Homebush Triage Standard

The Homebush Triage Standard methodology was developed in Australia in 1999 as an attempt to unify varying triage protocols across the country.¹⁴ It is based on the START and SAVE triage systems. It includes a fifth triage category called “dying” which is given a white label. This category is meant to separate the dead (labeled black) from the dying, so that comfort care can be provided to those patients who are dying. The red category is assigned to patients who have no palpable radial pulse, are unable to follow commands, or have respirations > 30 breaths per minute. Non-urgent and urgent patients are determined identically to START’s minor and delayed patients, respectively. This system also uses geographic location rather than triage tags to indicate the patients’ condition. In other words, patients are physically moved to the “level white” area, rather than placing a tag on their body to indicate their triage assignment. In addition to a color, each category also has a designated standard phonetic alphabet code (e.g., alpha, bravo, charlie, delta, and echo) to facilitate radio communication (see Figure 14.2).

Figure 14.2.

Homebush Triage Standard.

Finally, in addition to primary triage, this system includes a secondary patient assessment to evaluate the extent of injuries and consider them in light of the available resources. This secondary system is used to prioritize order of transport to the hospital.

Use of the Homebush Triage System was documented in the Bali bombing on October 12, 2002, but again, only descriptive information is provided, with no data regarding triage accuracy or effect on any particular outcome.¹⁵ Although it is not clear which triage system, if any, was used at the scene, the Homebush taxonomy was modified and used on board the first aircraft repatriating patients to Australia.

CareFlight Triage

The CareFlight system is a triage tool used in parts of Australia. Presence of breathing, level of consciousness, and presence of radial pulse determine the triage priority. This system is similar to START, with the notable exceptions that respiratory rate is not evaluated in CareFlight, and that assessment of mental status (ability to follow commands) is done prior to assessment of circulation. CareFlight also uses a four-color system to identify patients who should be triaged as unsalvageable, immediate, urgent, and delayed (see Figure 14.3).

Figure 14.3.

CareFlight Triage.

A retrospective 2001 study by Garner et al. compared START, modified START, and Triage Sieve with CareFlight and determined CareFlight to be more specific for critical injury (as defined by modified Baxt criteria) and faster to administer.⁵ However, this difference was minimal, with the difference between the upper limit of the 95% confidence interval for specificity of the modified START system (using radial pulse) and the lower limit of that for CareFlight being only 1%. Although Triage Sieve was significantly less sensitive (with roughly equivalent specificity) for critical injury in this study, some have noted that failure to include Triage Sort (the secondary triage system that is meant to follow Triage Sieve) as part of this algorithm may limit the applicability of these results to actual disasters.

Triage Sieve

Triage Sieve has been widely adopted in the United Kingdom, parts of Europe, and parts of Australia, and is accepted by NATO. Triage Sieve is similar to START in that a preliminary walking filter is followed by the use of respiratory rate and capillary refill or heart rate to classify patients into triage categories. Patients able to walk are classified as “delayed” priority III; patients who do not breathe following an attempt to open the airway are classified “dead” priority IV; and patients with a respiratory rate of <10 or >29, capillary refill time of >2 seconds, or heart rate of >120 beats/minute are classified “immediate” priority I. All other patients are considered “urgent” priority II. Triage Sieve does not measure level of consciousness (see Figure 14.4).

Figure 14.4.

Triage Sieve.

Use of Triage Sieve was documented in the London bombings of July 7, 2005.¹⁶ In general, Triage Sieve is used as a primary “triage-to-treatment” algorithm, and is followed by a secondary “triage-to-transportation” algorithm, Triage Sort.

Sacco Triage Method

The Sacco Triage Method was developed in the United States by conducting a logistic regression analysis using data from a statewide trauma registry. The Delphi technique was then used to estimate the chances of victim deterioration by obtaining consensus among a group of six experts based on changes in physiologic parameters of the patient.¹⁷ This triage system is intended to account for both the patient’s physiologic parameters and the available resources.

The Sacco Triage Method first requires on-scene personnel to enter available resource information into a computer database. A physiological score is then computed mathematically for each patient. This score considers the patient’s respiratory rate, pulse rate, and best motor response, assigns each variable a coded value, and then sums these values to calculate the Sacco Score (see Table 14.1).¹⁸

Prehospital personnel can calculate this score manually or using the computer. After data entry, the developers report that this score can be determined and a triage category assigned within 45 seconds. The victims are tagged and organized into groups according to the score. Triage tags have a large clock face with numbers representing the score. The triage officer contacts a central dispatcher and provides information on number of victims, the Sacco Scores, ambulance processing rate at the scene, and number of landing sites for helicopters. These data are entered into the proprietary software, which then produces the optimal triage strategy. This strategy defines the order in which victims are transported and treated and to which hospitals they are sent. The system can also alert the hospitals to the number, severity, and scheduled arrival of patients. The Sacco Triage Method is proprietary, and accordingly, the specific details of how triage and transport decisions are determined are not publicly available for review, research, or independent confirmation. Reliable information on current deployment and field success is not available. The developers report that the Sacco Score accurately predicts a patient’s survivability from trauma, although this has not been prospectively validated.¹⁹

CESIRA Protocol

The CESIRA Protocol, developed in Italy in 1990, has three basic categories: red, which includes patients who are unconscious, hemorrhaging, in shock, or having respiratory insufficiency; yellow for patients with broken bones and other injuries; and green for victims able to walk. CESIRA is the Italian acronym for the words describing these injuries (see Figure 14.5).

