Validation of secondary triage algorithms for mass casualty incidents : A simulation-based study-English version.

BACKGROUND: In the event of a mass casualty incident (MCI), the situation-related shortage of medical resources does not end when the patients are transported from the scene of the incident. Consequently, an initial triage is required in the receiving hospitals. In the first step, the aim of this study was to create a reference patient vignette set with defined triage categories. This allowed a computer-aided evaluation of the diagnostic quality of triage algorithms for MCI situations in the second step. METHODS: A total of 250 case vignettes validated in practice were entered into a multistage evaluation process by initially 6 and later 36 triage experts. This algorithm-independent expert evaluation of all vignettes-served as the gold standard for analyzing the diagnostic quality of the following triage algorithms: Manchester triage system (MTS module MCI), emergency severity index (ESI), Berlin triage algorithm (BER), the prehospital algorithms PRIOR and mSTaRT, and two project algorithms from a cooperation between the Federal Office of Civil Protection and Disaster Assistance (BBK) and the Hashemite Kingdom of Jordan-intrahospital Jordanian-German project algorithm (JorD) and prehospital triage algorithm (PETRA). Each patient vignette underwent computerized triage through all specified algorithms to obtain comparative test quality outcomes. RESULTS: Of the original 250 vignettes, a triage reference database of 210 patient vignettes was validated independently of the algorithms. These formed the gold standard for comparison of the triage algorithms analyzed. Sensitivities for intrahospital detection of patients in triage category T1 ranged from 1.0 (BER, JorD, PRIOR) to 0.57 (MCI module MTS). Specificities ranged from 0.99 (MTS and PETRA) to 0.67 (PRIOR). Considering Youden's index, BER (0.89) and JorD (0.88) had the best overall performance for detecting patients in triage category T1. Overtriage was most likely with PRIOR, and undertriage with the MCI module of MTS. Up to a decision for category T1, the algorithms require the following numbers of steps given as the median and interquartile range (IQR): ESI 1 (1-2), JorD 1 (1-4), PRIOR 3 (2-4), BER 3 (2-6), mSTaRT 3 (3-5), MTS 4 (4-5) and PETRA 6 (6-8). For the T2 and T3 categories the number of steps until a decision and the test quality of the algorithms are positively interrelated. CONCLUSION: In the present study, transferability of preclinical algorithm-based primary triage results to clinical algorithm-based secondary triage results was demonstrated. The highest diagnostic quality for secondary triage was provided by the Berlin triage algorithm, followed by the Jordanian-German project algorithm for hospitals, which, however, also require the most algorithm steps until a decision.

[Validation of secondary triage algorithms for mass casualty incidents-A simulation-based study-German version]. / Validierung innerklinischer Sichtungsalgorithmen für den Massenanfall von Verletzten ­ eine simulationsbasierte Studie ­ deutsche Version.

BACKGROUND: In the event of a mass casualty incident (MCI), the situation-related shortage of medical resources does not end when the patients are transported from the scene of the incident. Consequently, an initial triage is required in the receiving hospitals. In the first step, the aim of this study was to create a reference patient vignette set with defined triage categories. This allowed a computer-aided evaluation of the diagnostic quality of triage algorithms for MCI situations in the second step. METHODS: A total of 250 case vignettes validated in practice were entered into a multistage evaluation process by initially 6 and later 36 triage experts. This algorithm-independent expert evaluation of all vignettes-served as the gold standard for analyzing the diagnostic quality of the following triage algorithms: Manchester triage system (MTS module MCI), emergency severity index (ESI), Berlin triage algorithm (BER), the prehospital algorithms PRIOR and mSTaRT, and two project algorithms from a cooperation between the Federal Office of Civil Protection and Disaster Assistance (BBK) and the Hashemite Kingdom of Jordan-intrahospital Jordanian-German project algorithm (JorD) and prehospital triage algorithm (PETRA). Each patient vignette underwent computerized triage through all specified algorithms to obtain comparative test quality outcomes. RESULTS: Of the original 250 vignettes, a triage reference database of 210 patient vignettes was validated independently of the algorithms. These formed the gold standard for comparison of the triage algorithms analyzed. Sensitivities for intrahospital detection of patients in triage category T1 ranged from 1.0 (BER, JorD, PRIOR) to 0.57 (MCI module MTS). Specificities ranged from 0.99 (MTS and PETRA) to 0.67 (PRIOR). Considering Youden's index, BER (0.89) and JorD (0.88) had the best overall performance for detecting patients in triage category T1. Overtriage was most likely with PRIOR, and undertriage with the MCI module of MTS. Up to a decision for category T1, the algorithms require the following numbers of steps given as the median and interquartile range (IQR): ESI 1 (1-2), JorD 1 (1-4), PRIOR 3 (2-4), BER 3 (2-6), mSTaRT 3 (3-5), MTS 4 (4-5) and PETRA 6 (6-8). For the T2 and T3 categories the number of steps until a decision and the test quality of the algorithms are positively interrelated. CONCLUSION: In the present study, transferability of preclinical algorithm-based primary triage results to clinical algorithm-based secondary triage results was demonstrated. The highest diagnostic quality for secondary triage was provided by the Berlin triage algorithm, followed by the Jordanian-German project algorithm for hospitals, which, however, also require the most algorithm steps until a decision.

