Connecticut — Targeted Issue

Description

Objectives: Explore the evidence for current pediatric disaster triage systems, and the limitations of triage science; Synthesize means for initial and subsequent disaster triage training for a range of healthcare professionals; Describe strategies by which triage can account for the vulnerabilities of children in disasters

Description

Training PowerPoint targeting prehospital providers contains five narrated modules addressing the following: Recognizing a Disaster, Disaster Triage Rationale, Pediatric Triage Considerations, Triage Methodologies (JumpSTART, SMART, SALT, and clinical decision making); Special Triage Decisions).

Description

This course introduces clinicians to the needs of the pediatric population during a disaster and the widely used JumpSTART Triage System for pediatric victims. It also covers clinical manifestations and treatment for child victims of natural and human-caused disasters. Decontamination strategies are also covered. Estimated Course Time: 60 minutes

Author(s)/Presenter(s)

Nicole L Nadeau, Mark X Cicero

Abstract/Description

Objectives: The study goal was to determine which pediatric disaster triage (PDT) systems are used in US states/territories and whether there is standardization to their use. Secondary goals were to understand user satisfaction with each system, user preferences, and the nature and magnitude of incidents for which the systems are activated.

Methods: A survey was developed regarding PDT systems used in each state/territory, satisfaction with those used, preference for specific systems, and type and magnitude of incidents prompting system activation. The survey was distributed to emergency medical services for children leads in each state/territory.

Results: Eighty-six percent of states/territories responded. Eighty-eight percent of respondents used some formal PDT system, 50% of whom reported utilization of multiple systems. JumpSTART was most commonly used, most often in conjunction with other systems. Of formal systems, JumpSTART has been in use the longest. JumpSTART was also preferred by 71% of those stating a preference; it tied with Smart for median satisfaction level. Although types of incidents prompting system activation was similar across responding states/territories, number of patients prompting activation varied from 1 to 3 to greater than 20, median range of 4 to 7.

Conclusions: Most states/territories use some formal PDT system; few have 1 standardized approach. JumpSTART is predominantly used and is preferred by most respondents. With all systems, there is marked variation in number of patients prompting activation although the reported nature of incidents prompting activation is similar.

Author(s)/Presenter(s)

Mark X Cicero, Frank Overly, Linda Brown, Jorge Yarzebski, Barbara Walsh, Veronika Shabanova, Marc Auerbach, Antonio Riera, Kathleen Adelgais, Garth Meckler, David C Cone, Carl R Baum

Abstract/Description

Background: It is unclear which pediatric disaster triage (PDT) strategy yields the best accuracy or best patient outcomes.

Methods: We conducted a cross-sectional analysis on a sample of emergency medical services providers from a prospective cohort study comparing the accuracy and triage outcomes for 2 PDT strategies (Smart and JumpSTART) and clinical decision-making (CDM) with no algorithm. Participants were divided into cohorts by triage strategy. We presented 10-victim, multi-modal disaster simulations. A Delphi method determined patients' expected triage levels. We compared triage accuracy overall and for each triage level (RED/Immediate, YELLOW/Delayed, GREEN/Ambulatory, BLACK/Deceased).

Results: There were 273 participants (71 JumpSTART, 122 Smart, and 81 CDM). There was no significant difference between Smart triage and CDM. When JumpSTART triage was used, there was greater accuracy than with either Smart (P<0.001; OR [odds ratio]: 2.03; interquartile range [IQR]: 1.30, 3.17) or CDM (P=0.02; OR: 1.76; IQR: 1.10, 2.82). JumpSTART outperformed Smart for RED patients (P=0.05; OR: 1.48; IQR: 1.01,2.17), and outperformed both Smart (P<0.001; OR: 3.22; IQR: 1.78,5.88) and CDM (P<0.001; OR: 2.86; IQR: 1.53,5.26) for YELLOW patients. Furthermore, JumpSTART outperformed CDM for BLACK patients (P=0.01; OR: 5.55; IQR: 1.47, 20.0).

Conclusion: Our simulation-based comparison suggested that JumpSTART triage outperforms both Smart and CDM. JumpSTART outperformed Smart for RED patients and CDM for BLACK patients. For YELLOW patients, JumpSTART yielded more accurate triage results than did Smart triage or CDM.

Author(s)/Presenter(s)

Mark Cicero, Linda Brown, Frank Overly, et al

Abstract/Description

Objective: There is a need for rigorously designed pediatric disaster triage (PDT) training simulations for paramedics. First, we sought to design three multiple patient incidents for EMS provider training simulations. Our second objective was to determine the appropriate interventions and triage level for each victim in each of the simulations and develop evaluation instruments for each simulation. The final objective was to ensure that each simulation and evaluation tool was free of bias toward any specific PDT strategy.

Methods: We created mixed-methods disaster simulation scenarios with pediatric victims: a school shooting, a school bus crash, and a multiple-victim house fire. Standardized patients, high-fidelity manikins, and low-fidelity manikins were used to portray the victims. Each simulation had similar acuity of injuries and 10 victims. Examples include children with special health-care needs, gunshot wounds, and smoke inhalation. Checklist-based evaluation tools and behaviorally anchored global assessments of function were created for each simulation. Eight physicians and paramedics from areas with differing PDT strategies were recruited as Subject Matter Experts (SMEs) for a modified Delphi iterative critique of the simulations and evaluation tools. The modified Delphi was managed with an online survey tool. The SMEs provided an expected triage category for each patient. The target for modified Delphi consensus was ≥85%. Using Likert scales and free text, the SMEs assessed the validity of the simulations, including instances of bias toward a specific PDT strategy, clarity of learning objectives, and the correlation of the evaluation tools to the learning objectives and scenarios.

