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.

Tactical medicine--competency-based guidelines.

BACKGROUND: Tactical emergency medical support (TEMS) is a rapidly growing area within the field of prehospital medicine. As TEMS has grown, multiple training programs have emerged. A review of the existing programs demonstrated a lack of competency-based education. OBJECTIVE: To develop educational competencies for TEMS as a first step toward enhancing accountability. METHODS: As an initial attempt to establish accepted outcome-based competencies, the National Tactical Officers Association (NTOA) convened a working group of subject matter experts. RESULTS: This working group drafted a competency-based educational matrix consisting of 18 educational domains. Each domain included competencies for four educational target audiences (operator, medic, team commander, and medical director). The matrix was presented to the American College of Emergency Physicians (ACEP) Tactical Emergency Medicine Section members. A modified Delphi technique was utilized for the NTOA and ACEP groups, which allowed for additional expert input and consensus development. CONCLUSION: The resultant matrix can serve as the basic educational standard around which TEMS training organizations can design programs of study for the four target audiences.

Comparison of two packable hemostatic Gauze dressings in a porcine hemorrhage model.

BACKGROUND: Uncontrolled hemorrhage remains the primary cause of preventable battlefield mortality and a significant cause of domestic civilian mortality. Rapid hemorrhage control is crucial for survival. ChitoGauze and Combat Gauze are commercially available products marketed for rapid hemorrhage control. These products were selected because they are packable gauze that work via differing mechanisms of action (tissue adhesion versus procoagulant). OBJECTIVE: To compare the effectiveness of ChitoGauze and Combat Gauze in controlling arterial hemorrhage in a swine model. METHODS: Fourteen swine were studied. Following inguinal dissection and after achieving minimum hemodynamic parameters (mean arterial pressure [MAP] ≥ 70 mmHg), a femoral arterial injury was created using a 6-mm vascular punch. Free bleeding was allowed for 45 seconds, and then the wound was packed alternatively with ChitoGauze or Combat Gauze. Direct pressure was applied to the wound for 2 minutes, followed by a three-hour monitoring period. Resuscitation fluids were administered to maintain an MAP of ≥ 65 mmHg. Time to hemostasis, hemodynamic parameters, total blood loss, and amount of resuscitation fluid were recorded every 15 minutes. Data were analyzed using the Wilcoxon rank sum test. Histologic sections of the vessels were examined using regular and polarized light. RESULTS: No statistically significant differences were found between the groups regarding any measured end point. Data trends, however, favor ChitoGauze over Combat Gauze for time to hemostasis, fluid requirements, and blood loss. There was no evidence of retained foreign material on histologic analysis. CONCLUSION: ChitoGauze and Combat Gauze appear to be equally efficacious in their hemostatic properties, as demonstrated in a porcine hemorrhage model.

The effects of a community-based disaster drill of simulating Disaster Medical Assistance Team (DMAT) on the knowledge and attitudes.

BACKGROUND: We evaluated the effects of community-based disaster drill of simulating disaster medical assistance team on the knowledge and the attitudes. METHODS: Eight hours disaster drills, including didactic lectures, table simulation, and outdoor field simulation, were developed for participants who were recruited from community health centers, emergency departments, fire stations, emergency medical technicians' academy, and emergency information center in the Seoul Metropolitan City area from 2006 to 2008. We surveyed on the knowledge and the attitude using designed questionnaire before and after drill. We compared changes using t-test and repeated measure ANOVA. RESULTS: In this study, 14 community-based drills were performed and 525 (79.4%) people responded to both pre- and post-drill survey. Of these, the doctor was the second common occupation (26.9%) after volunteer students (47.1%). Overall, knowledge and attitude score significantly increased from 3.9±1.0 to 4.3±0.9 (p<0.001) and from 21.4±3.4 to 22.4±3.2 (p<0.001), respectively. The difference among professional license groups between pre- and post-drill knowledge level was significant (p=0.03), while the difference among jobs for attitude between pre- and post-drill was not different (p=0.78). CONCLUSION: Disaster drills on the establishment and operation of DMAT may affect both knowledge and attitude of participants positively.

Use of SALT triage in a simulated mass-casualty incident.

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 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.

The national disaster life support programs: a model for competency-based standardized and locally relevant training.

With grant funding from the Department of Health and Human Services under the Bioterrorism Training and Curriculum Development Program, the Medical College of Georgia Center of Operational Medicine (MCG-COM) provided an integrated disaster medicine continuing education program for the state of Georgia. This educational program was based on the American Medical Association (AMA) National Disaster Life Support (NDLS) curricula. With supplemental funding, the MCG-COM developed and piloted a national training strategy for all-hazards disaster preparedness education. This strategy built upon the existing 47 training centers delivering NDLS curricula. State advisory committees were established in four model states, developing state-specific modules based on a Hazard and Vulnerability Assessment. These modules were piloted as a model for the deployment of a national curriculum with state and local integration. In addition, the AMA established an educational consortium for the purpose of continual curriculum revision. This consortium, currently consisting of more than 75 participating organizations and federal liaisons, is responsible for all curriculum updates for the NDLS courses. Under this model, multidisciplinary crosscutting disaster medicine competencies and a proposed educational framework were developed. The resulting competencies and framework have been published in the peer-reviewed literature and are being integrated into the NDLS curricula.

National disaster life support programs: a platform for multi-disciplinary disaster response.

Proper training must prepare responders to consider various hazards and means by which to mitigate their effects. This article describes one such training program (the National Disaster Life Support program) as a possible means to prepare dental providers to better respond to disasters and describes a simple triage technique that can be used by dental professionals to triage patients.

Mass casualty triage: an evaluation of the science and refinement of a national guideline.

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The 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. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

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.

The location and incidence of out-of-hospital cardiac arrest in Georgia: implications for placement of automated external defibrillators.

OBJECTIVE: Prior studies of automated external defrillator placement strategies for public access defibrillation (PAD) have addressed only the venue of out-of-hospital cardiac arrest (OOHCA) in large urban areas. This study evaluates the relationship between population density and the incidence and location of OOHCA. METHODS: This study was a retrospective analysis of 624,199 Georgia state emergency medical services patient care reports (PCRs) in 2000. The PCR categorized these cardiac arrests by county into 12 location options. Counties were divided into population densities of <100, 100-400, 400-1,000, and >1,000 persons per square mile. The incidence of cardiac arrest for each location type was calculated for each population density group. RESULTS: The <100 density group had only 21.77% of the state's population but 30.96% of the state's cardiac arrests, whereas the >1,000 density group had 35.46% of the population but only 23.55% of the cardiac arrests (p<0.0001). The relative risk (95% confidence interval) for OOHCA in the <100 density group compared with the >1,000 density group was 2.14 (2.00, 2.29). The percentage of OOHCAs that occurred in the home for each population density group was: <100 persons per square mile, (67.67%); 100-400 persons per square mile, (68.83%); 400-1,000 persons per square mile, (65.75%); and >1,000 persons per square mile (62.09%) (p=0.0001). CONCLUSIONS: There are variations in incidence and location of OOHCA based on population density in Georgia. As population density increases, the incidence percentage of OOHCAs decreases. However, as population density increases, there is an increase in the percentage of cardiac arrests occurring outside the home, where more OOHCAs could potentially benefit from PAD.