A Brief Introduction to Disaster Medicine
Disaster Medicine is a medical discipline that centers around events significant enough that, without external aid, emergency departments (ED) would not be able to adequately provide care to those affected [1]. For example, a multi-vehicle car accident may result in multiple casualties, but would not be considered a disaster if the responding medical infrastructure was able to handle the influx of patients. Many entities including the United Nations International Strategy for Disaster Reduction (UNISDR) and the World Health Organization (WHO) have amended their definitions of the term “disaster” to specify occurrences that exceed a community’s ability to cope with the effects of said disaster [2,3]. Incidents that have satisfied this requirement include natural disasters and more modern occurrences such as water contamination, human conflict, chemical spills, radiation, power outages resulting in infrastructure collapse, etc. [1]. The field of disaster medicine operates with the goal of aiding with these disaster-level events and all of the associated medical, logistical, and ethical issues that come along with them [4].
This is accomplished through a joint effort by many disciplines within healthcare including emergency medicine (EM), Emergency Medical Services, pediatrics, public health, social work, and many more [5]. However, emergency medicine providers’ experience in high acuity, large patient volume settings set them up to take a leadership role in disaster medicine. The emergency department is also typically the first point of contact between patients and health care providers in a disaster setting providing emergency medicine physicians an advantage in these responses [6]. In addition to their traditional responsibilities of stabilization and disposition of disaster patients, EM physicians are typically delegated the responsibilities of coordinating disaster response as chief medical officer, interfacing with government and community relief efforts, and directing disaster triage efforts [6].
Disaster Triage
According to the World Health Organization, “triage” is the rapid examination and sorting of patients into groups according to their medical needs and the availability of resources [8]. In this setting of mass casualties and resource scarcity, disaster triage protocols are governed by the utilitarian concept of doing the greatest good for the greatest number[9]. As opposed to routine triage seen in the ED, this requires a shift of focus from the outcomes of single patients to outcomes on a population level [7].
However, despite the common misconception, disaster triage is not simply making the decision of whether to treat a patient or not. Disaster triage is more complex with most decisions centering around what level of treatment a patient should receive [7]. Rarely is it decided or even proposed that a patient should receive no treatment at all [7]. The consensus within disaster medicine is that disaster triage should optimize patient care and resource allocation by considering the incremental improvement in survival that a treatment would provide a patient in their current condition[10]. In order to make these decisions, the foundation of disaster triage lies in the use of triage tools and protocols to systematically assess patient conditions and prognoses following these devastating events. With proper triage and resultant treatment, it has been shown that trauma patients can experience at least a 25% reduction in mortality [11]. In disaster settings where hundreds to thousands of lives hang in the balance, 25% is not an insignificant number.
Measures of Success: Undertriage and Overtriage
Prior to discussing the wide array of triage methods used in disasters, it is pertinent to describe the terms used describe and assess them. Triage efficacy is typically judged by its validity, or how accurate the acuity assigned during triage, by tool or clinical assessment, is to the actual acuity of the patient. In order to measure this validity, we rely on rates of undertriage and overtriage observed during real world scenarios (Table 1) [12].
Concept | Definition | Impact | Sensitivity & Specificity | Acceptable Rate |
Undertriage | Patient condition is classified as a lower acuity than it actually is. | Patients are under prioritized, under treated, and providers may miss savable lives. | Low sensitivity | Low (<5-10% of patients) |
Overtriage | Patient condition is classified as a higher acuity than it actually is. | Patients are overtreated leading to disorganization, misallocation of scarce resources, and wasting time that could be used to save other patients. | Low specificity | Variable depending on context (25-35% and others 50-60%) |
Table 1: Definitions, major impacts, relationships to sensitivity and specificity, and acceptable rates of overtriage and undertriage [11, 12, 13, 15, 17].
