National Guideline for Mass Casualty Triage Proposed

Newswise — A national guideline for triage following a mass casualty incident has been proposed by a national multidisciplinary workgroup lead by a researcher at the Medical College of Wisconsin in Milwaukee. This guideline allows providers to sort patients for treatment based on the severity of their conditions and establishes a standardized nomenclature.

The workgroup, led by E. Brooke Lerner, Ph.D., associate professor of emergency medicine at the Medical College, today published its proposed national guideline in the September supplemental issue of Disaster Medicine and Public Health Preparedness focusing on triage.

The workgroup's proposed guideline is known as SALT triage, an acronym for Sort, Assess, Life Saving Interventions, Treatment and/or Transport. It includes a standardized naming and color-coding system to identify and prioritize patients medical needs, and was developed with the intention that it could be used to treat all types of patients in all types of incidents.

Other triage systems in the United States focus on treating adults or children exclusively. SALT, on the other hand, can be used to treat all patients in any type of mass casualty event. "Since it relies on existing evidence supporting the effectiveness of other triage systems, it is expected that it would be easy to incorporate into current triage protocol through simple modifications to existing plans," says Dr. Lerner.

Currently there is no nationally agreed upon triage system. However, because mass casualty events often cross jurisdictional lines, a national guideline is needed. A national committee of physicians, EMS providers, and scientists felt that it was possible to use the best available scientific information and consensus opinion to develop a system that could serve as a proposed national guideline for mass casualty triage.

"The specific system of mass casualty triage that a prehospital care provider learns to use has been dependent largely on local or regional protocols with little consistency or interoperability between jurisdictions," says Dr. Lerner.

The workgroup reviewed existing triage systems in the United States and evaluated the scientific evidence available to support each system. The committee conducted an exhaustive literature review identifying nine existing triage systems.

SALT represents the committee's position on which elements of those nine triage systems were most effective and could be included in a proposed national guideline. This was done by using the grid of existing systems to generate a list of key components for a triage system. Each component was discussed by the group until consensus was reached.

The first step in SALT, the Sort process, represents where SALT differs most from previous triage systems. In this first step, patients are prioritized for individual assessment through simple voice commands, like asking patients to walk to a designated area or wave their hands. Other triage systems usually sort patients by asking them to walk, but then consider all those patients to be minimally injured without conducting an individual assessment. This might cause patients who are able to walk but need immediate care to be ignored for long periods of time. This guideline requires that those patients be individually assessed prior to designating them as minimally injured.

"This guideline suggests that providers begin the triage process by identifying those who are able to walk," says Dr. Lerner. "Simple voice commands are used to prioritize patients for individual assessment and to give those who can walk clear instructions regarding where to go for help. These instructions may keep casualties from self-triaging to the closest hospital by giving them a specific place to go for additional assistance."

The wave command allows responders to distinguish between patients who are not able to follow a command from those who can follow a command but can not walk; this gives responders an opportunity to more easily identify which patients need critical care.

"By assessing those patients who are not waving or making purposeful movements first, the provider is likely to approach those patients who may require lifesaving interventions first," says Dr. Lerner.

The second step in SALT is individual assessment of patients. The first priority during the assessment is to provide lifesaving interventions. These include controlling major hemorrhage; opening the patient's airway; decompressing the chest of patients with tension pneumothorax, and providing antidotes for chemical exposures.

"These interventions were selected because they can be applied rapidly and can have a profound impact on survival," says Dr. Lerner. Once the lifesaving interventions are provided patients are prioritized for treatment based on assignment to one of five color-coded categories. Patients in need of immediate care are given the color code red. Expectant patients, or those who are likely to die even given the available resources, are given the color code gray. Patients whose injuries are minimal and can tolerate a delay in care without an increased risk to mortality are given the color code green. Dead patients are given the color code black. The remaining patients, displaying injuries that need care but not immediately, are categorized as delayed and given the color code yellow.

Once patients are sorted into categories they have been prioritized for treatment and or transport to a hospital. Those who are critically injured are the first to be transported to emergency centers for further treatment and/or treated at the site of the event.

"It is common for disasters to cross multiple jurisdictional lines and/or require responders to be deployed from across the country," she explains. "A national standard will allow responders to use the same language and processes." The project was supported by the Department of Health and Human Services, Centers for Disease Control and Prevention, ''Terrorism Injuries: Information Dissemination and Exchange.'' The findings and conclusions of the project are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

For more in formation go to: http://www.mcw.edu//Releases/2008Releases/NatlGuidelineMassCasualtyTriage.htm.