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Development of a Mass-Gathering Triage Tool: An Australian Perspective

Published online by Cambridge University Press:  08 December 2016

Matt Cannon ,
Rebecca Roitman ,
Jamie Ranse  and
Julia Morphet
Matt Cannon*
Affiliation:
St John Ambulance Australia (NSW), Sydney, New South Wales, Australia
Rebecca Roitman
Affiliation:
St John Ambulance Australia (NSW), Sydney, New South Wales, Australia
Jamie Ranse
Affiliation:
St John Ambulance Australia (NSW), Sydney, New South Wales, Australia Faculty of Health, University of Canberra, Canberra, Australia
Julia Morphet
Affiliation:
School of Nursing & Midwifery, Monash University, Victoria, Australia
*
Correspondence: Matt Cannon, RN, BN St John Ambulance Australia (NSW) Sydney, New South Wales, Australia E-mail: matt.cannon@stjohnnsw.com.au
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Abstract

Many health service organizations deploy first responders and health care professionals to mass gatherings to assess and manage injuries and illnesses. Patient presentation rates (PPRs) to on-site health services at a mass gathering range from 0.48-170 per 10,000 participants. Transport to hospital rates (TTHRs) range from 0.035-15 per 10,000 participants. The aim of this report was to outline the current literature pertaining to mass-gathering triage and to describe the development of a mass-gathering triage tool for use in the Australian context by first responders. The tool is based on the principles of triage, previous mass-gathering triage tools, existing Australian triage systems, and Australian contextual considerations. The model is designed to be appropriate for use by first responders.

CannonM, RoitmanR, RanseJ, MorphetJ. Development of a Mass-Gathering Triage Tool: An Australian Perspective. Prehosp Disaster Med. 2017;32(1): 101–105.

Keywords

Emergency Medical Serviceshealthmass gatheringplanned eventtriage
Type
Special Reports
Information
Prehospital and Disaster Medicine , Volume 32 , Issue 1 , February 2017 , pp. 101 - 105
Copyright
© World Association for Disaster and Emergency Medicine 2016 

Introduction

A mass gathering can be defined as an event where a group of people come together for a common purpose within a particular space or venue, such as a sporting event, music festival, or agricultural show.Reference Cannon, Roitman, Ranse and Morphet 1 Patient presentation rates (PPRs) to on-site health services at a mass gathering range from 0.48-170 per 10,000 participants.Reference Arbon 2 , Reference Ranse and Hutton 3 This variation in patient presentations is dependent on biomedical, psychosocial, and environmental factors of an event.Reference Ranse, Hutton, Turris and Lund 4 Similar to variation in PPRs, there is reported variation in the literature pertaining to transport to hospital rates (TTHRs) from mass gatherings. Transport to hospital rates range from 0.035-15 per 10,000 participants.Reference Arbon 2 , Reference Ranse and Hutton 3 The disparity between the PPR and the TTHR demonstrates that the majority of mass-gathering participants who present for clinical assessment and/or management at mass gatherings are managed by on-site health services. Case series reported in the literature highlight that the majority of patient presentations to on-site health services at mass gatherings are of a low acuity.Reference Arbon 5

Many health service organizations deploy first responders and health care professionals such as, doctors, nurses, and paramedics to mass gatherings to assess and manage injuries and illnesses; these clinicians can be professional, volunteer, or a mix of both.Reference Hutton, Ranse and Verdonk 6 First responders usually are laypersons with additional training. At times, first responders may need to prioritize the initial assessment and management of patients. However, formal triage as a way to prioritize care is not well established in the mass-gathering environment for first responders. Additionally, they do not have similar clinical experience or expertise to undertake triage when compared to health care professionals.Reference Hutton, Ranse and Verdonk 6

Aim

The aim of this report was to outline the current literature pertaining to mass-gathering triage and to describe the development of a mass-gathering triage tool for use in the Australian context by first responders.

Development of a Mass-Gathering Triage Tool

This report proposes the introduction of an Australian mass-gathering triage tool (Figure 1). There were five key considerations in the development of a mass-gathering triage tool for use by first responders in the Australian context. These considerations include a tool based on: (1) the principles of triage; (2) previous mass-gathering triage tools; (3) existing Australian triage tools, such as the Australasian Triage Scale (ATS) and SMART Triage; (4) Australian contextual considerations, such as between the flags; and (5) the target population of first responders.

Figure 1 Proposed Triage Tool for the Australian Context used by First Responders.

