Workgroup Proposes National Guideline for Mass Casualty Triage

A national guideline for triage following a mass casualty incident has been proposed by a national multidisciplinary workgroup lead by a researcher at the Medical College of Wisconsin in Milwaukee. This guideline allows providers to sort patients for treatment based on the severity of their conditions and establishes a standardized nomenclature.

The workgroup, led by E. Brooke Lerner, Ph.D., associate professor of emergency medicine at the Medical College, recently published its proposed national guideline in the September supplemental issue of Disaster Medicine and Public Health Preparedness focusing on triage.

The workgroup's proposed guideline is known as SALT triage, an acronym for Sort, Assess, Life Saving Interventions, Treatment and/or Transport. It includes a standardized naming and color-coding system to identify and prioritize patients medical needs, and was developed with the intention that it could be used to treat all types of patients in all types of incidents.

According to the report, other triage systems in the United States focus on treating adults or children exclusively. SALT, on the other hand, can be used to treat all patients in any type of mass casualty event. "Since it relies on existing evidence supporting the effectiveness of other triage systems, it is expected that it would be easy to incorporate into current triage protocol through simple modifications to existing plans," Lerner said.

Because mass casualty events often cross jurisdictional lines, a national guideline is needed. "The specific system of mass casualty triage that a prehospital care provider learns to use has been dependent largely on local or regional protocols with little consistency or interoperability between jurisdictions," Lerner said.

The workgroup reviewed existing triage systems in the United States and evaluated the scientific evidence available to support each system. The committee conducted an exhaustive literature review identifying nine existing triage systems.

The first step in SALT, the Sort process, represents where SALT differs most from previous triage systems. In this first step, patients are prioritized for individual assessment through simple voice commands, like asking patients to walk to a designated area or wave their hands. Other triage systems usually sort patients by asking them to walk, but then consider all those patients to be minimally injured without conducting an individual assessment. This might cause patients who are able to walk but need immediate care to be ignored for long periods of time. This guideline requires that those patients be individually assessed prior to designating them as minimally injured.

"This guideline suggests that providers begin the triage process by identifying those who are able to walk," Lerner said. "Simple voice commands are used to prioritize patients for individual assessment and to give those who can walk clear instructions regarding where to go for help. These instructions may keep casualties from self-triaging to the closest hospital by giving them a specific place to go for additional assistance."

The wave command allows responders to distinguish between patients who are not able to follow a command from those who can follow a command but can not walk; this gives responders an opportunity to more easily identify which patients need critical care.

"By assessing those patients who are not waving or making purposeful movements first, the provider is likely to approach those patients who may require lifesaving interventions first," Lerner said.

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