PREHOSPITAL CARE
Comparison of paediatric major incident primary
triage tools
L A Wallis, S Carley
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See end of article for
authors’ affiliations
. . . . . . . . . . . . . . . . . . . . . . .
Correspondence to:
Dr S Carley, Consultant in
Emergency Medicine,
Emergency Department,
Manchester Royal
Infirmary, Oxford Road,
Manchester M13 9WL,
UK; s.carley@btinternet.
com
Accepted for publication
8 February 2006
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Emerg Med J 2006;23:475–478. doi: 10.1136/emj.2005.032672
Objectives: To determine the sensitivity and specificity of paediatric major incident triage scores. The
Paediatric Triage Tape (PTT), Careflight, Simple Triage and Rapid Treatment (START), and JumpSTART
systems were tested.
Methods: In total, 3461 children presenting to a South African emergency department with trauma were
scored using the four different methods. The sensitivity and specificity of the four scores was calculated
against the Injury Severity Score (ISS), New ISS (NISS), and a modification of the Garner criteria (a
measure of need for urgent clinical intervention). We also performed a Bayesian analysis of the scores
against three different types of major incident.
Results: None of the tools showed high sensitivity and specificity. Overall, the Careflight score had the best
performance in terms of sensitivity and specificity. The performance of the PTT was very similar. In contrast,
the JumpSTART and START scores had very low sensitivities, which meant that they failed to identify
patients with serious injury, and would have missed the majority of seriously injured casualties in the
models of major incidents.
Conclusion: The Careflight or PTT methods of triage should be used in paediatric major incidents in
preference to the jumpSTART or START methods.
A
lthough major incidents are relatively uncommon
events,1
they can seriously test the responses of
emergency medical services and hospitals.2
All major
incidents are characterised by a period of time when the
casualty load exceeds the available resources. It is therefore
vital that medical resources are effectively directed towards
those patients who are most likely to benefit. A key step in
facilitating a smooth response is effective triage, which
occurs in two phases. At the scene of an incident, primary
triage is a rapid ‘‘once over’’ to quickly identify those patients
in most urgent need of medical intervention and those who
can wait for further assessment. Secondary triage usually
occurs at the location of the incident’s main treatment centre,
where time and resources allow for a more in depth triage
process.
Children are commonly involved in major incidents, either
as a significant proportion of the casualties or as the total
patient load.3
If children are involved, a number of factors
influence and complicate triage decisions. Firstly, children
have different physiological norms. Such differences mean
that using adult scores on children will often lead to an
inappropriately high triage category.4
Secondly, there is often
an emotional desire among rescuers to accord children, and
especially young children, a higher priority. Both these
factors may mean that resources will be directed away from
more seriously injured adults (in a mixed adult/child
incident) or that the score may fail to discriminate priorities
at all (in a child only incident). In order to try to minimise
these predictable problems, specific paediatric primary triage
algorithms have been devised. These include: (a) the
Paediatric Triage Tape (PTT),4
used in the UK, and parts of
Europe, India, Australia, and South Africa; (b) CareFlight,5
in
use in parts of Australia; (c) Simple Triage and Rapid
Treatment (START),6
in use in the USA for children aged
older than 8 years; and (d) JumpSTART,7
in use in the USA
for children aged 1–8 years.
For practical and ethical reasons, primary triage algorithms
are highly unlikely ever to be validated in real incidents.
Computer modelling and major incident registries may help
future work in this area although there are obvious potential
problems with the validity of such data. Typically, triage
algorithms have been compared against the gold standard of
the Injury Severity Score (ISS),8
although some authors have
suggested that the New ISS (NISS)9
may be better.10
However, the use of anatomical measures of injury such as
the ISS has been questioned, as it fails to predict the
requirement for medical intervention accurately.11
Neither
ISS nor NISS give any indication of the requirement for
medical intervention at the scene of a major incident, which
must surely be the most important outcome of any primary
triage score. Garner et al12
proposed the use of clinical
interventions in place of ISS in the validation of adult major
incident primary triage tools: the requirement for any of
these interventions was taken as indicating a T1 (immediate
priority) patient. These interventions are presented in table 1,
and are easily modifiable to be applicable to the paediatric
setting.
In this study, our aim was to determine the sensitivity and
specificity of primary triage scores in the assessment of
paediatric casualties.
METHODS
We prospectively tested paediatric triage scores on paediatric
attendees at the Trauma Unit of the Red Cross Children’s
Hospital, Cape Town. This unit sees children aged up to
12 years of age and is the major tertiary referral centre for the
Cape Town area, receiving approximately 9000 injured
children each year.
