USE OF SALT TRIAGE IN A SIMULATED MASS-CASUALTY INCIDENT

Transcription

1 USE OF SALT TRIAGE IN A SIMULATED MASS-CASUALTY INCIDENT E. Brooke Lerner, PhD, Richard B. Schwartz, MD, Phillip L. Coule, MD, Ronald G. Pirrallo, MD, MHSA ABSTRACT Objectives. To determine the accuracy of SALT (sort assess lifesaving interventions treatment/transport) triage during a simulated mass-casualty incident, the average time it takes to make triage designations, and providers opinions of SALT triage. Methods. Seventy-three trainees participating in one of two disaster courses were taught to use SALT triage during a 30-minute lecture. The following day they participated in teams, in one of eight simulated mass-casualty incidents. For each incident trainees were told to assess and prioritize all victims. Each scenario comprised 28 to 30 victims, including 10 to 11 moulaged manikins and 18 to 20 moulaged actors. Each victim had a card that stated the victim s respiratory effort, pulse quality, and ability to follow commands. Initial and final assigned triage categories were recorded and compared with the intended category. Ten of the victims were equipped with stopwatches to measure the triage time interval. Timing began when the trainee approached the victim and ended when the trainee verbalized his or her triage designation. The times were averaged and standard deviations were calculated. After the drill, trainees were asked to complete a survey regarding their experience. Results. There were 217 victim observations. The initial triage was correct for 81% of the observations; 8% were overtriaged and 11% were undertriaged. The final triage was correct for 83% of the observations; 6% were overtriaged and 10% were undertriaged. The mean triage interval was 28 seconds (±22; range: 4 94). Nine percent reported that prior to the drill they felt very confident using SALT triage and 33% were not confident. After the drill, no one reported not feeling confident using SALT triage, 26% were at the same level of confidence, 74% felt more confident, and none felt less confident. Before the drill, 53% of the respondents felt SALT triage was easier to use than their current disaster triage protocol, 44% felt it was similar, and 3% felt it was more Received March 23, 2009, from the Department of Emergency Medicine, Medical College of Wisconsin (EBL, RGP), Milwaukee, Wisconsin; and the Department of Emergency Medicine, Medical College of Georgia (RBS, PLC), Augusta, Georgia. Revision received June 2, 2009; accepted for publication June 9, Presented at the National Association of EMS Physicians annual meeting, Jacksonville, Florida, January The authors would like to acknowledge the cooperation of the National Disaster Life Support Foundation in the conduct of this study. Dr Lerner was partially supported by CDC grant R49/CE The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper. Address correspondence and reprint requests to: E. Brooke Lerner, PhD, Department of Emergency Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI eblerner@mcw.edu doi: / difficult. After the drill, no one reported that SALT triage was more difficult to use. Conclusion. We found that assessments using SALT triage were accurate and made quickly during a simulated incident. The accuracy rate was higher than those published for other triage systems and of similar speed. Providers also felt confident using SALT triage and found it was similar or easier to use than their current triage protocol. Using SALT triage during a drill improved confidence. Key words: disaster; triage; emergency medical services: triage; SALT triage PREHOSPITAL EMERGENCY CARE 2010;14:21 25 INTRODUCTION The process of sorting multiple casualties for treatment was first described over 200 years ago and today is known as mass-casualty triage. 1,2 Civilian emergency medical services (EMS) providers are routinely trained in a method of prioritizing patients for treatment and/or transport. Triage becomes even more critical whenever they are faced with more patients than EMS providers. This can occur during a large-scale disaster or may more commonly occur during a smaller event such as a multivehicle crash. Within the United States, the specific system of mass-casualty triage a prehospital care provider uses is largely dependent on local or regional protocols, with little consistency or interoperability between jurisdictions. A recent Centers for Disease Control and Prevention (CDC)-sponsored panel developed a proposed national guideline for mass-casualty triage called SALT (sort assess lifesaving interventions treatment/transport) triage (Fig. 1). 3 They recommended that across the United States a uniform standard be adopted so that all EMS providers would use a similar language and process when responding to a mass-casualty event. The proposed guideline incorporated aspects from all of the existing triage systems to create a single overarching guide for unifying masscasualty triage. This nonproprietary guideline can be used for any patient regardless of age or physical or mental limitations. The concept has been endorsed by many national organizations, 4 but scientific validation of the guideline is still needed. Key aspects of SALT triage include a global sorting of patients using voice commands so that individual assessment can be prioritized, lifesaving interventions are considered first during individual assessment, and an expectant category is included that is dependent on resource availability. 3 The objective of this study was to evaluate SALT triage. This study had three specific aims: 1) to 21

