Traditional Triage Research Articles

Development and application of triage and medical evacuation system for casualties at sea.

Traditional triage could not meet the needs of battlefield casualties’ care in modern warfare. This paper designs of triage and medical evacuation system for casualties at sea that can quickly address mass-casualty triage, and store and transmit medical information during battlefield treatment and medical evacuation. This system consists of a high-capacity medical information card, a simulated patient generator, a triage classifier and a multifunctional airbag triage vest.

Thrombolysis in acute ischemic stroke: issues and options

China is one of the countries with highest incidence of stroke in the world. However, the rate of intravenous thrombolysis for ischemic stroke is extremely low in China, which is related to traditional triage system and inefficient management, the potential of hemorrhagic transformation, and narrow therapeutic time window. In order to improve the clinical implementation of thrombolysis, it is necessary to look at the related issues and to refine the therapeutic protocol according to the international experiences. Careful screening of eligible patients is crucial to reduce the rate of symptomatic intracranial hemorrhage. The advanced penumbral imaging is believed to enhance patient selection and extend the therapeutic time window. In addition, endovascular therapy is increasingly utilized to raise the recanalization rate. All these measures would enhance the improvement of the clinical management for acute stroke patients.

Prediction of in-hospital mortality and admission to ICU using vital signs - a study of Early Warning Score as an alternative to traditional triage

Background Triage of patients in the Emergency Department includes scoring of vital parameters. The objective of this study was to compare two such triage systems for assessing vital parameters - a single-parameter system, T-vital, as used in Danish Emergency Process Triage, and a multiple-parameter system, T-EWS, which we based on Early Warning Score (EWS) - and correlate the triage scores to in-hospital mortality and admission to ICU. Studies examining EWS in triage are currently limited in number. Methods Using data from the Acute Admission Database of Nordsjaellands Hospital (n = 6164 admissions), we calculated and stratified EWS into four T-EWS colour codes (red, orange, yellow, and green), testing different stratifications’ correlation to in-hospital mortality and admission to ICU. Afterwards, we compared the ability of the chosen T-EWS and T-vital to predict patients at risk (red and orange category) of in-hospital mortality or admission to ICU. The data were analysed using area under the receiver operating curve (AUROC), sensitivity, specificity, overtriage, undertriage, and diagnostic rates. Results

Re-engineering an American emergency department with Team Triage - adapting to increasing patient volume in emergency services

Overcrowding in U.S. emergency departments (ED) is a critical issue. In a privatized health care system, patients with limited access to insurance benefits (as influenced by challenging socio-economic conditions) often utilize the ED as crucial point of access to care. Non-acute patients seeking primary care in ED facilities can congest operations and contribute to overcrowding. In Hawaii’s second busiest ED (Hospital 1), a non-traditional method of emergency triage – team triage – has been implemented to improve patient throughput and satisfaction, and mitigate effects of overcrowding. This study defines trends and compares two prominent and nationally recognized EDs (Hospital 1 and Hospital 2) in the state of Hawaii - employing team and traditional triage respectively, to examine changes in patient population, demographics, acuteness, and departmental throughput measures.

Selection of Deep Brain Stimulation Candidates in Private Neurology Practices: Referral May Be Simpler than a Computerized Triage System

The objective of this study is to compare a computerized deep brain stimulation (DBS) screening module (Comparing Private Practice vs. Academic Centers in Selection of DBS Candidates [COMPRESS], NeuroTrax Corp., Bellaire, TX, USA) with traditional triage by a movement disorders specialized neurologist as the gold standard. The COMPRESS consists of a combination of the Florida Surgical Questionnaire for Parkinson disease (FLASQ-PD), a cognitive assessment battery provided by MindStreams® (NeuroTrax Corp.), and the Geriatric Depression Scale and the Zung Anxiety Self-Assessment Scale. COMPRESS resulted in the classification of patients into three categories: "optimal candidate,""probable candidate," and "not a good candidate." Similar categorical ratings made by a referring private practice neurologist and by a trained movement disorders specialist were compared with the ratings generated by COMPRESS. A total of 19 subjects with Parkinson's disease were enrolled from five private neurological practices. The clinical impressions of the private practice neurologist vs. those of the movement disorders specialist were in agreement approximately half the time (10/19 cases). The movement disorders specialist and COMPRESS agreed on 15/19 cases. A further comparison between outcomes from the entire COMPRESS module and the FLASQ-PD questionnaire by itself resulted in high agreement (18/19 cases in agreement). The COMPRESS agreed with an in-person evaluation by a movement disorders neurologist approximately 80% of the time. The computerized COMPRESS did not provide any screening advantage over the short FLASQ-PD paper questionnaire. Larger studies will be needed to assess the utility and cost effectiveness of this computerized triage method for DBS.

