization time was 17 days (range, 5 to 38 days). The fractures treated included nine mandibles, 12 zygomaticomaxillary-orbital complexes, 16 orbital floors, eight Le Fort, four naso-orbitoethmoid, and two cranial vault fractures. The soft-tissue injuries treated were two heminasal avulsions, two traumatic cleft lips, and eight other complex facial lacerations. Short-term complications included wound dehiscence (6 percent) and postoperative malocclusion (6 percent). There were no postsurgical wound infections, visual field changes, or mortality. Complex craniofacial surgery services can be safely delivered onboard a United States Navy hospital ship for devastating injuries caused by natural disasters. Although craniofacial injuries represented a small percentage of the total patients admitted to our hospital ship, the survivors of facial injury required complex and multiple procedures to achieve optimal results. Despite heavy wound contamination and the intrinsic delay in presentation associated with mass casualty triage, facial fractures can be treated adequately and with low morbidity and mortality.

Disaster and Mass Casualty Triage

An overview of disaster and mass casualty triage, the philosophies that have shaped current triage strategies, and the two most common triage systems in the U.S., SALT (Sort-Assess-Lifesaving Interventions-Treatment/Transport) and START (Simple Triage and Rapid Transport). Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

-PLUS Prehospital Mass-Casualty Triage: A Strategy for Addressing Unusual Injury Mechanisms

Simple Triage and Rapid Treatment (START) and more recently developed prehospital casualty triage algorithms are widely used, in part because they are easy to teach and learn, and can be performed rapidly. Every rapid triage protocol has inherent, significant limitations: (1) no mechanism of injury (MOI) considerations; (2) limited assessment points; and (3) no refinement in truly mass-casualty situations where transport of "minor" or "moderate" patients may be delayed. When rapid initial triage protocols are utilized, a significant triage deficiency ("under-triage") may occur when "minor" or "moderate" casualties actually are more severely injured than initially triaged. Some MOI produce casualties with subtle or latent (i.e., hidden or delayed) signs and symptoms not considered in the commonly used prehospital triage algorithms. This research did not focus on START or other initial triage screening methods. Instead, it focuses on developing follow-on triage guidance to more specifically prioritize "delayed transport" casualties based upon signs and symptoms related to their MOI. Using expert opinion and accepted clinical criteria, triage algorithms were developed to re-evaluate patients triaged to "minor" and "moderate" cohorts. A detailed literature search produced a draft list of relevant signs and symptoms for each selected MOI. The lists then were evaluated by a multi-disciplinary panel of experts via an anonymous, mail-based Delphi method. The input shaped triage algorithms for each selected MOI, which then were subjected to a second stage Delphi process. Consensus was achieved using the Delphi method. The algorithms extend patient assessment beyond the rapid initial triage protocols and incorporate triage criteria specific to each selected injury mechanism or condition: (1) penetrating injuries; (2) unconventional MOI (burns, blast, chemical, radiation); (3) smoke and other inhalation exposure; and (4) injuries with concomitant pregnancy. The full list of triage protocols is designated by the acronym "-PLUS". "-PLUS" Prehospital Casualty Triage may supplement the strengths of already existing, widely accepted mass-casualty triage strategies. It does not displace START or other rapid initial triage protocols, but in mass-casualty situations with extensive delays in transport, it provides a method to identify under-triage of seriously injured casualties. "-PLUS" also presents a framework for capturing the triage considerations used by experienced medical providers, and so may provide a valuable teaching tool for training future triage professionals. Further research and field assessment is required.

-PLUS Prehospital Mass-Casualty Triage: A Strategy for Addressing Unusual Injury Mechanisms

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Healthcare ethics: The experience after the Haitian earthquake

On January 12, 2010, a 7.0 Richter earthquake devastated Haiti and its public health infrastructure leading to a worldwide humanitarian effort. The United States sent forces to Haiti's assistance including the USNS Comfort, a tertiary care medical center on board a ship. Besides setting a transparent triage and medical regulating system, the leadership on the Comfort instituted a multidisciplinary Healthcare Ethics Committee to assist in delivering the highest level efficient care to the largest number of victims. Allocation of resources was based on time-honored ethics principles, the concept of mass casualty triage in the setting of resource constraints, and constructs developed by the host nation's Ministry of Health. In offering aid in austere circumstances, healthcare practitioners must not only adhere to the basic healthcare ethics principles but also practice respect for communities, cultures, and traditions, as well as demonstrate respect for the sovereignty of the host nation. The principles outlined herein should serve as guidance for future disaster relief missions. This work is in accordance with BUMEDINST 6010.25, Establishment of Healthcare Ethics Committees.