2 22 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2010 VOLUME 14 / NUMBER 1 FIGURE 1. The SALT triage guideline. LSI = lifesaving intervention; SALT = sort assess lifesaving interventions treatment/transport. determine trainee accuracy when using SALT triage during a simulated mass-casualty incident, 2) to determine the average time required to make triage designations during individual patient assessment, and 3) to determine trainees opinions of SALT triage. METHODS This prospective observational study was conducted during two Advanced Disaster Life Support (ADLS) courses. One course was conducted in Augusta, Georgia, in July 2008 and the other in Milwaukee, Wisconsin, in December The courses had open enrollment and were widely advertised within each community. The Augusta course was held on a military base and had a combination of military and civilian trainees. The Milwaukee course was held at a Veterans Affairs hospital and had primarily civilian trainees. During the mass-triage section of each course, the trainees were taught to use the SALT triage method. The SALT triage training was provided as a 30-minute lecture. The training in Augusta was provided by an ADLS-certified instructor who was also a member of the CDC panel that developed SALT. The training in Milwaukee was provided by an ADLS-certified instructor who had had limited previous experience with the SALT triage method. Both presentations used a similar set of slides differing only in the correction of minor typographical errors and improvement in formatting. The day after the SALT training was provided, all trainees participated in one of eight simulated mass-casualty incidents. The trainees were placed in teams of eight to 11 people and were told that they were responding to a bomb blast at a community concert. Each incident included between 28 and 30 bomb blast victims. Moulaged manikins represented between 10 and 11 of the victims and 18 to 20 moulaged actors were used to represent the remaining victims. Each victim had a card that stated the victim s respiratory effort, pulse quality, and ability to follow commands. The actors were also given instructions on how to act out their symptoms, and several were told to disrupt the scene by yelling for help, acting intoxicated, or demanding assistance for their friend. The drills were made as realistic as possible with noise, sirens, and other real-life distractions such as interruptions by members of the media and having to deal with a secondary device on one of the victims (i.e., a bomb or gun). The simulated incident in Augusta was conducted outside and used a group of teenaged boys as the actors. The Milwaukee session was conducted in a gymnasium with limited lighting and used a variety of community volunteers as victims. Each incident used the same scenario, a bomb blast at a local concert, and the same victims. Because two actors were not available for all drills, a few of the incidents were not able to use all of the patient scenarios. An observer who was identified as an instructor monitored the drill and recorded the initial and final assigned triage categories for each simulated victim.

