Need For Lifesaving Interventions Research Articles

Effectiveness of and Adherence to Triage Algorithms during Prehospital Response to Mass Casualty Incidents

Introduction:At mass casualty incidents (MCIs) medical needs exceed available resources, requiring prioritization of response efforts and materials. Principles of triage have evolved since the 18th century into several modern-day algorithms that sort casualties into priority groups based on clinical parameters. It is unclear, however, if such algorithms are effective and practical during real-world MCIs. This analysis reviews the literature on use and efficacy of prehospital MCI triage algorithms.Method:The MEDLINE, Scopus, and Google Scholar databases were searched for peer-reviewed and grey literature on prehospital MCI medical response. Articles discussing MCI triage concepts, triage at MCIs, or algorithm efficacy were included. Articles were excluded if they described law enforcement, ethical, psychological or epidemiological perspectives without detailing the medical response.Results:Frequently-cited MCI triage algorithms include START (Simple Triage & Rapid Treatment); Triage Sieve; CareFlight; SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport); and RAMP (Rapid Assessment of Mentation & Pulse). They differ in the physiologic parameters assessed, inclusion of numerical measurements, and number of triage categories. Surveyed providers were less likely to have performed full triage at MCIs (16%) than in training (69%), and more likely to have performed no triage (29% vs. 1%). In retrospective trauma registry analyses, algorithms were generally poorly predictive of the need for life-saving interventions (13-58% sensitive, 72-97% specific) in one study, and variably predictive of critical injury (45-85% sensitive, 86-96% specific) in another. The Glasgow Coma Scale motor component was associated with critical injury (73% sensitive, 96% specific if <6); other physiologic variables had sensitivities under 40%. In prospective studies, algorithms were accurate for 36-52% of adults and 56-59% of children. Some suggest clinician judgment may be similarly effective.Conclusion:Multiple algorithms exist for MCI triage, but they are infrequently utilized and may be inaccurate. Simpler, more realistic, scalable, and widely accepted response systems need to be instituted.

Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms – A prospective observational study

BackgroundAn immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms. MethodsAll patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient’s ECG. The main study outcome was the diagnosis of an acute cardiovascular event. ResultsOf the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse–physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001). ConclusionsECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.

Utilizing Near-Infrared Spectroscopy to Identify Pediatric Trauma Patients Needing Lifesaving Interventions: A Prospective Study.

The aim of this study was to prospectively investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs). Prospective cohort study of children age 0 to 18 years who activated the trauma team response between August 15, 2017, and February 12, 2019, at a large, urban pediatric emergency department (ED).The relationship between the lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) was investigated. Categorical variables were analyzed by χ 2 test, and continuous variables were analyzed by Student t test. A total of 148 pediatric trauma patients had somatic NIRS monitoring and met the inclusion criteria. Overall, 65.5% were male with a mean ± SD age of 10.9 ± 6.0 years. Injuries included 67.6% blunt trauma and 28.4% penetrating trauma with mortality of 3.4% (n = 5). Overall, the median lowest somatic NIRS value was 72% (interquartile range, 58%-88%; range, 15%-95%), and 43.9% of patients had a somatic NIRS value <70%. The median somatic NIRS duration recorded was 11 minutes (interquartile range, 7-17 minutes; range, 1-105 minutes). Overall, 36.5% of patients required a LSI including 53 who required a lifesaving procedure, 17 required blood products, and 17 required vasopressors. Among procedures, requiring a thoracostomy was significant.Pediatric trauma patients with a somatic NIRS value <70% had a significantly increased odds of requiring a LSI (odds ratio, 2.11; 95% confidence interval, 1.07-4.20). Somatic NIRS values <70% had a sensitivity and specificity of 56% and 63%, respectively. Pediatric trauma patients with somatic NIRS values <70% within 30 minutes of ED arrival have an increased odds of requiring LSIs. Among LSIs, pediatric trauma patients requiring thoracostomy was significant. The role of NIRS in incrementally improving the identification of critically injured children in the ED and prehospital setting should be evaluated in larger prospective multicenter studies.

Comparative analysis of major incident triage tools in children: a UK population-based analysis

IntroductionTriage is a key principle in the effective management of major incidents. There is currently a paucity of evidence to guide the triage of children. The aim of this study...