Medical student disaster medicine education: the development of an educational resource

BackgroundDisaster medicine education is an enormous challenge, but indispensable for disaster preparedness.AimsWe aimed to develop and implement a disaster medicine curriculum for medical student education that can serve as a peer-reviewed, structured educational guide and resource. Additionally, the process of designing, approving and implementing such a curriculum is presented.MethodsThe six-step approach to curriculum development for medical education was used as a formal process instrument. Recognized experts from professional and governmental bodies involved in disaster health care provided input using disaster-related physician training programs, scientific evidence if available, proposals for education by international disaster medicine organizations and their expertise as the basis for content development.ResultsThe final course consisted of 14 modules composed of 2-h units. The concepts of disaster medicine, including response, medical assistance, law, command, coordination, communication, and mass casualty management, are introduced. Hospital preparedness plans and experiences from worldwide disaster assistance are reviewed. Life-saving emergency and limited individual treatment under disaster conditions are discussed. Specifics of initial management of explosive, war-related, radiological/nuclear, chemical, and biological incidents emphasizing infectious diseases and terrorist attacks are presented. An evacuation exercise is completed, and a mass casualty triage is simulated in collaboration with local disaster response agencies. Decontamination procedures are demonstrated at a nuclear power plant or the local fire department, and personal decontamination practices are exercised. Mannequin resuscitation is practiced while personal protective equipment is utilized. An interactive review of professional ethics, stress disorders, psychosocial interventions, and quality improvement efforts complete the training.ConclusionsThe curriculum offers medical disaster education in a reasonable time frame, interdisciplinary format, and multi-experiential course. It can serve as a template for basic medical student disaster education. Because of its comprehensive but flexible structure, it should also be helpful for other health-care professional student disaster education programs.

Mass-Casualty Triage Training for International Healthcare Workers in the Asia-Pacific Region Using Manikin-Based Simulations

More than half of the world's disasters occur in the Asia-Pacific region. A simulation-based exercise to teach healthcare workers prehospital triage, tagging, and treatment methods was used to link disaster management theory to practice with a student-centered, hands-on educational activity. Various strategies for teaching disaster health education have been advocated, and best-practice disaster education models continue to be sought. A manikin-based, primary triage and treatment course was adapted for international healthcare providers in the Asia-Pacific region using symbolic representations of triage categories and physical findings. The pedagogical construct that was used was an interactive, formative assessment in which faculty members mediated learner information gathering and interpretation during four simulation scenarios. After establishing a multi-casualty disaster context, a wireless, audience response system anonymously collected learner responses to four clinical situations: (1) leg wound (hemorrhagic shock/immediate); (2) chest wound (tension pneumothorax/immediate); (3) head wound (traumatic brain injury/expectant); and (4) limb trauma (leg fracture/delayed). There were 182 healthcare providers from eight Asia-Pacific countries (including the US) that participated in four simulation seminars. The simulation sessions were successfully tailored to groups of learners that varied in size and professional composition. Expectant and delayed triage categories posed the greatest challenge to learners. In one of two groups that were queried, learner self-confidence in applying principles of triage and treatment improved significantly. At the conclusion of the simulation sessions, learners strongly agreed that manikin-based simulation improved their understanding of triage, and should be used to teach principles of primary triage and treatment. Simulation training represents an opportunity to engage learners regardless of language and cultural barriers. Simulation-based training can be effective in introducing healthcare professionals to principles of primary triage and treatment in an effective and culturally sensitive manner. The characteristics of the course with respect to planned formative assessment and culturally competent scholarship were reviewed.

