Introduction
The term triage means to sort or select. EMS personnel and other health care providers use the principle of triage at different times for a variety of reasons during the provision of emergency care. Examples range from determining whether an injured patient needs the resources of a trauma center to identifying which emergency department patient needs to be placed in a treatment room first. During a mass casualty incident, triage decisions must be made more rapidly; EMS providers have less time to gather information and decide who to treat first. Further, the emphasis shifts during a mass casualty incident from ensuring the best possible outcome for each patient to ensuring the best possible outcomes for the greatest number of patients. Military organizations were the first to develop the concept of mass casualty triage and these concepts have been adopted for use in the civilian setting [1–3].
Mass casualty triage occurs when there is more than one casualty and the available resources require a provider to initiate care for one patient over another. In a synthesis of available evidence, Frykberg found that during mass casualty incidents there is an almost linear relationship between overtriage and poor patient outcome [4]. This finding indicates that the methods used to prioritize victims of a multicasualty event for treatment and transport may have a significant effect on patient outcome.
Triage systems
There are many triage schemes that are used around the world. In the United States, the decision of which triage system to use has typically been made at the local agency level. However, this could lead to poor interoperability in situations where multiple agencies must respond to the same incident and are using different triage systems. In an effort to correct for this issue and to encourage evidence-based practices, the Model Uniform Core Criteria (MUCC) were developed [5,6]. The criteria lay out a list of minimum standards that triage systems should incorporate to ensure interoperability, and they identify the evidence that is available to support each criterion. In July 2013 the Federal Interagency Committee on EMS approved an implementation plan for establishing the MUCC as a national guideline [7]. This document recommends that state and local EMS agencies use triage systems that comply with the MUCC, and allows for the use of federal funds for the transition. There has not been sufficient time since this plan was published to describe the results. Further, it is currently a transition period so each medical director and EMS physician should be familiar with all the mass casualty triage systems that may currently be in use [8].
A review of existing triage systems was conducted by a multidisciplinary panel sponsored by the Centers for Disease Control and Prevention (CDC) prior to publication of the MUCC, and they identified nine existing mass casualty triage systems, including two pediatric-specific systems [8,9]. These systems include Simple Triage and Rapid Treatment (START) [10], JumpSTART [11], Homebush [12], Triage Sieve [13,14], Pediatric Triage Tape (PTT) [15], CareFlight [14], Sacco Triage Method (STM), military triage [16], and the Italian CESIRA (Coscienza, Emorragie, Shock, Insufficienza respiratia, Rottureossee, Altro) protocol. These systems have been described in detail in other works [8,9],and are relatively similar in that most use a four- or five-category scheme that is grounded on basic physiological criteria. A notable exception is the STM, which uses a proprietary computer-based algorithm to generate a numeric treatment priority score based on physiological criteria and available community resources. Several secondary triage tools, such as Secondary Assessment of Victim Endpoint (SAVE) triage and System of Risk Triage (SORT), also exist. These systems allow responders to further prioritize patients once they have been placed in the four or five groups.