The Berlin Acute Trauma Care Instrument Set (BATMIN) - A Selected Combination of Surgical Instruments for Damage Control and Hemostasis Surgery in Severe Acute Trauma.

A lack of sterile surgical instrument sets for damage control surgeries of severely injured patients became evident in a series of in-hospital mass casualty trainings in the German capital of Berlin. Moreover, the existing instrument trays contained mostly specialized instruments for elective interventions and were not well composed for the treatment of poly-traumatized patients. After a literature search on the most common injury patterns in Mass Casualty Incidents (MCIs), an expert group of surgeons from different disciplines designed an optimized instrument set. A set of 194 instruments was assembled and distributed into two containers. These 2 sets were subjected to a 6-month trial phase in our hospital, and the evaluation of usability was subsequently analyzed through feedback forms administered to the staff. After analysis of the feedback sheets, only minor alterations had to be incorporated. The Berlin Acute Trauma Care Instrument Set (BATMIN) was then made available by the state of Berlin to Berlin Hospitals providing acute trauma care. Out of the need to be prepared for mass casualties, we created an instrument set suitable for the damage control surgery of severely injured patients in individual care and MCIs.

Safety, reactogenicity, and immunogenicity of homologous and heterologous prime-boost immunisation with ChAdOx1 nCoV-19 and BNT162b2: a prospective cohort study.

