Comparative Analysis of META and SALT Disaster Triage in an Adult Trauma Population: A Retrospective Observational Study.

BACKGROUND: Medical professionals can use mass-casualty triage systems to assist them in prioritizing patients from mass-casualty incidents (MCIs). Correct triaging of victims will increase their chances of survival. Determining the triage system that has the best performance has proven to be a difficult question to answer. The Advanced Prehospital Triage Model (Modelo Extrahospitalario de Triaje Avanzado; META) and Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) algorithms are the most recent triage techniques to be published. The present study aimed to evaluate the META and SALT algorithms' performance and statistical agreement with various standards. The secondary objective was to determine whether these two MCI triage systems predicted patient outcomes, such as mortality, length-of-stay, and intensive care unit (ICU) admission. METHODS: This retrospective study used patient data from the trauma registry of an American College of Surgeons Level 1 trauma center, from January 1, 2018 through December 31, 2020. The sensitivity, specificity, and statistical agreement of the META and SALT triage systems to various standards (Revised Trauma Score [RTS]/Sort Triage, Injury Severity Score [ISS], and Lerner criteria) when applied using trauma patients. Statistical analysis was used to assess the relationship between each triage category and the secondary outcomes. RESULTS: A total of 3,097 cases were included in the study. Using Sort triage as the standard, SALT and META showed much higher sensitivity and specificity in the Immediate category than for Delayed (Immediate sensitivity META 91.5%, SALT 94.9%; specificity 60.8%, 72.7% versus Delayed sensitivity 28.9%, 1.3%; specificity 42.4%, 28.9%). With the Lerner criteria, in the Immediate category, META had higher sensitivity (77.1%, SALT 68.6%) but lower specificity (61.1%) than SALT (71.8%). For the Delayed category, SALT showed higher sensitivity (META 61.4%, SALT 72.2%), but lower specificity (META 75.1%, SALT 67.2%). Both systems showed a positive, though modest, correlation with ISS. For SALT and META, triaged Immediate patients tended to have higher mortality and longer ICU and hospital lengths-of-stay. CONCLUSION: Both META and SALT triage appear to be more accurate with Immediate category patients, as opposed to Delayed category patients. With both systems, patients triaged as Immediate have higher mortality and longer lengths-of-stay when compared to Delayed patients. Further research can help refine MCI triage systems and improve accuracy.

Role of Emergency Medical Services in Disaster Response - National Association of EMS Physicians Position Statement.

This is the official position statement of the National Association of EMS Physicians on the role of emergency medical services (EMS) in disaster response.

A Rare Presentation of Epstein-Barr Virus Infection.

BACKGROUND: Epstein-Barr virus (EBV) is a herpesvirus spread by intimate contact. It is known to cause infectious mononucleosis. Complications, including hematologic pathology and splenic rupture, are uncommon. This report is a case of EBV-induced autoimmune hemolytic anemia and biliary stasis. CASE REPORT: An 18-year-old man presented to the emergency department with abdominal pain, nausea, vomiting, and jaundice. He did not have risk factors for liver injury or hepatitis. His vital signs were notable for a fever. On examination, he was obviously jaundiced, but not in distress. Laboratory evaluation showed hemolytic anemia and biliary stasis. Ultimately, his inpatient workup yielded positive EBV serology and a positive direct agglutinin test with cold agglutinins. He made a full recovery with supportive care. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: EBV is a widely disseminated herpesvirus. Infectious mononucleosis is a common presentation of acute infection, and treatment of EBV-related diseases are largely supportive. Complications, such as splenic rupture and hematologic pathology, are uncommon. Biliary stasis and autoimmune hemolytic anemia in the form of cold agglutinin disease secondary to EBV is rare, and typically resolves with supportive care and cold avoidance. More advanced treatment methods are available in the setting of severe hemolysis. Elevated transaminases, direct hyperbilirubinemia, or evidence of hemolytic anemia in the setting of a nonspecific viral syndrome should raise suspicion for EBV infection. Rapid recognition can lead to more prompt prevention and treatment of other EBV-related complications.

Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population.