Report from the National Society of Genetic Counselors Service Delivery Model Task Force: A Proposal to Define Models, Components, and Modes of Referral

The Service Delivery Model Task Force (SDMTF) was appointed in 2009 by the leadership of the National Society of Genetic Counselors (NSGC) with a charge to research and assess the capacity of all existing service delivery models to improve access to genetic counseling services in the context of increasing demand for genetic testing and counseling. In approaching this charge, the SDMTF found that there were varying interpretations of what was meant by "service delivery models" and the group held extensive discussions about current practices to arrive at consensus of proposed definitions for current genetic service delivery models, modes of referral and components of service delivery. The major goal of these proposed definitions is to allow for conversations to begin to address the charge to the committee. We propose that current models of service delivery can be defined by: 1) the methods in which genetic counseling services are delivered (In-person, Telephone, Group and Telegenetics), 2) the way they are accessed by patients (Traditional referral, Tandem, Triage, Rescue and Self-referral) and 3) the variable components that depend upon multiple factors unique to each service setting. This report by the SDMTF provides a starting point whereby standardized terminology can be used in future studies that assess the effectiveness of these described models to overcome barriers to access to genetic counseling services.

From the Editors’ Desk: Why NCATS Should Read this Issue of JGIM

From the Editors’ Desk: Why NCATS Should Read this Issue of JGIM

Blood Pressure Monitoring Technique Impacts Hypertension Treatment

In 2005 the American Heart Association (AHA) released updated recommendations for blood pressure (BP) monitoring in order to ensure accurate BP measurements. To determine if current methods of BP assessment in an ambulatory clinic result in significantly different BP measurements than those obtained by following the AHA recommendations and if these BP differences impact treatment decisions. Randomized prospective analysis. University of New Mexico Hospital Adult Internal Medicine clinic. Forty adults with hypertension Patient BPs were measured using both the traditional triage method and the AHA-recommended method in cross-over fashion in random order. Two complete medical profile summaries were then constructed for each patient: one for each BP measurement obtained by each technique. These profiles were then reviewed by a panel of providers who provided hypothetical hypertension treatment recommendations. Individual BP results varied greatly between the two methods. SBP readings differed by ≥5mmHg in either direction for 68% of patients while 78% of patient's DBP readings differed by ≥2mmHg in either direction. Overall, 93% of patients had a BP difference of either ≥5mmHg systolic or ≥2mmHg diastolic. Five patients were determined to be at goal with the triage method, but were higher than their goal BP with the AHA method Significant differences were also seen in treatment recommendations for a given patient based on the differences seen between the two obtained BP readings. The number of patients with treatment variations between their two profiles ranged from 13% to 23% depending on the reviewing provider (p < 0.01 for all providers). Inaccurate BP assessment is common and may impact hypertension treatment decisions.

