Major incident triage: Comparative validation using data from 7th July bombings
Introduction
Initial triage of mass casualties at major incidents is currently almost entirely devoid of an evidence base. There is a well-identified information gap in the reporting of health services response to mass casualty incidents (MCIs),1 in contrast to the structured investigation of the causes of such incidents. This is despite calls for a standard structure (similar to Utstein2) to facilitate reporting and comparison. Attempts have been made to validate various triage systems, but these have used proxy data sets such as trauma registries, rather than actual MCI data.3, 4
MCIs still have a significant impact on health services; from 1968 to 1996 the UK alone saw up to 11 per year with up to 165 deaths and up to 500 patients at each.5 Although the implications for an individual patient of undertriage (failure to send a critically injured patient to a high acuity facility) are self-evident, an association has been demonstrated between rates of overtriage (transport of non-critically injured patients to high acuity facilities) and critical mortality (death rate in those surviving the initial event).6 We therefore aimed to assess the predictive power of three different MCI triage systems using data from an actual MCI (the London bombings of 7th July 2005).
The requirement for formal ethical approval was waived by the chair of South Manchester Local Research Ethics Committee given the lack of patient contact.
Section snippets
Patients
We collected patient data via London Ambulance Service (LAS) and the Royal London Hospital (RLH). We selected the RLH because 208 of the 404 bombing victims conveyed to hospital were treated there.7 We analysed all LAS Patient Report Forms (PRF) relating to bombing victims. We examined Emergency Department (ED) or Walk-in Centre and hospital notes from the RLH both for triage categories allocated on 7th July if available and for physiological data required to complete the three triage
Results
PRFs were obtained from LAS for 42 patients, representing all the PRFs relating to the bombings. Due to redacted demographic information we were unable to match any LAS PRFs to RLH patient notes thus no further analysis of LAS data is presented.
We examined 203 sets of patient ED and hospital notes from RLH (of 208 reported to have been assessed there7). We were able to obtain outcome data for 166 patients; the rest of the notes were unavailable due to ongoing care or missing. We found 8
Discussion
We have demonstrated that all three MCI triage systems examined performed similarly in a retrospective analysis, identifying three of four critically injured patients; the same missed patient in all cases walked into hospital (and was triaged as P3 – green) but later required neurosurgical intervention. Application of all the systems resulted in a number of patients being allocated to lower triage categories than were applied at RLH; no patient was given a higher triage category systematically
Conflict of interest
The authors declare that they have no conflicts of interest.
Role of the funding source
Authors were employees of University Hospital of South Manchester NHS Foundation Trust at the time of writing but retained full autonomy over the design, methodology and interpretation of the research.
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