Validity and reliability of the triage scale in older people in a regional emergency department in Hong Kong

Background: Older people (⩾65 years) present a unique challenge in emergency department triage. Hong Kong’s Hospital Authority adopts a five-level emergency department triage system, with no special considerations for older people. We evaluated the validity and reliability of this triage scale in older people in a regional Hong Kong emergency department. Methods: In total, 295 cases stratified by triage category were randomly selected for review from November 2016 to January 2017. Validity was established by comparing the real emergency department patients’ triage category against (1) that of an expert panel and (2) the need for life-saving intervention. Triage notes were extracted to make case scenarios to evaluate inter- and intra-rater reliabilities. Emergency department nurses (n = 8) were randomly selected and grouped into &lt;5 and ⩾5 years emergency department experience. All nurses independently rated all 295 scenarios, blinded to clinical outcomes. Results: The percentage agreement between the real emergency department patients’ triage category and the expert panel’s assignment was 68.5%, with 16.3% and 15.3% over-triage and under-triage, respectively. Quadratic weighting kappa for agreement with the expert panel was 0.72 (95% confidence interval: 0.53–0.91). The sensitivity, specificity and positive likelihood ratio for the need for life-saving interventions were 75.0% (95% confidence interval: 47.6%–92.7%), 97.1% (95% confidence interval: 94.4%–98.8%) and 26.2 (95% confidence interval: 12.5%–54.8%), respectively. The Fleiss kappa value for inter-rater reliability was 0.50 (95% confidence interval: 0.47–0.54) for junior and senior nurse groups, respectively. Conclusion: The current triage scale demonstrates reasonable validity and reliability for use in our older people. Considerations highlighting the unique characteristics of older people emergency department presentations are recommended.

Utilizing Near-Infrared Spectroscopy (NIRS) to Identify Pediatric Trauma Patients Needing Lifesaving Interventions (LSIs): A Retrospective Study.

The aim of this study was to investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs). Retrospective chart review of children age 0 to 18 years who activated the trauma team response between January 1, 2015 and August 14, 2017, at a large, urban pediatric emergency department. The lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) were abstracted from the chart. χ2 and descriptive statistics were used for analysis. The charts of 84 pediatric trauma patients were reviewed. Overall, 80% were boys with a mean age of 10.4 years (SD, 6.2 years). Injuries included 56% blunt trauma and 36% penetrating trauma with mortality of 10.7% (n = 9). Overall, the median lowest NIRS value was 67% (interquartile range, 51-80%; range, 15%-95%) and 54.8% of the patients had a NIRS value less than 70%. The median somatic NIRS duration recorded was 12 minutes (interquartile range, 6-17 minutes; range, 1-59 minutes). Overall, 50% of patients required a LSI, including 39 who required a lifesaving procedure, 11 required blood products, and 14 required vasopressors. Pediatric trauma patients with NIRS less than 70% had a significantly increased odds of requiring a LSI (odds ratio, 2.67; 95% confidence interval, 1.10-6.47). NIRS less than 70% had a sensitivity and specificity of 67% and 57% respectively. Pediatric trauma patients with somatic NIRS less than 70% within 30 minutes of emergency department arrival are associated with the need for LSIs. Continuous NIRS monitoring in the pediatric trauma population should be evaluated prospectively.

Relationship between the Injury Severity Score and the need for life-saving interventions in trauma patients in the UK

IntroductionMajor trauma is the third leading cause of avoidable mortality in the UK. Defining which patients require care in a major trauma centre is a critical component of developing, evaluating...

Predicting severe clinical events by learning about life-saving actions and outcomes using distant supervision.

Medical error is a leading cause of patient death in the United States. Among the different types of medical errors, harm to patients caused by doctors missing early signs of deterioration is especially challenging to address due to the heterogeneity of patients' physiological patterns. In this study, we implemented risk prediction models using the gradient boosted tree method to derive risk estimates for acute onset diseases in the near future. The prediction model uses physiological variables as input signals and the time of the administration of outcome-related interventions and discharge diagnoses as labels. We examine four categories of acute onset illness: acute heart failure (AHF), acute lung injury (ALI), acute kidney injury (AKI), and acute liver failure (ALF). To develop and test the model, we consider data from two sources: 23,578 admissions to the Intensive Care Unit (ICU) from the MIMIC-3 dataset (Beth-Israel Hospital) and 16,612 ICU admissions on hospitals affiliated with our institution (University of Washington Medical Center and Harborview Medical Center, the UW-CDR dataset). We systematically identify outcome-related interventions for each acute organ failure, then use them, along with discharge diagnoses, to label proxy events to train gradient boosted trees. The trained models achieve the highest F1 score with a value of 0.6018 when predicting the need for life-saving interventions for ALI within the next 24h in the MIMIC-3 dataset while showing a median F1 score of 0.3850 from all acute organ failures in both datasets. The approach also achieves the highest F1 score of 0.6301 when classifying a patient's ALI status at the time of discharge from the MIMIC-3 dataset, with a median F1 score of 0.4307 in both datasets. This study shows the potential for using the time of outcome-related intervention administrations and discharge diagnoses as labels to train supervised machine learning models that predict the risk of acute onset illnesses.