A scoring system for elective triage of referrals: Spine Severity Score

Background context The Spine Severity Score (SSS) is a 15-point scoring system devised for the purpose of triaging elective surgical spine referrals. From the referral letter and the accompanying radiology report, a total score is calculated based on clinical, pathological, and radiological criteria; a maximum score of 5 can be obtained within each category. A higher total score represents a referral that should be seen more urgently. Purpose To report interrater and intrarater reliability for the SSS and compare the scoring system against the traditional system for triage, that is, the surgeon's clinical experience. Study design A prospective cross-comparison design was used to evaluate the reliability and convergent validity of the SSS using spine case referrals. Methods Four spine surgeons (experts) and three administrative assistants (nonexperts) at the University of Calgary scored 25 referrals. A second iteration of scoring was performed with a minimum time interval elapsed of 6 weeks. Raters were instructed to choose the most concerning (the one with the highest associated score) descriptor in each category that was thought relevant to the individual referral. No further instructions were given on how to interpret the referral letter or the radiology report. The surgeons also scored the referrals using their own preexisting four-point scoring systems. The results were analyzed with independent and dependent t tests, Pearson product moment correlation coefficient, and generalizability and decision analysis. Results An independent-measures t test (p>.05) revealed no statistical differences between experts and nonexperts (ie, interrater reliability) for both Iterations 1 and 2 on total scores of the SSS and a moderately strong relationship between their ratings across iterations (r=0.79, p<.001). Similarly, a paired-samples t test (p>.05) indicated a nonsignificant mean difference between Total SSS ratings at Time 1 and Time 2 (ie, intrarater reliability) and a high degree of agreement (r=0.96, p<.001) between the two iterations. These results were confirmed with correlational analyses. Pearson product moment correlation coefficients between the gold standard and the mean score were calculated from expert ratings on Total SSS at Time 1 (r=0.71, p<.001) and at Time 2 (r=0.69, p<.001). Conclusions The SSS is a reliable scoring system for triage of elective spine referrals, even among nonexperts. We have been able to demonstrate strong interrater and intrarater reliability for the SSS and moderately strong correlation with the traditional triage system.

Exploring New Intake Models for the Emergency Department

The objective of this article was to explore new intake models for processing patients into the emergency department (ED) and disseminate these new ideas. In the fall of 2008, the Board of Directors of the Emergency Department Benchmarking Alliance (EDBA) identified intake as an area of focus and asked its members to submit new intake strategies alternative to traditional triage. All EDBA members were invited to participate via an e-mail survey. New models could be of their own design or developed by another organization and presented with permission. In all, 25 departments provided information on intake innovations. These submissions were collated into a document that outlines some of the new models. Collaborative methodology promoted the diffusion of innovation in this organization. The results of the project are presented here as an original article that outlines some of the new and mostly unpublished work occurring to improve the intake process into the ED.

The Incidence of Cancer Diagnosis Following Microdochectomy

The Incidence of Cancer Diagnosis Following Microdochectomy

A Strategy to Overcome the Radiology Lottery in the Staging of Head and Neck Cancer: An Aid to Attaining the 30-Day Rule

Rapid access to radiological services is essential, if the British Association of Otolaryngologists - Head and Neck Surgeons Minimum Temporal Standards are to be met in the management of head and neck cancer patients. This study assesses a new initiative whereby the multidisciplinary team prioritises allocated imaging appointments rather than using the traditional radiological triage system. This study was a prospective audit of all patients referred over a 3-month period with suspected head and neck cancer. The main outcome measures were: (i) median interval in days from general practitioner (GP) referral to staging scan; and (ii) median interval in days from first clinic appointment to staging scan. The new multidisciplinary team booking system led to a statistically significant reduction in the 'request-to-scan time' (from 12 days to 5 days). The time from 'GP to scan' also improved. This new multidisciplinary team-led booking system, could, in the future, speed up access to radiology services for head and neck cancer patients, allowing earlier definitive treatment.

Abstract 860: Alteration In Blood Pressure Monitoring Technique Impacts Hypertension Treatment

Objectives : Our study investigated the hypothesis that current methods of blood pressure (BP) assessment in an ambulatory clinic result in significantly different BP measurements than those obtained by following the American Heart Association (AHA) recommendations as well as the hypothesis that these BP differences result in treatment variation. Methods: This was a randomized, cross-over study in 40 patients with hypertension presenting to the UNMH Adult Internal Medicine Clinic. BP was measured in all patients in random order by the clinic staff using the traditional triage method and by the Principal Investigator using the AHA-recommended method. Trained observers documented BP techniques used. Two complete patient profiles were constructed for each patient one with the AHA BP and one with the triage BP. A panel of blinded providers including internists, a cardiologist, and a clinical pharmacist was asked to provide hypertensive treatment recommendations for each profile. Results: Only DBP differed significantly (77.6 mmHg ± 11.9 vs. 80.4 mmHg ± 10.5; p=0.02) between the triage and AHA methods, respectively. However, individual BP results varied greatly between the two methods. SBP readings differed by ≥5 mmHg in either direction for 68% of patients while 78% of patient’s DBP readings differed by ≥2 mmHg in either direction. Overall, 65% of patients were not at their goal BP when measured with the AHA method compared to 52% with the triage method (p&lt;0.001). Multiple technical errors were seen during the triage method that likely accounted for the variation. Significant differences in treatment between profiles existed. The number of patients with treatment variations between their two profiles ranged from 13% to 23% (p&lt;0.01 for all providers). Kappa scores indicated moderate to substantial clinical agreement between the physicians but only slight agreement between the pharmacist and physicians. Conclusions: When comparing the two methods of BP measurement, clinically significant differences were observed in a large percentage of patients. This difference significantly impacted hypertension treatment recommendations. Inaccurate BP assessment may lead to inappropriate treatment of hypertension.

