Performance characteristics of five triage tools for major incidents involving traumatic injuries to children
Introduction
The term ‘big bang’ major incident is used to describe a major incident caused by sudden catastrophic events with little or no warning, where the number of casualties is relatively constant from the time of the incident but has the potential to outstrip resources [1], [2]. Such incidents test the response of emergency medical services and hospitals and it is essential that resources are used in an optimal way to target those with greatest need [3]. In order to achieve this, one of the first priorities is to undertake rapid and accurate triage to prioritise and provide care to as many casualties as possible with the intention of minimising loss of life and suffering, moderated by the available resources. However, there is uncertainty around the efficacy of commonly used triage systems, particularly in children
[4], and a recent systematic review of the literature concluded that there is limited evidence of the validity of triage tools in major incidents of this nature [1].
This study aims to assess the performance accuracy of five manual/paper based triage tools when assessing paediatric casualties and to compare the level of agreement between them. The tools assessed are: JumpSTART (age ≤8 years) [5], START (age >8 years) [6], CareFlight [7], Paediatric Triage Tape/Sieve [8], Triage Sort [9].
Section snippets
Study design and data collection
A retrospective observational cohort study was undertaken. Approval was obtained from the Trauma Audit and Research Network (TARN; www.tarn.ac.uk) to analyse data from the TARN database. TARN collects and records data from hospitals across England and Wales for patients who sustain injury resulting in hospital admissions for >3 days, critical care admission or death. A dataset was obtained in August 2009 containing 31,560 paediatric trauma patient records for patients aged less than 16 years,
Results
A total of 31,292 patients aged less than 16 years were included in the study; 10,048 females (32.1%) and 21,244 males (67.9%), with mean ages 7.9 years (standard deviation 4.9 years) and 8.7 years (standard deviation 4.8 years), respectively. A total of 1029 patients (3.3%) died and the median ISS was 9 (IQR 5–13), with 6842 (21.9%) having an ISS >15. Within the group of patients who survived, 19.4% (5878/30,263) had an ISS >15 compared to 93.7% (964/1029) of those in the non-survivor group.
Discussion
There are two key issues in assessing the performance of a triage tool in paediatric major incidents. The tool must be sensitive enough to identify patients at greatest need, but at the same time must ensure the best use of available resources by delaying treatment for patients who do not require immediate attention [17]. This study has used a large dataset to evaluate the performance of five paediatric triage tools against two separate outcomes, survival (dead or alive) and injury severity
Conclusion
There is variation in the performance of existing triage tools used for predicting patient outcome and treatment priority in children. No single tool performed consistently well across all evaluated scenarios.
Conflict of interest statement
The authors declare: GDP, NS, SJBM and CLP had financial support from Department of Health for the submitted work; no other financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Funding
This work was supported by a grant from the Department of Health Emergency Department. The funder had no role in the design, analysis, interpretation of the results, or the writing of the manuscript.
Acknowledgement
We would like to thank Fiona Lecky, Research Director, and Antoinette Edwards, Projects and Research Manager, as the Trauma Audit and Research Network for facilitating access to the TARN database.
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