We prospectively collected data on all attendees meeting
the following criteria: age ,13 years, and presentation
within 12 hours of an acute injury. Physiological, anatomical,
and demographic information needed to complete the
Abbreviations: ISS, Injury Severity Score; NISS, New Injury Severity
Score; PTT, Paediatric Triage Tape; START, Simple Triage and Rapid
Treatment
475
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different scores were collected at triage using standardised
printed material (for the PTT, CareFlight, and START or
JumpSTART, depending on the child’s age). All children were
prospectively followed through to death or discharge, when
the ISS and NISS scores were calculated. In addition, the case
notes were examined for evidence of any of the modified
Garner criteria.
Outcome measures
We defined the performance of the scores against their ability
to discriminate between T1 (immediate priority) and not-T1
(urgent or delayed priority). For comparison against ISS,
children were considered to be seriously injured (and
therefore rated as T1) if they had a total ISS .15. Children
with an ISS (15 were considered to be not-T1. The same
cutoff was applied against the NISS. For analysis against the
modified Garner criteria, the requirement for one or more of
these interventions was considered an indicator that the child
was T1.
The sensitivity and specificity of the PTT, Careflight, and
START/JumpSTART were calculated individually against ISS,
NISS and modified Garner criteria. Sensitivity reflects the
proportions of those patients who are T1 who are correctly
identified as T1, while specificity is the proportion of patients
who are not-T1 who are correctly identified as not-T1.
To determine how the scores would perform in practice, we
calculated the ability of the score to perform in three different
types of major incident with varying proportions of seriously
injured casualties. The principle outcome was the proportion
of children correctly identified as truly T1 and truly not-T1
against falsely T1 and falsely not-T1 (that is, the accuracy of
the score for each scenario). The characteristics of the
hypothetical incidents were as shown below:
N Incident 1: 100 paediatric casualties, 10% T1
N Incident 2: 100 paediatric casualties, 30% T1
N Incident 3: 100 paediatric casualties, 60% T1.
The results against the hypothetical incidents were
rounded to the nearest whole number. The flowcharts for
each triage methodology are available online (http://
www.emjonline.com/supplemental).
RESULTS
In the study period, 5508 children presented to the trauma
unit within 12 hours of injury. Of these, 3597 children met
the entry criteria for the study, and 3461 (96%) children were
enrolled. The study population was 63% male, with a median
age of 7 years. JumpSTART was used to triage 2441 children
(aged 1–8 years); the remaining 1020 were triaged by START
methodology in accordance with the algorithms’ instructions.
Of the 3461 patients in this study, 1983 (57.3%) presented
within 1 hour of injury, 2476 (61.5%) within 2 hours, and
2910 (84%) within 4 hours. There were 46 patients (1.3%)
with penetrating trauma.
There were 188 children (5.4%) with an ISS of .15 and
314 (9.1%) with an NISS .15, and 312 modified Garner
criteria were present in 200 (5.8%) children. For each of these
three standards, the sensitivity and specificity rates for the
different triage algorithms are presented in table 2.
Table 3 shows how each score performs in each type of
hypothetical incident with differing proportions of seriously
injured casualties. The score with the best performance in
each incident is marked in bold. The JumpSTART and START
methods were analysed independently and also as a 50:50
split, as they are components of the same triage system, only
divided as to which age they should be applied.
DISCUSSION
Principal findings
We found that there are significant differences in the
performance of the triage scores when analysed against a
pool of patients presenting to an emergency department.
Analysis of the sensitivity and specificity figures suggests that
the performance of the PTT and CareFlight scores is similar,
and both are better than the JumpSTART and START scores.
The JumpSTART and START scores have worryingly low
sensitivities when measured against anatomical injuries,
resulting in identification of very few patients with serious
injury; in other words, they miss the majority of serious
anatomical injuries.
It is our belief that the Garner criteria are probably a better
measure of score performance than the anatomical descriptors
of injury. In this regard, overall performance of the
CareFlight and PTT scores is better than the JumpSTART/
START methodologies in all but the most severe incidents.
Overall, the CareFlight score appears to be the best performing,
although the difference between it and the PTT is
probably clinically insignificant.
Strengths and weaknesses of the study
Our study uniquely applied a range of scores simultaneously
to the same group of paediatric patients presenting with
trauma. This allowed us to determine the performance of
each score against interventional and anatomical criteria, and
to draw direct comparisons between the scores. Our analysis
against hypothetical major incidents shows how a score
might actually help triage officers in the field with their triage
decisions. In essence, it informs us of how well the score
might discriminate between those who need immediate care
and those who do not.
Our study does have some weaknesses. The regular
recording of the triage score criteria over a period of months
may have led to a much greater degree of familiarity with the
methods than could be expected in a real incident. Our
results probably therefore demonstrate the best performance
that the scores could hope to achieve. While this study was
designed to prospectively assess the usefulness of the primary
triage algorithms, the numbers of patients classified as T1 by
ISS (or NISS/modified Garner criteria) is relatively small.