The Advanced Health and Disaster Aid Network: A Light-Weight Wireless Medical System for Triage

Advances in semiconductor technology have resulted in the creation of miniature medical embedded systems that can wirelessly monitor the vital signs of patients. These lightweight medical systems can aid providers in large disasters who become overwhelmed with the large number of patients, limited resources, and insufficient information. In a mass casualty incident, small embedded medical systems facilitate patient care, resource allocation, and real-time communication in the advanced health and disaster aid network (AID-N). We present the design of electronic triage tags on lightweight, embedded systems with limited memory and computational power. These electronic triage tags use noninvasive, biomedical sensors (pulse oximeter, electrocardiogram, and blood pressure cuff) to continuously monitor the vital signs of a patient and deliver pertinent information to first responders. This electronic triage system facilitates the seamless collection and dissemination of data from the incident site to key members of the distributed emergency response community. The real-time collection of data through a mesh network in a mass casualty drill was shown to approximately triple the number of times patients that were triaged compared with the traditional paper triage system.

A primer on triage and mass casualty events.

Traditional triage of patients is based on giving care to the most critically ill persons first. In a disaster situation or mass casualty event, the type of triage used would change from caring for the most ill first to caring for those most likely to survive first. This change is related to the scarcity of healthcare personnel and resources in a situation where thousands of persons would be ill or injured. Mass casualty collection points would be the site of triage to prevent hospitals from being overrun by patients.

Initial approach to patient management after large-scale disasters

2Preparedness for mass casualty incidents has taken on a new prominence in the United States since the events of September 11th, 2001. Large numbers of pediatric victims are possible in the future, which could overwhelm traditional triage systems in most hospitals. To help prepare the emergency physician for such a disaster, this article briefly outlines an organized approach to mass casualty incidents. Two triage algorithms, one for general disasters, and one for nuclear, biological, and chemical events, are discussed. Decontamination triage is also discussed. Finally, personal observations from the World Trade Center attacks and one hospital's experience are discussed.

Cutting edge discussions of management, policy, and program issues in emergency care

Cutting edge discussions of management, policy, and program issues in emergency care

The case for a universal, valid, reliable 5-tier triage acuity scale for US emergency departments

When sitting in a first grader's desk as an adult, it does not take long to realize that the desk no longer fits. Similarly, the US emergency departments' traditional triage acuity rating scales no longer fulfill their intended purpose.