Undertriage
Undertriage is when a patient’s condition or injury is under classified in terms of acuity, and the patient is under prioritized or under treated as a result. This results in situations where critically ill patients could have benefited from a justifiable use of resources to further evaluate and treat their injuries [13, 14]. An example of this could be a severely injured patient that was transferred to a non-trauma center, or a patient that could have survived with prioritized evacuation and admission to the ICU or OR. However, it is worth noting that moderately injured patients are the most often undertriaged since severe acuity patients are more easily recognized [11]. Nonetheless, these are essentially missed opportunities to save patients and, statistically, this would represent a low sensitivity of the triage process. Therefore, there is a low tolerance for undertriage with most entities recommending an acceptable undertriage level of less than 5-10% of patients [15].
Overtriage
Overtriage is defined as the inaccurate classification of a patient as high priority or acuity when their injuries are actually non-urgent [11]. A classic example of overtriage would be when a stable, non-critical patient is unnecessarily expedited ahead of sicker patients for a surgery they do not acutely require. According to Foley and Reisner, another form of overtriage is when patients with little to no chance of surviving receive aggressive medical treatment, inappropriately allocating scarce resources [13]. Compared to undertriage, overtriage represents a poor specificity and complicates triage by creating disorganization that misallocates time and resources [14,16]. In the setting of a disaster, overtriage can be just as dangerous as undertriage as this misallocation can take away scarce resources and time that could be used to save other patients. The acceptable level of overtriage is more debated, with some sources recommending 25-35% [15] and others 50-60% of patients [13].
The reason for less stringency surrounding acceptable overtriage rates is due to the influence the two rates have on each other. Overtriage and undertriage do not exist independently of one another and demonstrate an inverse relationship [13]. As overtriage rates increase and patients are treated more liberally, undertriage rates decrease as less savable patients are missed. Therefore, when faced with the decision of overallocating resources or missing a potential savable life, most entities recommend maintaining a higher allowance for overtriage in order to reduce undertriage. Previously, it was reported that 50% of overtriage was required to reduce the rate of undertriage to 0% [17], but more recently that recommendation has been decreased to 25-35% [15] due to the detrimental effects higher overtriage can have on triage efforts with minimal decrease in undertriage rates [11, 18].
However, when applying these rules to real life disaster triage, it is important to also factor in the environment and working conditions of the disaster. The amount of acceptable overtriage and undertriage in a mass casualty event should change depending on resources and casualties present [13]. For example, in a scenario where casualties are few and resources are plenty, the risks of raising the overtriage rate are outweighed by the benefit of possibly reducing undertriage as there would be little chance of running out of resources or time. On the other hand, in a grand scale disaster where resources are extremely limited, a lower overtriage rate would be acceptable, despite the possible increase in undertriage, due to the higher likelihood of running out of resources and time. Therefore, it is imperative in disaster triage to always perform an initial survey of the amount of casualties and resources available in order to form an educated plan to maximize the greatest benefit for the greatest number of people [19].
Primary, Secondary, and Tertiary Triage
In comparison to traditional triage in an ED, disaster victims are triaged multiple times throughout their medical course beginning at the site of the incident and continuing through possible admission to the ICU or OR. These multiple points of reevaluation account for the evolving nature of disasters over time in terms of resource availability, treatment delays, and injury progression or resolution [20]. Triage in the setting of mass casualties can be broken down into three different types: primary, secondary, and tertiary triage (Table 2). These different classifications differ based on the triage timing, location, and what level of care is being addressed [19, 21, 22].
Primary Triage
Primary triage occurs at first contact with patients after a disaster [22]. This can occur at the scene of the disaster, or any other setting outside of the hospital including an area away from the incident [19]. The goal of primary triage is to establish the priority of injured patients for on-site treatment and evacuation to the nearest available hospital [21]. This can also include decisions such as routing patients to trauma versus non-trauma centers or performing life saving measures in the field [7, 19]. Primary triage is regarded as the most critical stage in the disaster triage process with the greatest potential to save lives and influence population outcomes [21, 23]. As a result, many different tools and methods for primary triage have been developed and primary triage will be the major focus of this chapter [14]. The tools and specifics of primary triage will be discussed in more detail in the Triage Tools section.