3 Lerner et al. SALT TRIAGE IN SIMULATED MASS-CASUALTY INCIDENT 23 The initial assigned triage category was the category that was assigned by the first trainee who assessed the patient. The final assigned triage category was the category that was assigned at the end of the drill. During the drill the victims conditions did not change, but frequently other members of the trainee responder group would identify what they perceived as errors in triage and change the victim s designation. The initial and final triage categories were then compared with the intended triage category for each simulated victim. The percentage of correct assignments was determined along with 95% confidence intervals (CIs). Ten of the victims were selected to measure the time required to individually assess the patient. The actors operated stopwatches themselves, while the manikins were timed by an instructor who was observing the drill and providing information on the manikin s condition. Timing began when the trainee approached the victim and ended when the trainee verbalized his or her triage designation or applied a triage tag. The recorded times were averaged and the standard deviations were calculated. Trainees were told that the drill was being studied, but they were not told that they were being timed. After the drill debriefing, trainees were asked to complete an optional retrospective before-and-after survey measuring the degree of self-reported competence before and after the drill. The survey explored trainees confidence with SALT and ease of use as well as basic demographic information. The survey had been previously pilot-tested. Results were analyzed using descriptive statistics. This study was considered exempt from institutional review board review by the institutional review boards at the Medical College of Georgia and the Medical College of Wisconsin. RESULTS Seventy-three (73) trainees participated in the two ADLS courses. There were 43 trainees at the Augusta course, including 16 physicians, 10 nurses, five prehospital care providers, five physician s assistants, three pharmacists, and four people from other backgrounds. There were 30 trainees at the Milwaukee course, including 11 physicians, six nurses, eight prehospital care providers, one nurse/prehospital care provider, and four people from other backgrounds. Overall, 63% of the trainees reported having prior drill experience. The mean number of prior drills for those with prior experience was 7 (minimum 1 and maximum 60). Twenty-nine percent of the trainees had prior actual mass-casualty incident experience. The mean number of prior mass casualty incidents for those with prior experience was 3 (minimum 1 and maximum 15). Twenty-one percent of the trainees re- TABLE 1. First Assigned Triage Category Compared with the Intended Category First Assigned Triage Category Intended Category Dead Expectant Immediate Delayed Minimal Dead Expectant Immediate Delayed Minimal Indicates the correct assignment. ported that they had heard of SALT triage prior to taking the course. During the eight simulated mass-casualty triage incidents, 235 victim observations were studied. Eighteen were excluded because the role was incorrectly acted by the actor victim (3), the victim was incorrectly moulaged (4), the victim was carrying a secondary device (5), the victim was not triaged during the allotted time (5), or the observer did not record the triage category (1). Overall, the initial triage was correct for 81% (95% CI: 75% 86%) of the observations; 8% were overtriaged and 11% were undertriaged (Table 1). The final triage was correct for 83% (95% CI: 78% 88%) of the observations; 6% were overtriaged and 10% were undertriaged (Table 2). During the course in Augusta, the final triage designation was correct for 86% of the observations; 7% were overtriaged and 7% were undertriaged. During the course in Milwaukee, the final triage designation was correct for 80% of the observations; 13% were overtriaged and 7% were undertriaged. There were a total of 58 timed victim observations because six times were not recorded; three victims were not triaged, so no time could be determined; and one victim was excluded from the time segment of the study. This victim participated in the Milwaukee course and was excluded from the analysis because the actor was told by the course observer/controllers to demand that the providers help her friend first. The actor was observed as being very insistent and distracting to the trainees, leading to extremely long triage times that ranged from 133 to 180 seconds. The overall mean triage interval was 28 seconds (standard deviation 22; minimum 4, maximum 94) (Fig. 2). If the TABLE 2. Final Assigned Triage Category Compared with the Intended Category Final Assigned Triage Category Intended Category Dead Expectant Immediate Delayed Minimal Dead Expectant Immediate Delayed Minimal Indicates the correct assignment.

4 24 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2010 VOLUME 14 / NUMBER 1 FIGURE 2. Frequency of observation for each range of time to triage. excluded victim s data had been included, the overall average would have increased to 34 seconds. During the Augusta course the mean triage interval was 27 seconds (standard deviation 23). During the Milwaukee course the mean triage interval was 30 seconds (standard deviation 21). Of the 73 trainees who participated in the two courses, 70 (96%) completed the retrospective survey. Prior to the drill, 33% did not feel confident using SALT triage and 32% were confident or very confident using SALT. After the drill, none of the respondents did not feel confident using SALT triage, 26% were at the same level of confidence, 74% felt more confident, and none felt less confident (Table 3). Before the drill, more than half, 53%, thought SALT was easier to use than their current disaster triage protocol and 3% thought it was more difficult to use than their current disaster triage protocol (Table 4). After the drill, no respondents reported that SALT was more difficult to use than their current disaster triage protocol. Further, 77% did not change how easy they felt SALT triage was to use, 18% thought it was easier after the drill, and 5% thought it was similar rather than easier to use after the drill. Twenty-three participants had prior actual disaster experience, and of those none thought SALT triage was harder to use than their current triage protocol. DISCUSSION This study found that trainees who were taught to use SALT triage had a high rate of accuracy. The 83% accuracy rate that was seen in this study is comparable to, if not better than, what has been reported when TABLE 3. Change in Confidence before the Drill Compared with after the Drill Confidence after the Drill Confidence Prior Very Somewhat Not to the Drill Confident Confident Confident Confident Very confident Confident Somewhat confident Not confident Simple Treatment and Rapid Transport (START) triage has been studied. These studies have shown that accuracy ranged from 48% 5 to 75%. 6 Further, 79% of the trainees had not heard of SALT triage prior to the training that was provided as part of the studied courses, and 37% had never before participated in a disaster drill. This indicates that SALT triage has the potential of being readily learned and correctly used with minimal training. The mean of 28 seconds to make a triage designation while individually assessing a victim is comparable to, if not better than, other systems. A previous study found that START triage had a mean triage time of 30 seconds and the Sacco triage method using the RPM (respiratory rate, pulse, motor) score had a mean triage time of 45 seconds. 7 It is hypothesized that the triage time using SALT triage might be reduced because it does not require an estimation of the victim s pulse or respiratory rate. However, additional research is needed to make this determination. Two-thirds of trainees thought SALT triage was easier to use than their current triage protocol. More importantly, of those who had prior actual mass-casualty incident experience, none of them felt that SALT triage was harder to use than their current triage protocol. This indicates that providers will not have difficulty changing to meet the SALT triage guideline. This study also determined that after initial didactic training, a minority of trainees felt very confident using SALT. After using SALT triage in a drill, all of the participants had some level of confidence using SALT triage, and almost a third felt very confident using it. This indicates that it is likely very important for trainees to be given experience using a triage system TABLE 4. Change in Ease of Use before the Drill Compared with after the Drill After the Drill SALT SALT SALT Is More Prior to the Drill Is Easier Is Similar Difficult SALT is easier SALT is similar SALT is more difficult 2 0 0