Figure 14.5.

CESIRA Triage Protocol.

CESIRA does not contain a “dead” category; non-physicians are not legally authorized to declare death in Italy, and the system is designed for prehospital use when physicians are not present.

Military/NATO Triage

The main objective of military triage is to treat and return injured soldiers to the front lines as soon as possible. For those who cannot return to duty, medical focus is on wound debridement, limb salvage, and preservation of life. Military triage is based on the North American Treaty Organization (NATO) triage classification, a subjective categorization based on expected survival and resource utilization. All NATO member countries follow a standardized triage system for their military operations providing consistency for multinational operations. Military triage begins with the immediate sorting of patients according to type and severity of injury and likelihood of survival, and the establishment of priority for treatment and evacuation to assure optimal medical care to the largest number of casualties. Most military triage systems use the “T” (treatment) system: T1, T2, T3, T4, and dead. Others such as the British Military use the “P” (priority) system: P1, P2, P3, and P1-hold.²⁰ Holding areas are set up for the victims according to their injuries following initial evaluation. Patients are treated and stabilized until they can be transported to a medical facility. The classification scheme is subjective, based on the experience of the triage provider rather than specified physiologic criteria (see Table 14.2).

SALT Triage

A U.S. government funded project to examine existing triage systems has resulted in the development of the SALT Triage system. After determining that no existing system had enough scientific support to recommend its use, a workgroup used the limited existing data and expert opinion to develop the SALT Triage system, attempting to incorporate the best features of the existing systems. SALT is intended to serve as a national all-hazards mass-casualty initial triage standard for all patients (e.g., adults, children, special populations).²¹

SALT begins with a global sorting of patients to prioritize them for individual assessment. Patients who are able to walk are instructed to walk to a designated area, and are assigned last priority for individual assessment. Those who remain are asked to wave or are observed for purposeful movement. Those who do not move (i.e., are still) and those with obvious life threats are assessed first, since they are the most likely to need lifesaving interventions (LSIs).

The individual assessment begins with limited LSIs that are only performed if the intervention is within the responder’s scope of practice, and only if the equipment is immediately available. The recommended LSIs include controlling major hemorrhage, opening the airway, providing chest decompression, and using auto injector antidotes. If the patient is a child and not breathing, the provider can consider giving two rescue breaths.

After any needed LSIs are provided, patients are prioritized for treatment and/or transport by assigning them to one of five categories. Patients who are not breathing even after LSIs are attempted are triaged as dead. Patients who have mild injuries that are self-limited if not treated, and can tolerate delays in care without increasing their risk of mortality, are triaged as minimal. Patients who do not obey commands, do not have a peripheral pulse, are in respiratory distress, or have uncontrolled major hemorrhage are triaged as immediate. Within this group of immediate patients, however, providers should also consider if a patient has injuries that are likely to be incompatible with life given the currently available resources. If so, then the provider triages that patient as expectant rather than immediate. The remaining patients are triaged as delayed (see Figure 14.6).

Figure 14.6.

SALT Mass Casualty Triage.

To assist with identification of patients, SALT recommends that the deceased be symbolized by the color black, expectant by gray, immediate by red, delayed by yellow, and minimal by green.

Standardizing the Structure for Disaster Triage

As is evident from the previous discussion, a lack of standardization exists across multiple mass-casualty triage platforms. Development of guidelines to promote interoperability and standardization in disaster triage would be a significant advancement. This has recently been achieved in the United States with the creation of the Model Uniform Core Criteria (MUCC). These Core Criteria review the science on mass-casualty triage and promulgate a set of principles that should be adhered to by whatever mass-casualty triage system is being used in a community. They were developed by expanding the work group that created SALT Triage using funding from the CDC.²² The concept of the Core Criteria is to allow local agencies to develop or modify their response plans in accordance with a national guideline that sets standards and creates interoperable terminology and definitions, while maintaining the local control required to ensure an appropriately flexible response.

There are four general categories of criteria in the MUCC: general considerations, global sorting, lifesaving interventions, and assignment of triage categories. While it is clear that there is a lack of scientific evidence to support most of the current components of mass-casualty triage – for example, only two of the twenty-four criteria listed in the MUCC are supported by direct science – the Core Criteria do provide a framework in which existing triage systems can be modified to ensure that even when working in different jurisdictions, emergency responders will have the basic knowledge needed to successfully perform triage. The U.S. government recently approved an implementation plan for ensuring that the Model Uniform Core Criteria are adopted nationwide.

One limitation of the Core Criteria is that the group creating them first developed SALT Triage. Therefore, potential bias exists in favor of SALT by the Core Criteria. To address this potential flaw, it might be useful to expand this concept to the global community using a group of international experts. Creating international guidelines standardizing disaster triage across countries could improve the effectiveness of response teams from multiple countries deployed to the same event.

Secondary Triage Systems

In situations where time to definitive care is extensively prolonged, or when resources are insufficient to meet demand, secondary triage systems may be used to further categorize victims for prioritization of transport or treatment. In severely resource-constrained environments, these systems are designed to consider the likelihood of a positive outcome in addition to the urgency of treatment and the amount of medical supplies and equipment required. Consequently, the resulting priority decisions for transport and other resource utilization may not be in complete concordance with the primary triage. Importantly, there has been even less research done to examine these systems compared to primary triage.

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