However, as the majority of patients from a major incident
setting are likely to be minor in nature,1
the patient
distribution in this study is therefore representative.
We had to modify the Garner criteria to a paediatric
population but believe that the changes made are intuitive
and reflect current paediatric resuscitation.13
Comparing developed world algorithms in a developing
country may lead to bias in the conclusions, as the
physiological parameters used by the tool may be different
in that country. However, work undertaken by one of the
Table 1 Interventional criteria taken from Garner et al12
,
with suggested paediatric modification
Patient requires Suggested paediatric modification
Operative intervention (nonorthopaedic;
within 6 hours)
Fluid resuscitation of 1000 ml or
more, to maintain BP .89 mmHg
Fluid resuscitation in excess of
20 ml/kg
Invasive CNS monitoring, or a
positive head CT scan
A procedure to maintain the
airway, or assisted ventilation
Decompression of a tension
pneumothorax
BP, blood pressure; CNS, central nervous system; CT, computed
tomography.
476 Wallis, Carley
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authors14
shows that the heart rate and respiratory rate of
children in the UK and South Africa may be considered the
same by age. Hence, direct extrapolation of the results to USA
or UK populations should be possible. It should also be
remembered that we tested tools in a hospital setting, not in
the prehospital environment where they would be used.
Strengths and weaknesses in relation to other studies
Many experts still consider that the ISS is the only
appropriate means against which to validate triage algorithms:
it has been studied extensively as a summary
measure against which day to day triage tools are tested.
An ISS of >16 is widely regarded as indicating serious injury,
and this cutoff point is used to direct patients to trauma
centre care in regionalised systems such as that in the
USA.15 16
The use of NISS has been suggested to be a more
accurate indicator of severity of injury,10
although it has still
to gain wide acceptance.
However, the ISS (and NISS) were not designed to serve as
markers of resource requirement, and there is good evidence
that the ISS fails to correlate with this measure.11
The NISS is
likely to suffer from the same limitation, although it has not
been studied in this regard. In primary triage at a major
incident, severity of injury is of little relevance; rather, triage
is aimed at prioritising the requirement for medical
intervention. A patient with a minor head injury but an
obstructed airway due to his position is of higher priority
than a patient whose airway is intact, regardless of the
severity of injury.
The use of clinical interventions given Garner et al12
as a
marker of urgency of requirement for intervention helps to
overcome the limitations of the ISS and NISS. Although they
chose a limited range of interventions on which to base their
analysis, their work is important in opening up this field for
future research. The requirement for any of the clinical
interventions that they proposed (modified slightly for
children to reflect different fluid resuscitation strategies)
may be used as a marker to indicate a patient who should be
triaged as T1 by any triage algorithm. Although their work
allows research in this field to begin to move away from the
use of inappropriate scoring systems, the interventions
proposed by Garner et al can still only be used to distinguish
between those patients who are T1 (immediate) and those
who are not. As with the use of ISS and NISS, further
analysis of the ability of triage algorithms to identify T2
(urgent) and T3 (delayed) patients is impossible.
Development of the use of clinical interventions as markers
of T2 and T3 patients should be possible, and we are currently
undertaking work in this regard.
Implications of the study
Either the Careflight or PTT should be adopted as the method
of choice for the initial pre-hospital triage of paediatric
patients in major incidents. Policymakers should decide
which method to use, based on current knowledge, exposure,
and the practicalities of each method for field use. We have
not compared the practicalities or ease of use in this study.
However, our experience suggests that there is little
difference in terms of time to perform or training.
Unanswered questions and future research
Our study was unable to discriminate between T2 and T3
casualties, which is arguably as important as discriminating
T1 casualties at the scene of an incident. In order to do this,
additional criteria, such as the Garner criteria but with T2
and T3 outcomes, must be available. We are currently
conducting a study to define exactly those criteria.
CONCLUSION
We have presented a comparison of the most commonly used
major incident paediatric primary triage algorithms, and
found that none of the tools have good sensitivity (the ability
to identify seriously injured children), but all have excellent
specificity (the ability to identify less seriously injured
children). A more accurately designed triage algorithm is
Table 2 Comparative analysis of MI primary triage algorithms: results by ISS, NISS, and
presence of one or more modified Garner criteria
ISS.15 NISS.15 Garner
% 95% CI % 95% CI % 95% CI
PTT
Sensitivity 37.8 32.7 to 42.5 26.1 23 to 28.8 41.5 36.8 to 45.6
Specificity 98.6 98.3 to 98.8 98.9 98.5 to 99.1 98.9 98.6 to 99.2
CareFlight
Sensitivity 48.4 43.4 to 52.8 31.5 28.5 to 34.1 46 41.2 to 50.2
Specificity 98.8 98.6 to 99.1 99 98.7 to 99.3 98.9 98.6 to 99.1
JumpSTART*
Sensitivity 3.2 1.3 to 7.5 2.4 1 to 5 0.8 0.1 to 4.1
Specificity 97.8 97.7 to 98 97.8 97.6 to 98 97.7 97.6 to 97.8
STARTÀ
Sensitivity 31.3 21.5 to 42.8 22.3 15.6 to 30.7 39.2 29.3 to 50
Specificity 77.9 77.3 to 78.7 77.3 76.6 to 78.3 78.7 77.9 to 79.5
*JumpSTART, n = 2441; ÀSTART, n = 1020.