5 Lerner et al. SALT TRIAGE IN SIMULATED MASS-CASUALTY INCIDENT 25 rather than simply being provided with a didactic lecture. However, additional research should be done to determine the optimal required training to be prepared to respond to a mass-casualty incident. Interestingly, minimal differences in the results were found between the Augusta and the Milwaukee drills, even though the instructors had very different experience levels with SALT. The Augusta instructor was one of the creators of SALT and the Milwaukee instructor had only limited experience with SALT. This may indicate that SALT is relatively easy to teach, although further research and evaluation are needed. However, this may also be due to the differences in the circumstances of the two drills (e.g., the differences in lighting) or some other unknown factor. LIMITATIONS This study was conducted during a simulated exercise. The findings may not be the same as what would be seen during a real mass-casualty incident. Further, the accuracy of the triage categories was based on the SALT triage category definitions, which have not been correlated to survival or patient outcome. This study was not capable of correlating triage category with patient outcome, so it was not possible to determine whether using SALT triage will improve patient outcome. This study was also limited to trainees in one of two ADLS courses. These trainees may not be generalizable to all of the types of responders who might be trained to use SALT triage, and we cannot report on the accuracy of different provider types. The retrospective self-assessment survey is designed to reduce response shift that can confound the validity of traditional self-ratings. This instrument is a wellestablished instrument to assess the effectiveness of teaching interventions. 8 The victims who timed the triage decision making were told to begin the timer when the responder approached them ; this may have introduced some variability in timing since victims may have interpreted this instruction differently. Further, although we used a variety of patient types for timing including two that needed lifesaving interventions, in a real incident these times may be longer if more lifesaving interventions are applied. CONCLUSION Trainee victim assessments made using SALT triage during a simulated disaster drill were found to be accurate. Providers with minimal experience and training were able to make quick and accurate triage decisions. The accuracy rate was higher than those published for the START triage system and of similar speed. Providers also felt confident using SALT triage and found it was similar to or easier to use than their current triage protocol. Using SALT triage during a drill improved confidence in its use. More work is needed, but SALT triage appears to be a promising triage tool for mass-casualty incidents. References 1. Hoey BA, Schwab CW. Level I center triage and mass casualties. Clin Orthop Relat Res May;(422): Kennedy K, Aghababian RV, Gans L, Lewis CP. Triage: techniques and applications in decision making. Ann Emerg Med. 1996;28: Lerner EB, Schwartz RB, Coule PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(suppl 1):S25 S SALT mass casualty triage. Disaster Med Public Health Prep. 2008;2(4): Risavi BL, Salen PN, Heller MB, Arcona S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care. 2001;5: Kahn C, Schultz C, Miller K, Anderson C. Does START triage work? An outcomes-level assessment of use at a mass casualty event [abstract]. Acad Emerg Med. 2007;14(suppl 1):S12a S13a. 7. Sacco WJ, Navin DM, Fiedler KE, Waddell RK 2nd, Long WB, Buckman RF Jr. Precise formulation and evidence-based application of resource-constrained triage. Acad Emerg Med. 2005;12: Pirrallo RG, Wolff M, Simpson DE, Hargarten SW. Analysis of an international EMS train-the-trainer program. Ann Emerg Med. 1995;25:656 9.

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