電子期刊 |
ISSN:1684-193X
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Updated
Feb 25, 2003
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Contents:
Volume 1, Nomber 2; Jan, 2003 |
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The
Role Tabletop Exercise Using START in Improving Triage Ability in
Disaster Medical Assistance Team |
Kuo-Chih Chen, MD; Chien-Chih Chen, MD; Tzong-Luen Wang,
MD, PhD |
From the Department of Emergency Medicine(Chen
KC, Chen CC, Wang TL), Shin-Kong Wu Ho-Su Memorial Hospital.
Correspondence to Dr. Tzong-Luen Wang, Department
of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95
Wen Chang Road, Taipei, Taiwan. E-mail M002183@ms.skh.org.tw
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Abstract
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Triage ability is a critical skill
the members of a disaster medical assistance team (DMAT) should
possess. There are few data concerning the triage accuracy in the
pre-hospital providers and the members of DMAT. We thus conducted
a lecture-based intervention and evaluated the impact of the triage
method using a written multiple-casualty incident (MCI) scenario.
We enrolled and tested 30 volunteers in a local DMAT training program.
The written scenario of a MCI consisted of 40 victims with 5 first
priority patients, 17 second priority patients, and 18 third priority
patients. The scenario was tested in the volunteers before and immediately
after a one-hour lecture of Simple Triage and Rapid Treatment (START)
with slide presentation. The mean immediate post-intervention score
(87.8% correct) was significantly improved compared with the mean
pre-intervention score (55.8% correct) for the 30 volunteers (P<0.001).
The over-triage rate was significantly reduced before (28.6%) and
immediate after (1%) the intervention (P<0.001). The under-triage
rate was also reduced from 15.5% to 11.2% (P<0.05). Tabletop
exercises have several advantages over field operation drills. Using
tabletop exercise can simulate the disaster or major incidents and
evaluate critical knowledge and skills. The training model using
START method in a tabletop exercise could significantly improve
the triage ability and reduce overtriage and undertriage rate. (Ann
Disaster Med. 2003;1:78-84)
Key words: Tabletop Exercise; START; Triage; Disaster Medicine |
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Introduction
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When facing multiple victims in
a disastrous event, the key to successfully manage many victims
with limited responders and resources is triage. There are several
triage systems such as daily triage, incident triage, disaster triage,
tactical-military triage, and special condition triage.1 Each triage
system has its special consideration and suitable condition. There
are several principles for a successful disaster triage: 1) never
move a casualty backward, 2) never hold a critical patient for further
care, 3) salvage life over limb, 4) triage officers do not stop
to treat patients, 5) never move patients before triaged except
in cases of risks due to bad weather, impending darkness or darkness
has fallen, a continued risk of injury, a triage facility that is
immediately available, or the tactical situation that dictates movement. 2
When facing multiple victims in a major multiple-casualty incident
(MCI) or a large-scaled disaster, the first responders such as emergency
medical technicians (EMTs) or members of disaster medical assistance
team (DMAT) should be familiar with a good triage system to fulfill
such tasks. The so-called titled Simple Triage and Rapid Treatment
(START) method has gained popularity in recent years. The system
takes into account the critical physiologic parameter such as the
respiratory status, the perfusion, and the mental status of the
patients and prioritizes patients into first priority (RED), second
priority (YELLOW), third priority (GREEN), and expectant (BLACK). 3
The training and education for members of disaster medical assistance
team should include the topic of triage because these persons are
the possible first responders in a disaster medical response. Tabletop
exercises or simulation drills have several advantages over field
operation drills in disaster and MCI such as better performance,
better chance to evaluate the response without the use of telephones. 4
Also, limitations of field operation drills such as communications,
coordination, assignment of responsibilities, and post-event mitigation
priorities were noted, and tabletop drills provided additional benefits
for these settings. 5 We sought to evaluate
the effect of START by a tabletop exercise on a local DMAT training
program.
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Methods |
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The participants in this study
were the voluntary candidates in a training program of local disaster
medical assistance team. The training program was a 12-hours curriculum
composed of disaster concepts and several essential disaster medicine
associated issues, included triage. The triage system adopted was
so-called START method because of its popularity and familiarity
in our Emergency Medical Services system.
We designed a simulated tabletop drill composed of 40 victims in
a workplace accident. The 40 victims consisted of 5 first priority
patients, 17 second priority patients, and 18 third priority patients.
The priority was determined by START system. The pre-designed scenario
was conducted to the participants before the triage course, and
then the START system was conducted in a one-hour lecture. Immediately
after the course, the participants practiced the same scenario.
The correct triage rate, incorrect triage rate, over-triage rate,
and under-triage rate were calculated. These results were analyzed
using the two-tailed Student’s t-test. Statistical significance
was set a priori at P<0.05.
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Results |
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The participants in this training
program were 30 volunteers consisted of doctors (n=4), nurses (n=18),
EMTs (n=4), and administrative officers (n=4) from several local
hospitals, fire department, and bureau of health. Six were male.