Objective: To use a previously published criterion standard to compare the accuracy of 4 different mass casualty triage systems (Sort, Assess, Lifesaving Interventions, Treatment/Transport [SALT], Simple Triage and Rapid Treatment [START], Triage Sieve, and CareFlight) when used in an emergency department-based adult population. Methods: We performed a prospective, observational study of a convenience sample of adults aged 18 years or older presenting to a single tertiary care hospital emergency department. A co-investigator with prior emergency medical services (EMS) experience observed each subject's initial triage in the emergency department and recorded all data points necessary to assign a triage category using each of the 4 mass casualty triage systems being studied. Subjects' medical records were reviewed after their discharge from the hospital to assign the "correct" triage category using the criterion standard. The 4 mass casualty triage system assignments were then compared to the "correct" assignment. Descriptive statistics were used to compare accuracy and over- and under-triage rates for each triage system. Results: A total of 125 subjects were included in the study. Of those, 53% were male and 59% were transported by private vehicle. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (52%; 95% CI 43-60) compared to START (36%; 95% CI 28-44), CareFlight (36%; 95% CI 28-44), and TriageSieve (37%; 95% CI 28-45). SALT also had the lowest under-triage rate (26%; 95% CI 19-34) compared to START (57%; 95% CI 48-66), CareFlight (58%; 95% CI 49-66), and TriageSieve (58%; 95% CI 49-66). SALT had the highest over-triage rate (22%; 95% CI 14-29) compared to START (7%; 95% CI 3-12), CareFlight (6%; 95% CI 2-11) and TriageSieve (6%; 95% CI 2-11). Conclusion: We found that SALT triage most often correctly triaged adult emergency department patients when compared to a previously published criterion standard. While there are no target under- and over-triage rates that have been published for mass casualty triage, all 4 systems had relatively high rates of under-triage.

A centralized system for providing dispatcher assisted CPR instructions to 9-1-1 callers at multiple municipal public safety answering points.

BACKGROUND: Dispatcher CPR instruction increases the odds of survival. However, many communities do not provide this lifesaving intervention, often citing the barriers of limited personnel, funding, and liability. OBJECTIVE: Describe the implementation of a novel centralized dispatcher CPR instruction program that serves seven public safety answering points (PSAPs). METHODS: Seven municipal PSAPs that did not previously provide dispatcher instructions implemented our program. Using a 30-min self-directed video, 84 PSAP dispatchers were trained to utilize a two-question protocol to identify and transfer suspected out-of-hospital cardiac arrest (OHCA) cases to a central communication center. At this central communication center, a trained communicator delivered CPR instructions to the caller. The 26 central communicators were trained with a 2-h in-person didactic session followed by a 2-h practice session. We collected and analyzed data from recordings of communicator-to-caller interactions. RESULTS: 169 calls were transferred to the central communication center. Of those, 106 needed CPR instructions and 56 of those callers performed chest compressions (53%). The county-wide EMS documented bystander CPR rate was 20% the prior year. The 63 remaining transferred calls were non-OHCA calls. Of the calls where CPR was needed and performed, 11 victims survived to hospital discharge (20%); the countywide survival rate was 12%. CONCLUSIONS: Using a central communication center for instructions allowed us to train and maintain a smaller group of communicators, leading to less cost and more experience for those communicators, while limiting the burden on PSAP dispatchers.

Comparing the Accuracy of Mass Casualty Triage Systems in a Pediatric Population.

INTRODUCTION: It was previously difficult to compare the accuracy of different mass casualty triage systems to one another. This pilot study is one of the first attempts to operationalize an expert panel's criterion standard definitions of triage categories in a pediatric population in order to compare accuracy between different systems. OBJECTIVE: To compare the accuracy of 4 different mass casualty triage systems (SALT, JumpSTART, Triage Sieve, and CareFlight) when used for children. METHODS: We observed the emergency department triage of patients less than 18 years old presenting to the only pediatric specialty hospital/Level 1 trauma center in Milwaukee County, Wisconsin. A single, certified EMS provider observed each patient's initial triage in the emergency department and recorded all findings that were necessary to categorize the patient using each of the 4 mass casualty triage systems being studied. Hospital medical records were then reviewed for each patient and assigned a criterion standard triage category based on the treatments received and final disposition. Descriptive statistics were used to compare accuracy, over-, and under-triage rates for each of the triage systems. RESULTS: A total of 115 subjects were enrolled. Of those, 51% were male and 57% were transported by ambulance. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (59%; 95% CI 50-68) compared to JumpSTART (57%; 95% CI 48-66), CareFlight (56%; 95% CI 47-65), and TriageSieve (56%; 95% CI 46-65). SALT also had the lowest under-triage rate (33%; 95% CI 24-42) compared to JumpSTART (39%; 95% CI 30-48), CareFlight (39%; 95% CI 30-48), and TriageSieve (39%; 95% CI 30-48). SALT had the highest over-triage rate (6%; 95% CI 2-11) compared to JumpSTART (4%; 95% CI 1-8), CareFlight (5%; 95% CI 1-9), and TriageSieve (5%; 95% CI 1-9). However, the confidence intervals for both the accuracy and under-triage rates overlapped between all triage systems. For each triage system, the most common error was designating a patient as "minimal" that, according to the criterion standard, should have been triaged as "delayed." CONCLUSION: We found that the 4 most popular mass casualty triage systems preformed similarly in an emergency department-based pediatric population. None of the systems were extremely accurate, and each demonstrated an unacceptable amount of under-triage. Better differentiating between patients categorized as "minimal" and "delayed" may improve the accuracy of mass casualty triage systems.

