Table 3.

Key Articles Discussing Mass Casualty Disasters and Triage Validation

Author(s)	Study Design	Disaster Type	Sample	Results
Olchin & Krutz, 201250	Literature review	All hazards	NA	Evidence-based pre-hospital guidelines for care of mass casualty victims
American Academy of Pediatrics et al., 201151	Literature review and expert panel consensus	All hazards	NA	Developed uniform criteria for mass casualty triage to include: general considerations, global sorting, lifesaving interventions, and assignment of triage categories for pediatric victims
Lerner et al., 201152	Consensus workgroup	All hazards	Workgroup of experts representing national stakeholder organizations	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.
Lerner et al., 201053	Simulated mass casualty incident using SALT	Bomb blast	28 to 30 victims, including 10 to 11 moulaged manikins triaged by 73 trainees	Of 217 victim observations initial triage showed:  81% correct  8% over-triaged  11% under-triaged.
Navin et al., 201054	Simulated parallel disaster exercises Critique of Simple Triage and Rapid Treatment (START) framework and validation of Sacco Triage Method (STM)	Building collapse	EMT-I and EMT-Ps with a minimum of 2 years of experience used a 99-victim simulated building collapse to determine the accuracy of patient assessment, the timeliness in clearing the scene, the prioritization of patients and attitudinal responses.	START performed poorly STM outperformed START Time to clear the scene:  STM (53 minutes) and START (63 minutes) STM:  12 of 13 most serious patients left the scene in the first 6 ambulances START:  2 of 13 most serious transported in the first 13 ambulances  3 most serious transported by bus nearly an hour later Surveyed providers:  Preferred START to STM falsely believing it to be more accurate, faster, and better able to identify the most serious patients
Neal et al., 201055	Delphi method consensus study	All Hazards	Convenience sample of six prehospital casualty care experts for Delphi expert panel	Develop the PLUS Casualty Triage method to incorporate triage criteria specific to each selected injury mechanism or condition : to identify under-triage of seriously injured casualties
Kahn et al., 200927	Secondary data analysis of START	Train crash	148 records reviewed	2 of 22 red-tagged patients – immediate life-threatening condition 62 of 120 patients – minor injuries over-triaged as red or yellow
Navin et al, 200956	Mathematical models applied to simulations used to correlate patient scores to survival probability using logistic and validated through measures of discrimination and calibration. Deterioration estimates determined through the Delphi method panel of experts Simulations enable outcome comparisons of STM and START Retrospective analysis of combat causalities were also included	Combat causalities with blunt, penetrating and blast overpressurelike trauma	99,369 military-age victims 1,266 patients	In 18 simulations, the projected survivors with STM ranged from 61% to 429% as compared to START’S maximum performance and increases more than 18 fold in comparison to START’S worst case performance. Independent retrospective analysis of the Navy/Marine Corps Combat Trauma Registry showed that of the 1,266 patients with STM scores of 12 (i.e., normal physiology) 28% tagged green 22% tagged red 25% tagged yellow 25% not tagged
Van Sickle et al., 200945	Analysis of the medical records and autopsy reports to describe the clinical presentation, hospital course and pathology from victim hospitalized or deceased as a result of a CL exposure	Chlorine leak casualties from a train derailment	80	Pulse oximetry and arterial blood gas analysis provided early indications of outcome severity. Hypoxia on room air and PO2/FIO2 ratio predicted severity of outcome.
Cone et al., 200837	Airport disaster drill to test CBRN system	Plane crash with release of organophosphate material	56 patient scenarios	Significant under-triage rate (10.7%) System can be applied rapidly by trained paramedics Needs refinement
Jenkins et al., 200840	Literature review to determine the evidence-based approach of existing triage tools	All Hazards	Triage Tools Evaluated:  Care Flight Triage  JumpSTART  Pediatric Triage Tape  Triage Sieve  SAVE  START  STM	Major tools are not developed on evidence-based science. Limited studies address their reliability and validity.
Lerner et al., 200825	Literature review consensus committee comparison of commonly used triage systems and development of a National mass casualty triage guidelines	All Hazards	9 existing mass casualty triage systems	No nationally agreed upon guidelines. Proposed SALT as the national triage guideline.
Gebhart et al., 200726	Secondary data analysis of trauma victims, not mass casualty victims	Trauma	357 trauma patient records randomly selected using a trauma database at a Level II trauma center	75.77% survived with a respiratoryrate <30, palpable radial pulse, and intact mental status. Data analysis suggest efficacy of START.
Hupert et al., 200757	Simulation model of trauma system response	Not specified	Hypothetical population of critically and noncritically injured patients	Examined the relationship between over-triage and critical mortality after a mass casualty incident (MCI) using a simulation model of trauma system response. Over-triage has a positive, negative, or variable association with critical mortality depending on its etiology. In all of the modeled scenarios, the ratio of critical patients to treatment capability has a greater impact on critical mortality than over-triage level or time-dependent mortality assumption.
Wenck et al., 200746	A rapid assessment of the health impact to determine morbidity caused by a chlorine leak and evaluate the effect of the mass-casualty event on health-care facilities.	train derailment	597 victims examined in emergency facilities	Several (exact number of patients not specified) patients experienced a delayed onset of pulmonary edema hours after the exposure. Emergency department physicians should be aware of this possibility and use caution in sending patients with substantial chlorine exposure home after a short period of observation.
Lerner, 200616	Literature review	Traumatic injuries	80 articles reviewed	Determined the sensitivity and specificity of the American College of Surgeon’s field triage criteria (physiologic, anatomic, mechanism of injury, and age and comorbidity). Concluded there is not sufficient research evidence to support the overall ACS field triage criteria.
Sacco et al., 200518	Mathematical models applied to simulation used logistic function-generated survival probability estimates from score based on respiratory rate, pulse rate, and motor response. Deterioration estimates determined through the Delphi method panel of experts. Simulations enable outcome comparisons of STM and START	Blunt trauma	76,459 blunt-injured patients from the Pennsylvania Trauma Outcome Study	STM resulted in greater expected survivorship than START in all simulations.
Navin et al., 200560	Tabletop exercises using START	Not specified	180 EMS providers 45 victims	START protocols not scalable. Strategy for a 20-victim incident is not the same as for a 200- or 2,000-victim incident. Numbers of victims tagged with each color varied widely within and across regions:  red-tagged top priority for transport and treatment ranged from 4 to 44 out of 45 victims.
Peral Gutierrez de Ceballos et al., 200458	Analysis of terrorist bomb explosion injuries in Madrid, Spain	Bomb injuries	2000 causalities	Of 312 patients taken to the hospital:  91 were hospitalized  62 had only superficial bruises or emotional shock.

Triage Tools/Systems:

CBRN: Chemical, Biological, Radiological/Nuclear

SAVE: Secondary Assessment of Victim Endpoint

JumpSTART

Pediatric Triage Tape tools

SALT: Sort, Assess, Lifesaving Interventions, Treatment/Transport

START: Simple Triage and Rapid Treatment

STM: Sacco Triage Method

Triage Sieve