Direct to operating room trauma resuscitation: Optimizing patient selection and time-critical outcomes when minutes count.

Although several trauma centers have developed direct to operating room (DOR) trauma resuscitation programs, there is little published data on optimal patient selection, practices, and outcomes. We sought to analyze triage criteria and interventions associated with optimal DOR outcomes and resource utilization. Retrospective review of all adult DOR resuscitations for a 6-year period was performed. Triage criteria were analyzed individually and grouped into categories: mechanism, physiology, anatomy/injury, or other. The best univariate and multivariate predictors of requiring lifesaving interventions (LSIs) or emergent surgery (ES) were analyzed. Actual and predicted mortality were compared for all patients and for predefined time-sensitive subgroups. There were 628 DOR patients (5% of all admissions) identified; the majority were male (79%), penetrating mechanism (70%), severely injured (40% ISS >15), and 17% died. Half of patients required LSI and 23% required ES, with significantly greater need for ES and lower need for LSI after penetrating versus blunt injury (p < 0.01). Although injury mechanism criteria triggered most DOR cases and best predicted need for ES, the physiology and anatomy/injury criteria were associated with greater need for LSI and mortality. Observed mortality was significantly lower than predicted mortality with DOR for several key subgroups. Triage schemes for both ES and LSI could be simplified to four to six independent predictors by regression analysis. The DOR program identified severely injured trauma patients at increased risk for requiring LSI and/or ES. Different triage variable categories drive the need for ES versus LSI and could be simplified or optimized based on local needs or preferences. Direct to operating room was associated with better than expected survival among specific time-sensitive subgroups. Therapeutic/Care Management, Level IV.

Validation of the Pediatric Physiological and Anatomical Triage Score in Injured Pediatric Patients.

Triaging plays an important role in providing suitable care to a large number of casualties in a disaster setting. A Pediatric Physiological and Anatomical Triage Score (PPATS) was developed as a new secondary triage method. This study aimed to validate the accuracy of the PPATS in identifying injured pediatric patients who are admitted at a high frequency and require immediate treatment in a disaster setting. The PPATS method was also compared with the current triage methods, such as the Triage Revised Trauma Score (TRTS). A retrospective review of pediatric patients aged ≤15 years, registered in the Japan Trauma Data Bank (JTDB) from 2012 through 2016, was conducted and PPATS was performed. The PPATS method graded patients from zero to 22, and was calculated based on vital signs, anatomical abnormalities, and the need for life-saving interventions. It categorized patients based on their priority, and the intensive care unit (ICU)-indicated patients were assigned a PPATS ≥six. The accuracy of PPATS and TRTS in predicting the outcome of ICU-indicated patients was compared. Of 2,005 pediatric patients, 1,002 (50%) were admitted to the ICU. The median age of the patients was nine years (interquartile range [IQR]: 6-13 years). The sensitivity and specificity of PPATS were 78.6% and 43.7%, respectively. The area under the receiver-operating characteristic (ROC) curve (AUC) was larger for PPATS (0.61; 95% confidence interval [CI], 0.59-0.63) than for TRTS (0.57; 95% CI, 0.56-0.59; P &lt;.01). Regression analysis showed a significant correlation between PPATS and the Injury Severity Score (ISS; r2 = 0.353; P &lt;.001), predicted survival rate (r2 = 0.396; P &lt;.001), and duration of hospital stay (r2 = 0.252; P &lt;.001). The accuracy of PPATS for injured pediatric patients was superior to that of current secondary triage methods. The PPATS method is useful not only for identifying high-priority patients, but also for determining the priority ranking for medical treatments and evacuation.