Comprehensive Emergency Mental Health Care

Back to table of contents Previous article Next article Book ReviewFull AccessComprehensive Emergency Mental Health CareDonna M. Moores, M.D.Donna M. MooresSearch for more papers by this author, M.D.Published Online:1 Jul 1998https://doi.org/10.1176/ps.49.7.976AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This very readable, practical book presents an excellent outline of emergency behavioral health services. The authors describe their text as presenting a model of effective mobile emergency treatment services, providing a core of information legitimizing high-quality mental health crisis services in nontraditional settings, and serving as a training manual. The book fairly admirably reaches these goals.The authors are practicing psychiatrists and teachers, and their expertise in both of these areas is evident in their writing. Their level of comfort with this subject and their low-key approach is obvious even in the section titles, such as Nuts and Bolts of Program Operation, and Crash Course in Medical Psychiatry for the Nonphysician.Comprehensive Emergency Mental Health Care is written for a multidisciplinary audience, assuming a team approach to treatment. It moves from organizational theory, with attention to fiscal and political realities, to operational detail. Attention is given to the position of emergency and mobile services on the full continuum of mental health care. The emergency treatment team, as the authors envision it and have organized it, moves out of the confines of a particular building or institution—away from the traditional triage service to one that can provide definitive treatment in an impressive, modern-day version of the house call.The unifying focus is the patient who typically presents in a multifaceted crisis involving psychiatric symptoms, social stressors and support failures, medical-status questions, and safety issues. Thoughtful, sound approaches to care as well as specific protocols, forms, and other tools are included. Rich clinical detail and useful case examples are interspersed in a helpful, enlivening manner. The authors also attend to the needs of the practicing clinicians, offering strategies to combat burnout, and enhance clinical effectiveness through education, involvement in the process, and intense supportEmergency psychiatry is a very hands-on practice that requires a high level of organization and integration. Patients must be thoroughly yet efficiently evaluated. Individuals who are out of control or out of touch need humane, respectful attention. Important linkages must be made with the family, community supports, systems of mental health care, and medical services. Each emergency intervention is a unique opportunity to have a positive impact on a vulnerable person, an overwhelmed family. The accompanying risks are high.It is into such a high-pressure environment that this book brings order and optimism where there so often can be chaos. Front-line staff need training and support. Administrative organization must be logical and accessible. The services should have a sense of overall mission as well as day-to-day goals to focus the work. Drs. Zealberg and Santos have faced these challenges and given us a guidebook that can be useful to those in training, in practice, and in management.Dr. Moores is chief of clinical programs in psychiatry at the Boston Medical Center and vice-chair for clinical programs in the department of psychiatry at Boston University School of Medicine.by Joseph J. Zealberg, M.D., and Alberto B. Santos, M.D., with Jackie A. Puckett, L.M.S.W.; New York City, W. W. Norton & Company, 1996, 290 pages, $37 FiguresReferencesCited byDetailsCited ByNone Volume 49Issue 7 July 1998Pages 976-976 Metrics History Published online 1 July 1998 Published in print 1 July 1998

Disaster triage: START, then SAVE--a new method of dynamic triage for victims of a catastrophic earthquake.

Triage of mass casualties in situations in which patients must remain on-scene for prolonged periods of time, such as after a catastrophic earthquake, differs from traditional triage. Often there are multiple scenes (sectors), and the infrastructure is damaged. Available medical resources are limited, and the time to definitive care is uncertain. Early evacuation is not possible, and local initial responders cannot expect significant outside assistance for at least 49-72 hours. Current triage systems are based either on a shorter time to definitive care or on a longer time to initial triage. The Medical Disaster Response (MDR) project deals with the scenario in which specially trained, local health-care providers evaluate patients immediately after the event, but cannot evacuate patients to definitive care. For this type of scenario, a dynamic triage methodology was developed that permits the triage process to evolve over hours or even days, thereby maximizing patient survival and resulting in a more efficient use of resources. This MDR system incorporates a modified version of "Simple Triage and Rapid Treatment" (START) that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed, "Secondary Assessment of Victim Endpoint" (SAVE). The SAVE triage was developed to direct limited resources to the subgroup of patients expected to benefit most from their use. The SAVE assesses survivability of patients with various injuries and, on the basis of trauma statistics, uses this information to describe the relationship between expected benefits and resources consumed. Because early transport to an intact medical system is unavailable, this information guides treatment priorities in the field to a level beyond the scope of the START methodology. Pre-existing disease and age are factored into the triage decisions. An elderly patient with burns to 70% of body surface area is unsalvageable under austere field conditions and would require the use of significant medical resources-both personnel and equipment-and would be triaged to an "expectant area." Conversely, a young adult with a Glasgow Coma Scale score of 12 who requires only airway maintenance would use few resources and would have a reasonable chance for survival with the interventions available in the field, and would be triaged to a "treatment" area. The START and SAVE triage techniques are used in situations in which triage is dynamic, occurs over many hours to days, and only limited, austere, field, advanced life support equipment is readily available. The MDR-SAVE methodology is the first systematic attempt to use triage as a tool to maximize patient benefit in the immediate aftermath of a catastrophic disaster.