BACKGROUND: Heterologous vaccine regimens have been widely discussed as a way to mitigate intermittent supply shortages and to improve immunogenicity and safety of COVID-19 vaccines. We aimed to assess the reactogenicity and immunogenicity of heterologous immunisations with ChAdOx1 nCov-19 (AstraZeneca, Cambridge, UK) and BNT162b2 (Pfizer-BioNtech, Mainz, Germany) compared with homologous BNT162b2 and ChAdOx1 nCov-19 immunisation. METHODS: This is an interim analysis of a prospective observational cohort study enrolling health-care workers in Berlin (Germany) who received either homologous ChAdOx1 nCov-19 or heterologous ChAdOx1 nCov-19-BNT162b2 vaccination with a 10-12-week vaccine interval or homologous BNT162b2 vaccination with a 3-week vaccine interval. We assessed reactogenicity after the first and second vaccination by use of electronic questionnaires on days 1, 3, 5, and 7. Immunogenicity was measured by the presence of SARS-CoV-2-specific antibodies (full spike-IgG, S1-IgG, and RBD-IgG), by an RBD-ACE2 binding inhibition assay (surrogate SARS-CoV-2 virus neutralisation test), a pseudovirus neutralisation assay against two variants of concerns (alpha [B.1.1.7] and beta [B.1.351]), and anti-S1-IgG avidity. T-cell reactivity was measured by IFN-γ release assay. FINDINGS: Between Dec 27, 2020, and June 14, 2021, 380 participants were enrolled in the study, with 174 receiving homologous BNT162b2 vaccination, 38 receiving homologous ChAdOx1 nCov-19 vaccination, and 104 receiving ChAdOx1 nCov-19-BNT162b2 vaccination. Systemic symptoms were reported by 103 (65%, 95% CI 57·1-71·8) of 159 recipients of homologous BNT162b2, 14 (39%, 24·8-55·1) of 36 recipients of homologous ChAdOx1 nCov-19, and 51 (49%, 39·6-58·5) of 104 recipients of ChAdOx1 nCov-19-BNT162b2 after the booster immunisation. Median anti-RBD IgG levels 3 weeks after boost immunisation were 5·4 signal to cutoff ratio (S/co; IQR 4·8-5·9) in recipients of homologous BNT162b2, 4·9 S/co (4·3-5·6) in recipients of homologous ChAdOx1 nCov-19, and 5·6 S/co (5·1-6·1) in recipients of ChAdOx1 nCov-19- BNT162b2. Geometric mean of 50% inhibitory dose against alpha and beta variants were highest in recipients of ChAdOx1 nCov-19-BNT162b2 (956·6, 95% CI 835·6-1095, against alpha and 417·1, 349·3-498·2, against beta) compared with those in recipients of homologous ChAdOx1 nCov-19 (212·5, 131·2-344·4, against alpha and 48·5, 28·4-82·8, against beta; both p<0·0001) or homologous BNT162b2 (369·2, 310·7-438·6, against alpha and 72·4, 60·5-86·5, against beta; both p<0·0001). SARS-CoV-2 S1 T-cell reactivity 3 weeks after boost immunisation was highest in recipients of ChAdOx1 nCov-19-BNT162b2 (median IFN-γ concentration 4762 mIU/mL, IQR 2723-8403) compared with that in recipients of homologous ChAdOx1 nCov-19 (1061 mIU/mL, 599-2274, p<0·0001) and homologous BNT162b2 (2026 mIU/mL, 1459-4621, p=0·0008) vaccination. INTERPRETATION: The heterologous ChAdOx1 nCov-19-BNT162b2 immunisation with 10-12-week interval, recommended in Germany, is well tolerated and improves immunogenicity compared with homologous ChAdOx1 nCov-19 vaccination with 10-12-week interval and BNT162b2 vaccination with 3-week interval. Heterologous prime-boost immunisation strategies for COVID-19 might be generally applicable. FUNDING: Forschungsnetzwerk der Universitätsmedizin zu COVID-19, the German Ministry of Education and Research, Zalando SE.

[The Berlin mass casualty hospital triage algorithm : Development, implementation and influence on exercise-based triage results]. / Der Berliner Krankenhaus-Sichtungsalgorithmus für den Massenanfall von Verletzten : Entwicklung, Implementierung und Einfluss auf übungsbasierte Sichtungsergebnisse.

BACKGROUND AND OBJECTIVE: Patient triage has a key function within the scope of the successful management of mass disasters and ensures the correct resource allocation. Analysis of unheralded hospital disaster training in Berlin hospitals revealed triage problems referring the correct classification of patients in the triage categories and relevant overtriaging and undertriaging. Therefore, a triage algorithm tailored to the clinical setting was developed in Berlin and after presentation and discussion within the circle of the representatives for clinical catastrophe protection, the algorithm was introduced as obligatory in 2015. This study was carried out to validate and investigate the effects of the triage algorithm. MATERIAL AND METHODS: This prospective observational study evaluated all unheralded hospital disaster training exercises from 2016/2017 initiated by the senate administration, with 556 roughed persons after implementation of the new triage algorithm and compared the results with disaster training exercises from the years 2010/2011 without a triage algorithm (n = 601). The correct allocation of the prescribed injury patterns to the triage category (T1-3), specificity, sensitivity and positive likelihood ratio of the algorithm are described and group differences were calculated. RESULTS: In 15 unheralded mass disaster drills with 556 actors in 2016-2017 a total of 85% of the category T1 (n = 83/98), 63% of the T2 category (n = 100/159) and 87% of the T3 category (n = 259/299) were correctly recognized. This corresponds to a significantly better triage result of 80% compared to 63% in 2010/2011. Overtriaging and undertriaging also were significantly reduced. The triage algorithm showed a specificity and sensitivity of 97% and 75%, respectively, for T1 (immediately life-threatening), 86%/67% for T2 (severely injured) and 85%/88% for T3 (slightly injured) patients. DISCUSSION: The Berlin hospital triage algorithm was successfully validated. The triage category allocation was significantly improved in all relevant aspects after implementation with a significant reduction of overtriaging and undertriaging.