Validation of the Pediatric Physiological and Anatomical Triage Score in Pediatric Patients with Burn Injuries

Introduction:Triaging plays an important role in providing suitable care to the largest number of casualties in a disaster setting. We developed the Pediatric Physiological and Anatomical Triage score (PPATS) as a new secondary triage method.Aim:This study was performed to validate the accuracy of the PPATS in pediatric patients with burn injuries.Methods:A retrospective review of pediatric patients with burn injuries younger than 15 years old registered in the Japan Trauma Databank from 2004 to 2016 was conducted. The PPATS, which was assigned scores from 0 to 22, was calculated based on vital signs, anatomical abnormalities, and need for life-saving intervention. The PPATS categorized the patients by their priority and defined the intensive care unit (ICU)-indicated patients as those with PPARSs more than 6. This study compared the accuracy of prediction of ICU-indicated patients between the PPATS and Triage Revised Trauma Score (TRTS).Results:Among 87 pediatric patients, 62 (71%) were admitted to the ICU. The median age was 3 years (interquartile range: 1 to 9 years old). The sensitivity and specificity of the PPATS were 74% and 36%, respectively. The area under the receiver-operating characteristic curve was not different between the PPTAS [0.51 (95% confidence interval: -0.51–1.48) and the TRTS [0.51 (-1.17–1.62), p=0.57]. Regression analysis showed a significant association between the PPATS and the Injury Severity Score (ISS) (r2=0.39, p&lt;0.01). On the other hand, there is no association between the TRTS and the ISS (r2=0.00, p=0.79).Discussion:The accuracy of the PPATS was not superior to that of current secondary-triage methods. However, the PPATS had the advantage of objectively determining the triage priority ranking based on the severity of the pediatric patients with burn injuries.

Development of a heart rate variability and complexity model in predicting the need for life-saving interventions amongst trauma patients

BackgroundTriage trauma scores are utilised to determine patient disposition, interventions and prognostication in the care of trauma patients. Heart rate variability (HRV) and heart rate complexity (HRC) reflect the autonomic nervous system and are derived from electrocardiogram (ECG) analysis. In this study, we aimed to develop a model incorporating HRV and HRC, to predict the need for life-saving interventions (LSI) in trauma patients, within 24 h of emergency department presentation.MethodsWe included adult trauma patients (≥ 18 years of age) presenting at the emergency department of Singapore General Hospital between October 2014 and October 2015. We excluded patients who had non-sinus rhythms and larger proportions of artefacts and/or ectopics in ECG analysis. We obtained patient demographics, laboratory results, vital signs and outcomes from electronic health records. We conducted univariate and multivariate analyses for predictive model building.ResultsTwo hundred and twenty-five patients met inclusion criteria, in which 49 patients required LSIs. The LSI group had a higher proportion of deaths (10, 20.41% vs 1, 0.57%, p < 0.001). In the LSI group, the mean of detrended fluctuation analysis (DFA)-α1 (1.24 vs 1.12, p = 0.045) and the median of DFA-α2 (1.09 vs 1.00, p = 0.027) were significantly higher. Multivariate stepwise logistic regression analysis determined that a lower Glasgow Coma Scale, a higher DFA-α1 and higher DFA-α2 were independent predictors of requiring LSIs. The area under the curve (AUC) for our model (0.75, 95% confidence interval, 0.66–0.83) was higher than other scoring systems and selected vital signs.ConclusionsAn HRV/HRC model outperforms other triage trauma scores and selected vital signs in predicting the need for LSIs but needs to be validated in larger patient populations.

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

IntroductionA key principle in the effective management of major incidents is triage, the process of prioritising patients on the basis of their clinical acuity. In many countries including the UK,...

2 Major incident triage and the implementation of a new triage tool, the MPTT-24

IntroductionOver the last decade, a number of European cities including London, have witnessed high profile terrorist attacks resulting in major incidents with large numbers of casualties. Triage, the process of...

The civilian validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to primary major incident triage

IntroductionTriage is a key principle in the effective management of a major incident. Existing triage tools have demonstrated limited performance at predicting need for life-saving intervention (LSI). Derived on a...

The prospective validation of the Modified Physiological Triage Tool (MPTT): an evidence-based approach to major incident triage

IntroductionTriage is a key principle in the effective management of major incidents. There is limited evidence to support existing triage tools, with a number of studies demonstrating poor performance at...

Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT)

BackgroundTriage is a key principle in the effective management at a major incident. There are at least three different triage systems in use worldwide and previous attempts to validate them, have revealed limited sensitivity. Within a civilian adult population, there has been no work to develop an improved system. MethodsA retrospective database review of the UK Joint Theatre Trauma Registry was performed for all adult patients (>18years) presenting to a deployed Military Treatment Facility between 2006 and 2013. Patients were defined as Priority One if they had received one or more life-saving interventions from a previously defined list.Using first recorded hospital physiological data (HR/RR/GCS), binary logistic regression models were used to derive optimum physiological ranges to predict need for life-saving intervention. This allowed for the derivation of the Modified Physiological Triage Tool–MPTT (GCS≥14, HR≥100, 12<RR≥22). A comparison of the MPTT and existing triage tools was then performed using sensitivities and specificities with 95% confidence intervals. Differences in performance were assessed for statistical significance using a McNemar test with Bonferroni correction. ResultsOf 6095 patients, 3654 (60.0%) had complete data and were included in the study, with 1738 (47.6%) identified as priority one. Existing triage tools had a maximum sensitivity of 50.9% (Modified Military Sieve) and specificity of 98.4% (Careflight). The MPTT (sensitivity 69.9%, 95% CI 0.677-0.720, specificity 65.3%, 95% CI 0.632-0.675) showed an absolute increase in sensitivity over existing tools ranging from 19.0% (Modified Military Sieve) to 45.1% (Triage Sieve). There was a statistically significant difference between the performance (p<0.001) between the MPTT and the Modified Military Sieve. Discussion & conclusionThe performance characteristics of the MPTT exceed existing major incident triage systems, whilst maintaining an appropriate rate of over-triage and minimising under-triage within the context of predicting the need for a life-saving intervention in a military setting. Further work is required to both prospectively validate this system and to identify its performance within a civilian environment, prior to recommending its use in the major incident setting.

MAJOR INCIDENT TRIAGE: THE CIVILIAN VALIDATION OF THE MODIFIED PHYSIOLOGICAL TRIAGE TOOL

Objectives & BackgroundTriage, the process of categorising patients based on clinical acuity, is a key principle in the effective management of a major incident (MI). Existing triage systems have so...

Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident

IntroductionTriage is a key principle in the effective management of major incidents. The process currently relies on algorithms assigning patients to specific triage categories; there is, however, little guidance as to what these categories represent. Previously, these algorithms were validated against injury severity scores, but it is accepted now that the need for life-saving intervention is a more important outcome. However, the definition of a life-saving intervention is unclear. The aim of this study was to define what constitutes a life-saving intervention, in order to facilitate the definition of an adult priority one patient during the definitive care phase of a major incident. MethodsWe conducted a modified Delphi study, using a panel of subject matter experts drawn from the United Kingdom and Republic of South Africa with a background in Emergency Care or Major Incident Management. The study was conducted using an online survey tool, over three rounds between July and December 2013. A four point Likert scale was used to seek consensus for 50 possible interventions, with a consensus level set at 70%. Results24 participants completed all three rounds of the Delphi, with 32 life-saving interventions reaching consensus. ConclusionsThis study provides a consensus definition of what constitutes a life-saving intervention in the context of an adult, priority one patient during the definitive care phase of a major incident. The definition will contribute to further research into major incident triage, specifically in terms of validation of an adult major incident triage tool.

Data quality of a wearable vital signs monitor in the pre-hospital and emergency departments for enhancing prediction of needs for life-saving interventions in trauma patients

This study was designed to investigate the quality of data in the pre-hospital and emergency departments when using a wearable vital signs monitor and examine the efficacy of a combined model of standard vital signs and respective data quality indices (DQIs) for predicting the need for life-saving interventions (LSIs) in trauma patients. It was hypothesised that prediction of needs for LSIs in trauma patients is associated with data quality. Also, a model utilizing vital signs and DQIs to predict the needs for LSIs would be able to outperform models using vital signs alone. Data from 104 pre-hospital trauma patients transported by helicopter were analysed, including means and standard deviations of continuous vital signs, related DQIs and Glasgow coma scale (GCS) scores for LSI and non-LSI patient groups. DQIs involved percentages of valid measurements and mean deviation ratios. Various multivariate logistic regression models for predicting LSI needs were also obtained and compared through receiver-operating characteristic (ROC) curves. Demographics of patients were not statistically different between LSI and non-LSI patient groups. In addition, ROC curves demonstrated better prediction of LSI needs in patients using heart rate and DQIs (area under the curve [AUC] of 0.86) than using heart rate alone (AUC of 0.73). Likewise, ROC curves demonstrated better prediction using heart rate, total GCS score and DQIs (AUC of 0.99) than using heart rate and total GCS score (AUC of 0.92). AUCs were statistically different (p < 0.05). This study showed that data quality could be used in addition to continuous vital signs for predicting the need for LSIs in trauma patients. Importantly, trauma systems should incorporate processes to regulate data quality of physiologic data in the pre-hospital and emergency departments. By doing so, data quality could be improved and lead to better prediction of needs for LSIs in trauma patients.