(K111) A Review of On-Scene Disaster Triage Schemes and Proposal for a Standardized Triage System

Introduction:Mass-casualty triage is a critical skill. The are any systems exist to guide providers in making triage decisions, however, there is little scientific literature to validate current systems. There are no internationally agreed upon categories or color. The lack of standardization in triage can lead to confusion.Methods:An expert panel reviewed existing triage systems. Each member was assigned a triage system and asked to conduct an exhaustive literature review and Internet search and to develop a report to the panel. Each system had two or more members assigned to conduct a review.Results:The committee identified nine existing mass casualty triage systems, including two pediatric-specific systems. The systems were noted to be similar in naming and color representations, but differed on the inclusion of an expectant category. Studies that compared the various mass casualty triage systems and found that the ability to obey commands and systolic blood pressure were the best predictors were identified.Conclusions:The committee concluded that no one system could be embraced as a validated system. The committee decided to use the best available scientific information and consensus opinion to develop a system that could serve as a proposed national guideline. The group discussed each component until consensus was reached. The guideline incorporates pieces of most existing triage systems; it was given the name SALT Triage (sort, assess, lifesaving interventions, and treatment and/or transport). This guideline is intended for use on-scene in all-hazards events for both adults and children.

Does START Triage Work? An Outcomes Assessment After a Disaster

The mass casualty triage system known as simple triage and rapid treatment (START) has been widely used in the United States since the 1980s. However, no outcomes assessment has been conducted after a disaster to determine whether assigned triage levels match patients' actual clinical status. Researchers hypothesize that START achieves at least 90% sensitivity and specificity for each triage level and ensures that the most critical patients are transported first to area hospitals. The performance of START was evaluated at a train crash disaster in 2003. Patient field triage categories and scene times were obtained from county reports. Patient medical records were then reviewed at all receiving hospitals. Victim arrival times were obtained and correct triage categories determined a priori using a combination of the modified Baxt criteria and hospital admission. Field and outcomes-based triage categories were compared, defining the appropriateness of each triage assignment. Investigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventy-nine patients were overtriaged, 3 were undertriaged, and 66 patients' outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% confidence interval [CI] 16% to 100%) and green was 89.3% specific (95% CI 72% to 98%). The Obuchowski statistic was 0.81, meaning that victims from a higher-acuity outcome group had an 81% chance of assignment to a higher-acuity triage category. The median arrival time for red patients was more than 1 hour earlier than the other patients. This analysis demonstrates poor agreement between triage levels assigned by START at a train crash and a priori outcomes criteria for each level. START ensured acceptable levels of undertriage (100% red sensitivity and 89% green specificity) but incorporated a substantial amount of overtriage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.

Teaching Mass Casualty Triage Skills Using Iterative Multimanikin Simulations

Objective. Effective mass casualty triage requires rapid andaccurate decision making. First responders need to be trained, but opportunities to practice triage andreceive individualized feedback during traditional mass casualty (MC) exercises are uncommon. It was hypothesized that novice learners would improve in speed, accuracy, andself-efficacy after deliberate practice triaging multiple simulated casualties in a MC exercise using high-fidelity manikins. Methods. Learners initially developed baseline knowledge of MC triage by listening to four short podcasts andpassing a written examination. They then experienced three sequential MC scenarios (A, B, andC) consisting of five manikin simulations each, coupled with individual feedback after each scenario. Students served as their own controls. A triage score (TS) andintervention score (IS) were recorded. For the TS, one point was awarded for each correctly identified main problem, required intervention, andtriage category. For the IS, one point was awarded for each correctly applied intervention. Before-and-after surveys measured self-efficacy andreaction to the training. Results. Twenty-one medical students were enrolled and20 students passed the examination. The TS andIS improved significantly during scenario B (p < 0.001). Time to complete each scenario decreased significantly from scenario A (8 min 27 sec) to scenario B (6 min 19 sec) (p < 0.001), but not from scenario B to scenario C (5 min 40 sec). Self-efficacy improved significantly after scenario C for prioritizing treatment andresources, identifying high-risk casualties, andlearning to be an effective first responder. Conclusion. Novice learners demonstrated improved triage andintervention scores, speed, andself-efficacy during an iterative, multimanikin MC training experience