Table 3 Accuracy scores for each triage
method in three hypothetical incidents.
Gold standard (%)
ISS NISS MGC
10% T1 casualties
PTT 93 73 90
Careflight 94 92 94
JS 88 88 88
START 73 72 75
50:50 JS:START 81 82
30% T1 casualties
PTT 80 77 81
Careflight 84 78 83
JS 69 69 92
START 64 61 67
50:50 JS:START 67 65 80
60% T1 casualties
PTT 63 56 65
Careflight 69 59 68
JS 41 40 87
START 50 44 55
50:50 JS:START 46 42 71
The score with the best performance for each incident is in
bold type. MGC, Modified Garner criteria; JS, JumpSTART
Comparison of paediatric major incident primary triage tools 477
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required. In the meantime, the use of START and
JumpSTART for children cannot be recommended.
Supplemental data can be found online at http://
www.emjonline.com/supplemental.
Authors’ affiliations
. . . . . . . . . . . . . . . . . . . . .
L A Wallis, Red Cross War Memorial Children’s Hospital, Rondebosch,
Cape Town, South Africa
S Carley, Manchester Royal Infirmary, Manchester, UK
Competing interests: there are no competing interests.
REFERENCES
1 Carley S, Mackway-Jones K, Donnan S. Major incidents in Britain over the
past 28 years: the case for the centralised reporting of major incidents.
J Epidemiol Community Health 1998;52:392–8.
2 Advanced Life Support Group. Major incident medical management and
support: the practical approach, 2nd ed. London: BMJ Books, 2005.
3 Mackway-Jones K, Carley SD, Robson J. Planning for major incidents
involving children by implementing a Delphi study. Arch Dis Child
1999;80:410–13.
4 Hodgetts TJ, Hall J, Maconochie I, et al. Paediatric Triage Tape. Pre-Hospital
Immed Care 1998;2:155–9.
5 Nocera A, Garner A. An Australian mass casualty incident triage system for
the future based upon triage mistakes of the past: the Homebush Triage
Standard. Aust N Z J Surg 1999;69:603–8.
6 Benson M, Koenig KL, Schultz CH. Disaster triage: START, then SAVE—a new
method of dynamic triage for victims of a catastrophic earthquake. Prehospital
Disaster Med 1996;11:117–24.
7 Romig LE. Pediatric triage. A system to JumpSTART your triage of young
patients at MCIs. JEMS. 2002;27: 52–8, 60–3.
8 Baker SP, O’Neill B, Haddon W Jr, et al. The injury severity score: a method
for describing patients with multiple injuries and evaluating emergency care.
J Trauma 1974;14:187–96.
9 Osler T, Baker SP, Long W. A modification of the injury severity
score that both improves accuracy and simplifies scoring. J Trauma
1997;43:922–5 (discussion 925–6).
10 Lavoie A, Moore L, LeSage N, et al. The New Injury Severity Score: a more
accurate predictor of in-hospital mortality than the Injury Severity Score.
J Trauma 2004;56:1312–20.
11 Baxt WG, Upenieks V. The lack of full correlation between the Injury Severity
Score and the resource needs of injured patients. Ann Emerg Med
1990;19:1396–400.
12 Garner A, Lee A, Harrison K, et al. Comparative analysis of
multiple-casualty incident triage algorithms. Ann Emerg Med
2001;38:541–8.
13 Advanced Life Support Group. Advanced paediatric life support: The
practical approach, 4th ed. London: BMJ Books, 2005.
14 Wallis LA, Maconochie I. Comparison of resting heart and respiratory rates in
UK and South African children. Arch Dis Child 2006;91:330–3.
15 Champion HR, Sacco WJ, Copes WS, et al. A revision of the Trauma Score.
J Trauma 1989;29:623–9.
16 Tepas JJ 3rd, Mollitt DL, Talbert JL, et al. he pediatric trauma score
as a predictor of injury severity in the injured child. J Pediatr Surg
1987;22:14–18.
478 Wallis, Carley
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