A consensus-based gold standard for the evaluation of mass casualty triage systems.

INTRODUCTION: Accuracy and effectiveness analyses of mass casualty triage systems are limited because there are no gold standard definitions for each of the triage categories. Until there is agreement on which patients should be identified by each triage category, it will be impossible to calculate sensitivity and specificity or to compare accuracy between triage systems. OBJECTIVE: To develop a consensus-based, functional gold standard definition for each mass casualty triage category. METHODS: National experts were recruited through the lead investigators' contacts and their suggested contacts. Key informant interviews were conducted to develop a list of potential criteria for defining each triage category. Panelists were interviewed in order of their availability until redundancy of themes was achieved. Panelists were blinded to each other's responses during the interviews. A modified Delphi survey was developed with the potential criteria identified during the interview and delivered to all recruited experts. In the early rounds, panelists could add, remove, or modify criteria. In the final rounds edits were made to the criteria until at least 80% agreement was achieved. RESULTS: Thirteen national and local experts were recruited to participate in the project. Six interviews were conducted. Three rounds of voting were performed, with 12 panelists participating in the first round, 12 in the second round, and 13 in the third round. After the first two rounds, the criteria were modified according to respondent suggestions. In the final round, over 90% agreement was achieved for all but one criterion. A single e-mail vote was conducted on edits to the final criterion and consensus was achieved. CONCLUSION: A consensus-based, functional gold standard definition for each mass casualty triage category was developed. These gold standard definitions can be used to evaluate the accuracy of mass casualty triage systems after an actual incident, during training, or for research.

Development of an EMS curriculum.

Emergency medical services (EMS) became an American Board of Medical Specialties (ABMS) approved subspecialty of emergency medicine in September 2010. Achieving specialty or subspecialty recognition in an area of medical practice requires a unique body of knowledge, a scientific basis for the practice, a significant number of physicians who dedicate a portion of their practice to the area, and a sufficient number of fellowship programs. To prepare EMS fellows for successful completion of fellowship training, a lifetime of subspecialty practice, and certification examination, a formalized structured fellowship curriculum is necessary. A functional curriculum is one that takes the entire body of knowledge necessary to appropriately practice in the identified area and codifies it into a training blueprint to ensure that all of the items are covered over the prescribed training period. A curriculum can be as detailed as desired but typically all major headings and subheadings of the core content are identified and addressed. Common curricular components, specific to each area of the core content, include goals and objectives, implementation methods, evaluation, and outcomes assessment methods. Implementation methods can include simulation, observations, didactics, and experiential elements. Evaluation and outcomes assessment methods can include direct observation of patient assessment and treatment skills, structured patient simulations, 360° feedback, written and oral testing, and retrospective chart reviews. This paper describes a curriculum that is congruent with the current EMS core content, as well as providing a 12-month format to deploy the curriculum in an EMS fellowship program. Key words: curriculum; education; emergency medical services; fellowships and scholarships.

Situation-Background-Assessment-Recommendation (SBAR) and Emergency Medicine Residents' Learning of Case Presentation Skills.

BACKGROUND: To date, no standardized presentation format is taught to emergency medicine (EM) residents during patient handoffs to consulting or admitting physicians. The Situation-Background-Assessment-Recommendation (SBAR) is a common format that provides a consistent framework to communicate pertinent information. OBJECTIVE: The objective of this study was to describe and evaluate the feasibility of using SBAR to teach interphysician communication skills to first-year EM residents to use during patient handoffs. METHODS: An educational study was designed as part of a pilot curriculum to teach first-year EM residents handoff communication skills. A standardized SBAR reporting format was taught during a 1-hour didactic intervention. All residents were evaluated using pretest/posttest simulated cases using a 17-item SBAR checklist initially, and then within 4 months to assess retention of the tool. A survey was distributed to determine resident perceptions of the training and potential clinical utility. RESULTS: There was a statistically significant improvement from the resident scores on the pretest/posttest of the first case (P  =  .001), but there was no difference between posttest of the first case and pretest of the second case (P  =  .34), suggesting retention of the material. There was a statistically significant improvement from the pretest and posttest scores on the second case (P  =  .001). The survey yielded good reliability for both sessions (Cronbach alpha  =  0.87 and 0.89, respectively), demonstrating statistically significant increases for the perceived quality of training, presentation comfort level, and the use of SBAR (P  =  .001). CONCLUSION: SBAR was acceptable to first-year EM residents, with improvements in both the ability to apply SBAR to simulated case presentations and retention at a follow-up session. This format was feasible to use as a training method and was well received by our resident physicians. Future research will be useful in examining the general applicability of the SBAR model for interphysician communications in the clinical environment and residency training programs.