All participants replied this program was the first time for them
to know START system. Before the triage intervention, the participants
could correctly prioritize 55.8% of victims. The over-triage rate
and under-triage rate were 28.6% and 15.5% before the triage course.
After the one-hour triage intervention, correct triage rate, over-triage
rate, and under-triage rate were 87.8%, 1%, 11.2%, respectively.
The tabletop drill provide a significant improvement in correct
triage rate (55.8% v 87.8%, P<0.001), and reduction in over-triage
rate (28.6% v 1%, P<0.001) and under-triage (15.5% v 11.2%, P<0.05).(Table
1 ) |
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Table 1. The result of certification and chi-square
test |
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Discussion |
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The Chi-Chi earthquake in Taiwan
in 1999 struck the country and resulted in 2,347 fatalities and
8,722 casualties. The property damage was estimated at more than
US$92 billion. The Liang et al. reported that the peak of medical
demand was 12 hours after the earthquake and significantly increased
demand for care lasted as long as 3 days.6 Different levels of disaster
medical assistance teams were built up in Taiwan since 1999. The
triage was the essential concept taught in the DMAT training program.
Good triage system should achieve the goal: the greatest good fthe
greatest number. Literatures and experts all suggest the senior
experienced staff should be the most appropriate person for the
triage task, especially when facing multiple victims. Garner et
al. compared several triage algorithms in multiple-casualty incident
by a retrospective review of adults patients transported by ambulance
and admitted to trauma center. They found that the differences between
CareFlight Triage, Simple Triage and Rapid Treatment, and modified
Simple Triage and Rapid Treatment were not dramatic. The sensitivity
and specificity in predicting critical injury were 82%-85% and 86%-96%,
respectively. Both forms of Triage Sieve were significantly poorer
predictor of severe injury.7 The START method has gained popularity
in recent years and the pre-hospital emergency medical education
in Taiwan adopted this system to educate the EMT and emergency personnel.
The START method results in a substantial over-triage rate. However,
the excess over-triage is offset by the ease of application over
a wide range of health care providers. 1
Tabletop exercises are a cost-effective and efficient method of
testing plans and procedures, which engaging players imaginatively
and generate high levels of realism. The Chi et al. reported tabletop
exercise could provide better performance in the ability of others
to fill in during the absence of key officials and adequate provisions
to link the results of disaster exercises to appropriate changes
in terms of training, equipment, supplies, and plans. 5
The Kilner tested the triage decision-making of pre-hospital emergency
health care providers using a multiple casualty scenario paper exercise.
He found that there is little difference in the accuracy of triage
decision-making between professional groups according to the Triage
Sieve method. 8
We modified the paper exercise presented by Kilner 8
into a multiple casualty scenario took place in a workplace accident.
We designed different severity of injured victims, and provided
their physiological parameters such as respiratory status, the perfusion,
and the mental status. The accuracy of triage was determined according
to the START method. We found that one-hour START method intervention
resulted in a significantly improved correct triage score before
and immediately after the test. The overtriage and undertriage rate
were significantly reduced. Risavi et al. reported similar result
using 2-hour START intervention in a MCI paper test. The mean immediate
post-test score was significantly improved compared with the mean
pre-test score (75% v 55%, P<0.001). 9
Acceptable undertriage rate have been defined as 5% or less 10,
and overtriage rate of up to 50% have been defined as acceptable. 11
Our results showed the pre-intervention and post-intervention scores
of overtriage and undertriage were 28.6% to 1% and 15.5% to 11.2%,
respectively. The overtriage rate has significantly reduced, but
the undertriage rate remains unacceptable despite significantly
improved. The undertriage condition may contribute to the scenario
design that consisted of 5 critical patents (priority 1, RED), 17
immediate patients (priority 2, YELLOW), and 18 delayed patients
(priority 3, GREEN). Since the participants were health care provider
(doctors, nurses, EMTs) and administrative officers, they do not
perform the triage task in their daily work. The improved triage
ability should be regard as “acceptable”.
Our study has several limitations. The number of participants was
small; therefore the training model should be tested in a rigorous
study with larger sample size to get more information about its
applicability. Also, the experience of tabletop exercise was limited
in Taiwan. 5 Hirshberg et al. 12
and Chi et al. 5 suggested tabletop
exercises are supplementing the traditional mock disaster drill
as effective planning and training tool. The training model using
tabletop exercise should be established to propagate the essential
knowledge and skills involved in disaster medicine training program,
such as triage. We didn’t have a control group of field exercise
to compare the tabletop exercise. Future application in field operation
drill is necessary to evaluate the efficacy of tabletop exercise.
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Conclusion |
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Tabletop exercises have several advantages over field
operation drills. Using tabletop exercise can simulate the disaster
or major incidents and evaluate critical knowledge and skills. The
training model using START method in a tabletop exercise could significantly
improve the triage ability and reduce over-triage and under-triage
rate. |
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References |
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