Secondary Triage
Secondary triage is the second evaluation of patients’ condition and overall acuity. This occurs upon patient arrival to the hospital and commonly takes place in the emergency department [21]. However, the level of care being addressed in secondary triage changes depending on the context of the disaster and the resulting bottlenecks in ED patient care. If it is a mass casualty event involving patients with highly acute complaints such as trauma, then secondary triage will focus on prioritizing patients for initial stabilizing measures in the ED [7]. Alternatively, if the disaster takes a less acute and more extended course, such as the Coronavirus Disease 2019 pandemic, then secondary triage will focus on determining disposition of patients from the ED after the initial stabilization has been performed. The disposition prioritization can include what patients are admitted to the hospital, transferred to more specialized areas within the ED, or discharged home [19, 21]. Secondary triage is especially vital when evacuation from the site of a disaster is prolonged resulting in a large influx of deteriorating patients arriving to the hospital [22].
Tertiary Triage
Tertiary triage is the third evaluation of patients involved in a disaster taking place after initial stabilization or hospital admission. This also occurs within the hospital, but does not need to be in the ED [19]. Tertiary triage is when questions of definitive care are addressed and prioritized such as ICU admission, surgery, and other procedures including those performed by interventional radiology [21]. This final form of triage is typically performed by a physician with critical care training or a surgeon [22]. This is also a chance to reassess continued medical management of severe patients in the setting of dwindling resources such as continuing life support measures or additional treatment after poor prognostic laparoscopic findings [19]. In disasters with fewer critical patients with life threatening injuries, tertiary triage is less utilized [7].
Triage | Timing | Location | Level of Care (LOC) |
Primary Triage | First patient contact | At the scene of the disaster | Determines the priority order for treatment in the field and emergency transport. Can also prioritize patients to be transported to trauma vs. non-trauma centers. |
Secondary Triage | Second evaluation upon entry into the hospital | In the emergency department | Determines priority order for resuscitation in the ED and disposition after stabilization |
Tertiary Triage | After initial treatment and stabilization in the ED | Anywhere in the hospital, not restricted to the ED | Determines the priority order for definitive care including ICU admission, surgery, or transfer to a higher-level facility, |
Table 2: Definitions, timing, location, and level of care being decided on for the three levels of triage: primary, secondary, and tertiary [19, 21, 22].
How to Triage: Primary Triage Classification & Tools
Classification
How to properly perform primary triage in the field of a disaster has been a highly contentious area of research since before the establishment of disaster medicine [14]. In non-disaster level traumas, most medical providers in North America minimize their pre-hospital evaluation and treatment in favor of more expedient transportation to the hospital[24]. This is known as “scoop and run” and restricts pre-hospital treatment to Basic Life Support (BLS) with minimal classification of patient acuity. “Scoop and run” has been proven to have significant benefits in terms of trauma outcomes[24, 25], but more rigid triage systems are typically utilized in disasters to expedite patient prioritization, minimize uncertainty, and maximize effective use of resources to do the “greatest good for the greatest number” [26].
Globally, differing disaster triage tools and systems are implemented without any clear consensus in the literature on their efficacy [21]. However, one commonality among the majority of these systems is the four-level classification schema they use to group and prioritize disaster victims [26, 27]. First proposed by the World Medical Association (WMA), this system categorizes disaster victims into four different groups based on their acuity and how urgently they require medical intervention (Table 3) [26]. The literature labels these groups in various manners including by triage tag color (red, yellow, green, black), urgency of required treatment (emergency/immediate, delayed, minimal, expectant), or their priority level (P1, P2, P3, P4) [13, 21, 26, 28].
The immediate/emergency group consists of patients who are in critical condition, but can still be saved with immediate treatment within, at most, the next few hours. A red triage tag is commonly used to label this group [28].
The delayed patients are those who are not experiencing an imminent threat to their life, but urgent, definitive medical care will be required at some point. These patients are often labeled with a yellow triage tag [26].
The minimal group are sometimes referred to as the “walking well” or “walking wounded” and have the least severe injuries [27, 29]. These nicknames stem from the fact that most patients in the minimal group can walk following the incident. Various triage tools will even use the ability to ambulate in their algorithms since multiple studies have shown that walking following a disaster is a strong indicator of a relatively low risk patient with a good prognosis [22, 30]. These patients are labeled with a green triage tag and often require only minimal treatment that can be delayed until the rest of the patient categories have been treated.
