Triage During Disaster

Triage During Disaster

Principles of Triage

Triage has 2 components: 1) sorting patients and prioritizing their care based on the severity of their illnesses and 2) rationing resources to optimize their availability and direct them to the patients who are most likely to benefit from them. The primary goal of triage, as originally used in mass casualty incidents, was to do the greatest good for the greatest number. However, as triage has evolved over time. Today, triage is used to identify priorities for patient care in emergency departments and most surge situations

in which resources are rarely limited. Triage is seldom used to ration care. Iserson and Moskop describe 5 commonly encountered types of triage: ED triage, Inpatient triage, incident triage, military triage, and disaster triage, as summarized in. In this chapter, we will focus on disaster triage, which is used in mass casualty incidents. During a mass casualty incident, triage may occur at multiple points as patients progress from

prehospital management to definitive care in operating rooms or ICUs. At the various points triage is usually classified as primary, secondary, or tertiary. Environment and safety, resource constraints, treatment options, and specificity of decisions vary considerably at each level.

A. Primary Triage

Primary triage occurs in the field. It is often performed by paramedics and based on very simple criteria that can be rapidly assessed. If, for example, a patient requires intubation due to acute respiratory distress, in all likelihood providers will perform that procedure if the scene is safe, they have the time, there is no risk to the providers (ie, highly transmissible infection), and they have accurate tools to determine if the patient will survive in higher levels of care in the ED or ICU. Intubation and other procedures may also require related treatment, such as manual ventilation during transport.

B. Secondary Triage

Secondary triage is typically performed by emergency physicians or surgeons immediately upon a patient's arrival at the hospital. They prioritize patients by assigning them to treatment areas for initial interventions. Efficient flow of critically injured or ill patients through this part of the system to definitive care is critical. Here treatment decisions may be more accurate than in the field, but they will remain limited until further information about the event or predicted outcomes can be ascertained. The goal is to provide critical initial ABC (airway, breathing, circulation) interventions

rather than full resuscitation. After initial interventions,

Tertiary triage will assign patients to definitive care in surgery or intensive care, and only judiciously to radiology, for ongoing management.

C. Tertiary Triage

Tertiary triage should be conducted by surgeons or intensivists in keeping with the best practices for triage officers discussed later in this chapter. At each stage of the triage process accuracy can be increased by measuring physiologic parameters and introducing structured physical examination. This third stage of triage is of primary relevance to critical care physicians because the situation and the patients' characteristics call for definitive critical care management. In disasters where most injuries are not life threatening or where few critically injured patients survive long enough to present to the hospital there will be less need to conduct tertiary triage. Using triage to ration resources should be done only when the system is overwhelmed and the resources are or will be insufficient to meet the demand. Critical care resources that may be depleted in a disaster

include ventilators, medications, monitors, and trained personnel. Although the specific resources required vary with the nature of the disaster, some resources, such as ventilators, are key to the provision of critical care and lack a reasonable substitute. Further, it is important to remember that only a single pool of critical care resources exists to serve the needs of those directly affected by the disaster and all other patients with critical illnesses or injuries unrelated to the major incident.

Effective triage not only requires a balance between the demands on the system and the supply of resources but also must balance over triage and under triage.

Primary Components of Triage

Disaster triage: Used in mass casualty incidents that overwhelms local and regional healthcare systems. Disaster triage protocols both prioritize salvageable patients for treatment and ration resources to ensure the greatest good for the greatest number.

Triage Protocols

In general, triage protocols classify patient's into1 of 3 categories signified by standardized color

codes: 1) those who will survive whether they receive care or not (green and yellow),

codes: 2) those who will benefit significantly from interventions (red), and

codes : 3) those who are likely to die despite maximal medical effort (blue or black)

Disaster Triage and Al location of Scarce Resources

• The ability of a healthcare system to respond to a surge is determined by such factors as the resources available, the number of patients, the time period over which those patients arrive, and the need for specialized services
• Resource allocation strategies must take into account both supply and demand. When demand exceeds supply, scarcities will ensue and triage will be required to prioritize and ration resources.
• Triage is a dynamic process requiring protocol adjustments to ensure that rationing (Infringement on individual liberties) does not exceed the expected or experienced shortfall between demand and supply.
• Triage is commonly used throughout the healthcare system to set priorities for patient care. Only in rare disaster circumstances does it form the basis for rationing resources.
• Disaster triage occurs at various points along the continuum of care and is classified accordingly as primary, secondary, or tertiary. Tertiary triage involves decisions related to allocating critical care resources.
• A strong ethical framework is necessary to guide the development and implementation of a triage protocol.