Elsevier

Injury

Volume 44, Issue 5, May 2013, Pages 629-633
Injury

Major incident triage: Comparative validation using data from 7th July bombings

https://doi.org/10.1016/j.injury.2012.06.026Get rights and content

Abstract

Introduction

The importance of health service planning for major incident management has been recognised since the World Trade Centre attacks of September 2001 and is highly relevant to planning for the 2012 Olympics. UK national Major Incident guidance stipulates the use of a system of triage for casualties to prioritise treatment and ensure “the greatest good for the greatest number”. However, at least three triage systems are in use worldwide and no evidence exists to demonstrate their relative efficacy. The transport bombings in London on 7th July 2005 caused the largest number of casualties on mainland UK soil since World War 2. We aimed to validate three major incident triage systems using patient data from the 7th July bombings.

Patients and methods

A retrospective cohort of patients from the 7th July bombings treated at the Royal London Hospital (RLH) was examined. Clinical information collected on arrival at RLH was used to allocate triage categories using the START, Manchester Sieve and CareFlight triage systems. The value of each system in identifying the critically injured patient was calculated.

Results

203 sets of records were examined. Outcome data was available for 166 patients, of whom 8 were critically injured. Of these 166 patients, triage categories could be retrospectively allocated for 124 (START), 127 (Manchester Sieve), 128 (CareFlight), including 4 of the critically injured. All three systems identified the same three patients as P1 or P2. The triage systems performed identically in identifying the critically injured, with sensitivity 50% and specificity 100% if using only the highest priority, or sensitivity 75% and specificity 99% if using the top 2 priority groups. Significant amounts of data were not recorded in prehospital and hospital notes.

Discussion and conclusions

Systematic triage of mass casualties is effective but the amount of missing data seriously compromises any attempt to evaluate systems of trauma care in a major incident.

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.

References (16)

  • T. Kilner et al.

    In ‘big bang’ major incidents do triage tools accurately predict clinical priority? A systematic review of the literature

    Injury

    (2011)
  • A. Garner et al.

    Comparative analysis of multiple-casualty incident triage algorithms

    Annals of Emergency Medicine

    (2001)
  • S. Carley et al.

    The casualty profile from the Manchester bombing 1996: a proposal for the construction and dissemination of casualty profiles from major incidents

    Journal of Accident and Emergency Medicine

    (1997)
  • World Association for Disaster and Emergency Medicine

    Health disaster management: guidelines for evaluation and research in the “Utstein style”. Chapter 1: introduction

    Prehospital & Disaster Medicine

    (2002)
  • S. Carley et al.

    Major incidents in Britain over the past 28 years: the case for the centralised reporting of major incidents

    Journal of Epidemiology and Community Health

    (1998)
  • E.R. Frykberg et al.

    Terrorist bombings: lessons learned from Belfast to Beirut

    Annals of Surgery

    (1988)
  • London Assembly
    (2006)
  • M. Benson et al.

    Disaster triage: START, then SAVE – a new method of dynamic triage for victims of a catastrophic earthquake

    Prehospital & Disaster Medicine

    (1996)
There are more references available in the full text version of this article.

Cited by (34)

  • Accuracy of prehospital triage systems for mass casualty incidents in trauma register studies - A systematic review and meta-analysis of diagnostic test accuracy studies

    2022, Injury
    Citation Excerpt :

    This resulted in a high risk of bias in patient selection for almost all studies. Regarding applicability for patient selection, a few studies [24,34] used patients from real MCIs and thus had low risk of bias. However, for many of the eligible studies males were predominantly included, especially studies examining military populations.

  • Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT)

    2017, Injury
    Citation Excerpt :

    The nature of military operations and the pressured environment that clinicians are working in, is likely to explain some of this missing data [11]. The major incident setting is no different, and the difficulties in maintaining contemporaneous medical records during a major incident have been described previously [21,28]. The extent of missing data in our study (39.3%) is directly comparable to that observed following the 7th July bombings (approximately 38.0%).

  • Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident

    2016, Injury
    Citation Excerpt :

    Major incidents occur on a regular basis across the world and range from natural disasters to transport incidents and terrorist activities [1].

View all citing articles on Scopus
View full text