The final category, deemed expectant, is marked with a black triage tag, and is made up of patients that are either dead or critically ill to the point that efforts to save them are deemed futile. This classification is typically made in situations where the patient’s condition is beyond treatment or when the complex treatment required to save the patient would be putting other patients at risk by misallocating already limited time and resources [21, 26]. It is important to acknowledge that this can be an especially difficult classification for providers to make. The WMA has addressed this by releasing a statement expressing that “It is unethical for a physician to persist, at all costs, at maintaining the life of a patient beyond hope, thereby wasting to no avail scarce resources needed elsewhere.[31]” However, as disasters are fluid and ever-evolving, it is the responsibility of a triage to repeatedly reassess the situation including reviewing the priority designations previously assigned to patients [28].
![Table 3 Priority number, color, name, and description for the four commonly used triage tags [21, 26, 28, 30].](https://i0.wp.com/iem-student.org/wp-content/uploads/2024/03/Screenshot-2024-03-31-at-13.49.13.png?fit=543%2C306&ssl=1)
Table 3: Priority number, color, name, and description for the four commonly used triage tags [21, 26, 28, 30].
Tools
Despite a consensus on what priority groupings are used to sort patients during a disaster, how to place patients in each grouping is still highly divisive. The literature has been unable to provide any significant evidence for or against specific triage strategies resulting in a wide array of disaster triage systems used internationally [14, 21, 22]. In the 1980’s, formal triage scoring systems were developed for primary triage that categorized patients based on objective measures. The most used scoring systems are the Revised Trauma Score (RTS) and Champion’s Trauma Score (CTS), both of which utilize a patient’s Glasgow Coma Scale (GCS), systolic blood pressure, and respiratory rate to calculate a total score that sorts patients into the appropriate priority groupings [32]. However, triage scoring systems have been shown to not be as efficacious in the pre-hospital setting since objective measures of vital signs do not always correlate with clinical condition. As a result, triage scores have demonstrated poor sensitivity in the field and there have been instances where normal vital signs masked critical illness in disaster patients resulting in undertriage [13, 32]. Additionally, vital signs taken at the scene of a disaster are not always reliable due to various confounding variables and can create provider uncertainty in the field [32]. Therefore, triage scoring systems have fallen out of favor in disaster triage and this chapter will focus on the use of multi-tier triage algorithms.
Formalized triage algorithms are a set of rigid, pre-determined decision trees that quickly guide providers through the initial assessment of disaster victims in the field [14]. Triage algorithms base their decision making more in components of clinical presentation such as ability to ambulate and breathe rather than objective measures. These algorithms tend to be more suitable for mass casualty disasters as they minimize the time spent making active decisions and are easy to learn in a restricted amount of time [13]. The disadvantage of these algorithms is their lack of flexibility. As discussed previously in the Measures of Success: Undertriage and Overtriage section, it is important to be able to tailor your protocol, and subsequently your over and undertriage rates, depending on the number of casualties and the availability of resources. However, the rigid procedure of these algorithms does not allow for modifications of treatment criteria when time and resources are more plentiful [13]. Many algorithms have been developed with slightly different applications based on patient demographics, mechanism of the disaster, geography, etc. [14]. Due to the sheer number of triage algorithms currently available, this chapter will focus on the most used primary triage tools in disaster medicine: the Simple Triage and Rapid Treatment (START) and Sort, Assess, Lifesaving interventions, Treatment/Transport (SALT) algorithms.
The Simple Triage and Rapid Treatment (START) triage algorithm was originally developed as a result of joint efforts between a California Fire department, Marine department, and medical providers in 1983 [33]. This was one of the first triage systems developed outside of the military and, following its conception, the Domestic Preparedness Program of the Department of Defense made it standard practice in disaster events [28]. It is now the most prolific mass casualty triage system used in the United States [27].