Results: After two rounds of the modified Delphi, consensus for expected triage level was >85% for 28 of 30 victims, with the remaining two achieving >85% consensus after three Delphi iterations. To achieve consensus, we amended 11 instances of bias toward a specific PDT strategy and corrected 10 instances of noncorrelation between evaluations and simulation.

Conclusions: The modified Delphi process, used to derive novel PDT simulation and evaluation tools, yielded a high degree of consensus among the SMEs, and eliminated biases toward specific PDT strategies in the evaluations. The simulations and evaluation tools may now be tested for reliability and validity as part of a prehospital PDT curriculum.

Author(s)/Presenter(s)

Jeannette R Koziel, Garth Meckler, Linda Brown, David Acker, Michael Torino, Barbara Walsh, Mark X Cicero

Abstract/Description

Background: In disasters, paramedics often triage victims, including children. Little is known about obstacles paramedics face when performing pediatric disaster triage.

Objective: To determine obstacles to pediatric disaster triage performance for paramedics enrolled in a simulation-based disaster curriculum.

Design: We conducted a qualitative evaluation of paramedics' self-reported obstacles to pediatric disaster triage performance. The paramedics were enrolled in a pediatric disaster triage curriculum at one of three study sites. An individually administered, semi-structured debriefing was created iteratively, and used after a 10-victim, multiple-family house fire simulation. The debriefings were audio-recorded, and transcribed. Two investigators independently analyzed the transcripts. Using grounded theory strategy, the data were analyzed via 1) immersion and coding of data, 2) clustering of codes to generate themes, and 3) theme-based generation of hypotheses. While analyzing the data, we employed peer debriefing to determine emerging codes, groups, and thematic saturation. Systematically applied data trustworthiness strategies included triangulation and member checking.

Results: A total of 34 participants were debriefed, with prehospital care experience ranging from 1 to 25 years of experience. We identified several barriers to pediatric disaster triage: 1) lack of familiarity with children and their physiology, 2) challenges with triaging children with special health-care needs, 3) emotional reactions to triage situations, including a mother holding an injured/dead child, and 4) training limitations, including poor simulation fidelity.

Conclusion: Paramedics report particular difficulty triaging multiple child disaster victims due to emotional obstacles, unfamiliarity with pediatric physiology, and struggles with triage rationale and efficiency.

Author(s)/Presenter(s)

Nicole Nadeau, MD, Mark X. Cicero, MD, FAAP

Abstract/Description

Purpose: Disaster medicine is a developing field, and even less is known about pediatric disaster medicine. Many pediatric disaster triage (PDT) systems exist, yet little is known about where and how they are used. We sought to understand which, if any, of these PDT systems are utilized in each U.S. state/territory. Further, we sought to understand the relative level of satisfaction with each PDT system, the nature of incidents for which PDT systems are being activated, and the number of patients prompting PDT activation.
Methods: We developed an electronic survey regarding PDT strategies utilized in each state/territory, level of satisfaction with PDT strategies via 5-point Likert scale ranging from very dissatisfied to very satisfied, and the types and magnitude of incidents that prompt PDT activation. A pilot survey was released to nine PDT experts. After revision the final survey was submitted to, and endorsed by, the National Association of State Emergency Medical Service Officials (NASEMSO). NASEMSO distributed the survey to EMS for Children (EMSC) contacts for each state/territory. Preferred responders were EMSC Program Managers, EMS Directors, other state EMS representatives—in that order. Data were compiled and reviewed; some responses were identified as duplicates within a state/territory, in which case the preferred respondent's survey was utilized where answers conflicted.
Results: Of 55 states/territories, we received surveys from 47 (85%). 41/47 (87%) utilized some formal PDT system. Twenty of those 41 (49%) did not utilize one system but rather reported utilization of multiple systems. While JumpSTART was the most commonly used, it was more often utilized in conjunction with other systems than used exclusively.
https://aap.confex.com/aap/2013/webprogram/Paper21923.html

Author(s)/Presenter(s)

Keith P Cross, Mark X Cicero

Abstract/Description

Study objective: A variety of methods have been proposed and used in disaster triage situations, but there is little more than expert opinion to support most of them. Anecdotal disaster experiences often report mediocre real-world triage accuracy. The study objective was to determine the accuracy of several disaster triage methods when predicting clinically important outcomes in a large cohort of trauma victims.

Methods: Pediatric, adult, and geriatric trauma victims from the National Trauma Data Bank were assigned triage levels, using each of 6 disaster triage methods: simple triage and rapid treatment (START), Fire Department of New York (FDNY), CareFlight, Glasgow Coma Scale (GCS), Sacco Score, and Unadjusted Sacco Score. Methods for approximating triage systems were vetted by subject matter experts. Triage assignments were compared against patient mortality at hospital discharge with area under the receiver operator curve. Secondary outcomes included death in the emergency department, use of a ventilator, and lengths of stay. Subgroup analysis assessed triage accuracy in patients by age, trauma type, and sex.

Results: In this study, 530,695 records were included. The Sacco Score predicted mortality most accurately, with area under the receiver operator curve of 0.883 (95% confidence interval 0.880 to 0.885), and performed well in most subgroups. FDNY was more accurate than START for adults but less accurate for children. CareFlight was best for burn victims, with area under the receiver operator curve of 0.87 (95% confidence interval 0.85 to 0.89) but mistriaged more salvageable trauma patients to "dead/black" (41% survived) than did other disaster triage methods (≈10% survived).

Conclusion: Among 6 disaster triage methods compared against actual outcomes in trauma registry patients, the Sacco Score predicted mortality most accurately. This analysis highlighted comparative strengths and weakness of START, FDNY, CareFlight, and Sacco, suggesting areas in which each might be improved. The GCS predicted outcomes similarly to dedicated disaster triage strategies.