Third-degree AV block from extended-release diltiazem ingestion in a nine-month-old.

Calcium channel blocker (CCB) overdose is associated with dysrhythmias and atrioventricular (AV) block, however, experience with infant CCB overdose is limited. A 9-month-old girl was found playing with tablets of extended-release diltiazem 120 mg. The patient had two episodes of emesis, which contained pill fragments, and was brought to the Emergency Department (ED) 4.5 h after being found. Vital signs were: rectal temperature 37.1 degrees C, pulse 87 beats/min, respiratory rate 30-40 breaths/min, blood pressure 72/48 mm Hg, and oxygen saturation (SpO(2)) 99% on room air. Otherwise, the patient was well-appearing, with normal skin color and examination. The electrocardiogram revealed third-degree atrioventricular block with a ventricular rate of 90 beats/min, QRS 68 ms, and QTc 411 ms. Atropine 0.1 mg i.v. was given, which increased the heart rate to 100-110 beats/min. Calcium gluconate 500 mg was also given intravenously. Laboratory evaluation revealed bicarbonate 17 mEq/L, anion gap 16, and glucose 129 mg/dL. On hospital day 1, the patient was noted to have a junctional rhythm with a rate of 90-100, and systolic blood pressure of 80-90 mm Hg. No additional medications were given. Early on day 2, the patient converted spontaneously to a normal sinus rhythm and was discharged approximately 42 h after presentation to the ED. In addition to bradycardia and hypotension, this 9-month-old patient manifested third-degree AV block after ingesting extended-release diltiazem.

Mass casualty triage: an evaluation of the data and development of a proposed national guideline.

Mass casualty triage is a critical skill. Although many systems exist to guide providers in making triage decisions, there is little scientific evidence available to demonstrate that any of the available systems have been validated. Furthermore, in the United States there is little consistency from one jurisdiction to the next in the application of mass casualty triage methodology. There are no nationally agreed upon categories or color designations. This review reports on a consensus committee process used to evaluate and compare commonly used triage systems, and to develop a proposed national mass casualty triage guideline. The proposed guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, was developed based on the best available science and consensus opinion. It incorporates aspects from all of the existing triage systems to create a single overarching guide for unifying the mass casualty triage process across the United States.

Hospital variability of out-of-hospital cardiac arrest survival.

BACKGROUND: Previous literature has identified patient and emergency medical services (EMS) system factors that are associated with survival of out-of-hospital cardiac arrest patients. OBJECTIVE: To determine variability in rates of survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients and to identify hospital-related factors associated with survival. METHODS: This was a retrospective, observational study of all adult (21 years or older) out-of-hospital Utstein criteria cardiac-etiology arrests treated by Milwaukee County EMS during the period 1995-2005 and surviving to hospital intensive care unit admission. The primary outcome measure was survival to hospital discharge. Logistic regression analysis was used to compare the odds of survival between hospitals, patient factors, and hospital factors. RESULTS: 1,702 patients at eight receiving hospitals were included in the study analyses. Hospital survival rates ranged from 29% to 42%. Patient and case factors associated with increased survival included younger age, male gender, nonwhite race, witnessed arrest in a public location, bystander cardiopulmonary resuscitation (CPR), a modest number of defibrillations, and initial cardiac rhythm of ventricular tachycardia. The only hospital characteristic correlated with survival was the number of beds per nurse. Patients admitted to a hospital with a ratio of beds to nurse less than 1.0 were over 1.5 times more likely to survive. CONCLUSIONS: Survival to discharge of resuscitated adult out-of-hospital cardiac arrest patients may vary by receiving hospital. A hospital's ratio of beds to nurse and several patient/case f actors are correlated with survival. Further research is warranted to investigate how this may affect resuscitation care, EMS transport policy, and research design.