The START triage algorithm was designed as an expedient triage system that would be easily teachable to emergency providers with minimal training [26]. The objective of the system is the be able to evaluate patients older than eight years old within 30-60 seconds and triage them into one of the four priority groupings discussed previously: immediate/emergency (red), delayed (yellow), minimal (green), expectant (black) [14, 27]. This is accomplished through strict criteria looking at patient ambulation, respiratory rate, radial pulse, mental status, and capillary refill, though many versions of START no longer assess capillary refill due to variabilities from the environment [13, 22, 33].
As depicted in Figure 5, the initial step of START is to prompt patients to walk [27]. If a patient can walk following a disaster, this has been shown to be an indicator of low risk and good prognosis [22, 30]. Therefore, patients who can walk are immediately classified as minimal, green, or priority 1. Following this initial step, the remaining non-minimal patients are evaluated based on their respiration, perfusion, and finally mental status. Examples of methods used to assess mental status during START triage include asking patients to perform simple command such as opening and closing their eyes or squeezing a hand [34]. A Yellow tag or delayed status is assigned to all patients that were not originally deemed minimal, but meet the respiratory, perfusion, and mental status criteria set by START. An easy mnemonic to remember the parameters looked at by START is “RPM:30-2-can do”, with RPM standing for Respiration,Perfusion, Mental status. The second portion “30-2-can do” are the associated cut off values for each category: > 30 respirations per minute, presence of radial pulse or capillary refill <2 seconds, and can follow simple commands [26, 27].
Figure 1: START Algorithm to triage patients based on severity [22, 28].
Though there is little research analyzing the overall efficacy of START, the triage system has demonstrated higher overtriage rates in more critically ill patients during a disaster [28]. In a study by Kahn et. al, START was shown to have an overall accuracy of 44.6% in assigning the correct acuity level for patients. Upon further analysis, START was shown to perform well when identifying patients in the minimal category, with the walk test demonstrating accurate prognostic predictions [35]. However, the triage system experienced higher levels of overtriage (53.38%) in the two more critical patient categories with a significant number of patients inappropriately being placed in the immediate/emergency classification when they belonged in the delayed category [35].
The Sort, Assess, Lifesaving interventions, Treatment/Transport (SALT) algorithm was designed to unify the many existing triage algorithms. Due to a significant lack of research surrounding the efficacy of these triage tools, the Center for Disease Control and Prevention (CDC) assembled a committee in 2008 to combine the most effective features of the current mass triage algorithms into a national standard [22, 28]. This resulted in a new triage algorithm that is very similar to START, but with some key differences. SALT performs a more comprehensive triage of patients of all ages by performing multiple stages of sorting and prioritization with opportunities for reassessment [27]. Additionally, SALT prioritizes life-saving interventions by incorporating them into the triage algorithm leaving less room for hesitancy and uncertainty [13]. The protocol and unique features of SALT can be further elucidated by breaking down what SALT stands for.
Sort refers to the first step, unique to the SALT protocol, which entails an initial sorting of patients into three groups, prior to formal evaluation, to determine what order patients should be clinically assessed. This pre-sorting is based on their ability to ambulate and perform simple commands (Figure 2) [36]. If patients are able to ambulate, then they are placed in the “Walk” or “Able to walk” group. These patients will be assessed last due to the low risk associated with the ability to ambulate [22, 30]. Patients who are unable to walk, but are able perform purposeful movements such as waving will be placed in the “Wave” or “Able to make purposeful movements category” and assessed second. Finally, patients who have obvious life-threatening injuries or remain still despite prompts to walk or wave are placed in the “Still” or “Severely injured” category. These patients will be clinically evaluated first [27].
Figure 2: Step 1 of SALT algorithm to prioritize who to clinically assess first [22, 27, 28].
The Assess and Lifesaving interventions steps come next and are performed almost simultaneously. Assessrepresents the clinical evaluations that are performed after the three priority groupings have been established during the Sort step. This step is looking for any life-threatening injuries that require immediate stabilization [14]. As threats to life are found during this evaluation, the Lifesaving interventions step calls for immediate medical intervention during triage to stabilize these patients. These interventions typically include opening the airway, hemorrhage control, needle thoracostomy for pneumothoraxes, and antidote auto-injection for poisoning [14, 22].