Pilot Test of the SALT Mass Casualty Triage System

Introduction. No existing mass casualty triage system has been scientifically scrutinized or validated. A recent work group sponsored by the Centers for Disease Control and Prevention, using a combination of expert opinion and the extremely limited research data available, created the SALT (sort–assess–lifesaving interventions–treat/transport) triage system to serve as a national model. An airport crash drill was used to pilot test the SALT system. Objective. To assess the accuracy and speed with which trained paramedics can triage victims using this new system. Methods. Investigators created 50 patient scenarios with a wide range of injuries and severities, and two additional uninjured victims were added at the time of the drill. Students wearing moulage and coached on how to portray their injuries served as “victims.” Assuming proper application of the SALT system, the patient scenarios were designed such that 16 patients would be triaged as T1/red/immediate, 12 as T2/yellow/delayed, 14 as T3/green/minimal, and 10 as T4/black/dead. Paramedics were trained to proficiency in the SALT system one week prior to the drill using a 90-minute didactic/practical session, and were given “flash cards” showing the triage algorithm to be used if needed during the drill. Observers blinded to the study purpose timed and recorded the triage process for each patient during the drill. Simple descriptive statistics were used to analyze the data. Results. The two paramedics assigned to the role of triage officers applied the SALT algorithm correctly to 41 of the 52 patients (78.8% accuracy). Seven patients intended to be T2 were triaged as T1, and two patients intended to be T3 were triaged as T2, for an overtriage rate of 13.5%. Two patients intended to be T2 were triaged as T3, for an undertriage rate of 3.8%. Triage times were recorded by the observers for 42 of the 52 patients, with a mean of 15 seconds per patient (range 5–57 seconds). Conclusions. The SALT mass casualty triage system can be applied quickly in the field and appears to be safe, as measured by a low undertriage rate. There was, however, significant overtriage. Further refinement is needed, and effect on patient outcomes needs to be evaluated.

SALT Mass Casualty Triage: Concept Endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association

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Teaching Mass Casualty Triage Skills Using Immersive Three‐dimensional Virtual Reality

Virtual reality (VR) environments offer potential advantages over traditional paper methods, manikin simulation, and live drills for mass casualty training and assessment. The authors measured the acquisition of triage skills by novice learners after exposing them to three sequential scenarios (A, B, and C) of five simulated patients each in a fully immersed three-dimensional VR environment. The hypothesis was that learners would improve in speed, accuracy, and self-efficacy. Twenty-four medical students were taught principles of mass casualty triage using three short podcasts, followed by an immersive VR exercise in which learners donned a head-mounted display (HMD) and three motion tracking sensors, one for their head and one for each hand. They used a gesture-based command system to interact with multiple VR casualties. For triage score, one point was awarded for each correctly identified main problem, required intervention, and triage category. For intervention score, one point was awarded for each correct VR intervention. Scores were analyzed using one-way analysis of variance (ANOVA) for each student. Before and after surveys were used to measure self-efficacy and reaction to the training. Four students were excluded from analysis due to participation in a recent triage research program. Results from 20 students were analyzed. Triage scores and intervention scores improved significantly during Scenario B (p < 0.001). Time to complete each scenario decreased significantly from A (8:10 minutes) to B (5:14 minutes; p < 0.001) and from B to C (3:58 minutes; p < 0.001). Self-efficacy improved significantly in the areas of prioritizing treatment, prioritizing resources, identifying high-risk patients, and beliefs about learning to be an effective first responder. Novice learners demonstrated improved triage and intervention scores, speed, and self-efficacy during an iterative, fully immersed VR triage experience.

Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline

Mass casualty triage is a critical skill. Although many systems exist to guide providers in making triage decisions, there is little scientific evidence available to demonstrate that any of the available systems have been validated. Furthermore, in the United States there is little consistency from one jurisdiction to the next in the application of mass casualty triage methodology. There are no nationally agreed upon categories or color designations. This review reports on a consensus committee process used to evaluate and compare commonly used triage systems, and to develop a proposed national mass casualty triage guideline. The proposed guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, was developed based on the best available science and consensus opinion. It incorporates aspects from all of the existing triage systems to create a single overarching guide for unifying the mass casualty triage process across the United States.