The last phase of SALT, Treatment/Transport, requires an additional evaluation of patients following lifesaving interventions in order to place patients in the same four priority classifications for evacuation and definitive treatment utilized in START (Figure 3). This step affords the triage an opportunity to reassess patients following life-saving interventions and factor in their response [14]. This reassessment involves many of the same parameters looked at in START including breathing, mental status, and peripheral pulse. However, it also includes a step to consider the patient’s condition in the setting of the resources available [22]. Similar to START, once the patients have been sorted and tagged, they are transported and treated according to their priority group.
![Figure 2 Step 2 of SALT algorithm [31, 36, 37].](https://i0.wp.com/iem-student.org/wp-content/uploads/2024/03/Figure-3-Step-2-of-SALT-algorithm.png?fit=656%2C369&ssl=1)
Figure 3: Step 2 of SALT algorithm [31, 36, 37].
SALT has taken over as one of the major triage algorithms used in disasters and is endorsed by numerous entities including the American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, American College of Emergency Physicians, and more [36]. Studies have already begun to show that SALT provides more accurate triaging when compared to START and other triage systems [37, 38]. On the other hand, some studies have observed high levels of overtriage in SALT, similar to those seen in START, and even instances of high undertriage [28, 37, 38]. However, it is important to keep in mind that no clear conclusions can be drawn regarding SALT’s efficacy until more research is performed.
Summary
Disaster Medicine Triage focuses on managing medical care during events that overwhelm local emergency departments, necessitating additional aid. Definitions of “disaster” have evolved to describe situations beyond a community’s coping capability, encompassing natural and man-made incidents like water contamination and power outages. Emergency Medicine, among other healthcare disciplines, plays a crucial role, particularly in disaster response coordination and triage, aiming to do the best possible care for the greatest number. Triage, a core component, involves sorting patients based on their medical needs versus resource availability. With mass casualties, effective use of resources becomes inevitable, underpinning the need for efficient triage to optimize care and resource allocation, emphasizing the utilitarian principle of maximizing survival on a population level.
Authors
Parker MADDOX BA, MS
Parker Maddox is a fourth-year medical student at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. He graduated from the University of Virginia with a double major in Biology and Chemistry and went on to obtain a master’s degree in Biophysics and Physiology at Georgetown University. Since arriving to medical school, Parker has developed a passion for Emergency Medicine and has performed research on a wide range of topics including early sepsis recognition, pandemic viruses including Coronavirus 2019 and Monkeypox, ischemic stroke, Bell’s palsy, and international ECMO critical care protocol. This work has yielded multiple publications and a presentation at the Society for Academic Emergency Medicine (SAEM) 2022 Conference.
Hassan KHURAM BS, MS
Hassan Khuram is a 4th year medical student at Drexel University College of Medicine, with a background in psychology, biotechnology, and business of healthcare. He graduated Magna Cum Laude with a Bachelor of Science in Psychology from Virginia Commonwealth University and a Master of Science in Biotechnology from Georgetown University. He is passionate about neurocritical care, medical education, and bioethics. He has an extensive background in research, having conducted studies on various subjects, including substance misuse, Parkinson's disease, mindfulness meditation and more. He has published articles on neurological emergencies and ethical issues in neurological care.
Scott GOLDSTEIN, DO, FACEP, FAEMS, FAAEM, EMT-PHP
Dr. Scott Goldstein started his medical career at New York College of Osteopathic Medicine in New York where he received his Doctorate of Osteopathy and continued his training at Einstein Healthcare Network in the field of Emergency Medicine, Philadelphia. Dr. Goldstein is dual-boarded through the American Board of Emergency Medicine in Emergency Medicine and Emergency Medicine Services (EMS). He currently works at a Level 1 academic trauma center, Temple University Hospital, in Philadelphia where he is the Chief of EMS and Disaster Medicine. He has continued to be an active member of the education community and EMS community where he holds the title of Fellow of American College of Emergency Medicine through ACEP, Fellow of the Academy of Emergency Medical Services through NAEMSP and Fellow of the American Academy of Emergency Medicine through AAEM. His current academic title is one of Clinical Associate Professor of Emergency Medicine at Lewis Katz School of Medicine at Temple University.
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Reviewed By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