The Principles of Triage

As a principle, triage historically originated during the 1800s by Baron Dominique Jean Larrey who prioritized the surgical intervention of patients with battlefield injuries.Reference Ranse and Zeitz 7 Since, triage has been used in many contexts where the number of patients presenting exceeds the resources available to treat patients.Reference Robertson-Steel 8 The purpose of triage is to ensure the greatest good in terms of patient outcomes for the greatest number of patients. Triage is a process designed to prioritize patient assessment and management, ensuring resources are available to patients who need them most urgently.Reference Sztajnkrycer, Madsen and Baez 9

In the development of an Australian mass-gathering triage tool, having an understanding of the principles of triage was important. This understanding keeps the tool orientated towards doing the greatest good for the greatest number of people. Additionally, the proposed tool takes into context the Australian mass-gathering environment and the available resources in this environment.

Previous Mass-Gathering Triage Tools

Previous research has been conducted in the mass-gathering environment reporting on mass-casualty incidents.Reference Arbon, Zeitz and Ranse 10 Additionally, research has reported on the ability of ambulance paramedics to apply triage within the mass-gathering environment. This research showed a statistically significant level of sensitivity and specificity for differentiating patients who require transport to hospital or those patients who can be managed onsite.Reference Turris, Lund and Bowles 11 However, first responders have not been a sample of any studied populations relating to the application of triage in mass gatherings.

In 2012, Turris and LundReference Salhanick, Sheahan and Bazarian 12 published a discussion paper on a series of interlinking research projects relating to mass-gathering triage in the Canadian context. This discussion paper reviewed mass-gathering triage as a concept and discussed the need for a mass-gathering triage tool that is versatile, simple, evolving, supportive of communication, and practical. At the conclusion of their work, Turris and LundReference Salhanick, Sheahan and Bazarian 12 suggested that the University of British Columbia (Vancouver, British Columbia, Canada) Mass-Gathering Medical Triage Acuity Scale/Discharge Acuity Scale be implemented within the Canadian mass-gathering environment. The authors stated that this triage tool was based on the Canadian Triage Acuity Scale and the principles of mass-casualty incident triage. However, while the principles of this triage tool were outlined in the discussion paper, the details of the triage tool as a product were not published. Additionally, the reliability and validity of this tool has not since been reported.

The proposed Australian mass-gathering triage tool is based on the principles of the existing mass-gathering triage tools. In particular, the Australian tool includes strong elements of objective data, such as vital sign parameters to assist in guiding the decision making of first responders.

Existing Australian Triage Tools

In the Australian context, triage is used both in the in-hospital and out-of-hospital environments. In the emergency department (ED), triage involves a brief patient assessment that determines the clinical urgency of the patient’s presenting problem and culminates with the allocation of an ATS category to prioritize patient care and resource use.Reference Turris and Lund 13 , 14 The ATS places emphasis on the importance of the patient being seen by a medical doctor and is based on the premise that a patient should not wait longer than a set period of time for medical assessment and management (Table 1). For example, a patient who is allocated an ATS Category 2 should not wait longer than 10 minutes. 14 Evidence shows that the ATS is a reliable and valid instrument for prioritizing patients according to their care requirements, and thereby optimizing clinical outcomes in the ED. 15 , Reference Forero 16

Table 1 Australasian Triage Scale 14

In the Australian in-hospital context, triage is an autonomous nursing role. Given the importance of the decisions the triage nurse makes, which affect both patient outcomes and ED resources, triage must be performed by an experienced and specifically trained registered nurse with a minimum of two years’ experience working in an ED.Reference Turris and Lund 13 , Reference Christ, Grossmann, Winter and Bingisser 17 The ATS was not designed as a mass-gathering triage tool. In the mass-gathering environment, a medical doctor is not always present. Additionally, the ATS was not designed for use in settings outside of the ED, and the consistent application of the ATS is dependent on appropriate experience and training. The ATS was considered for adaptation within the Australian mass-gathering triage tool. However, a decision was made not to include the principles of the ATS because the tool is designed for use by specifically trained and experienced registered nurses.

Debate exists regarding the most appropriate triage tool to be used within the Australian out-of-hospital environment. However, there is a trend towards the use of SMART triage. In one study relating to SMART triage, doctors, nurses, paramedics, and defense medics participated in a prospective, randomized, cross-over trial exploring the use of various triage tools. This study concluded that SMART triage was the preferable triage system based on timeliness to categorize patients and preference of health professionals. 18 Further, a number of Australian ambulance services have adopted SMART triage as their tool for mass-casualty incidents. The simple design of SMART triage, such as vital sign parameters and use of colors, was considered and incorporated into the Australian mass-gathering triage tool.Reference Field and Norton 19

Australian Contextual Considerations

Between the flags is a health initiative initially designed for hospitals and later implemented in the prehospital environment by the New South Wales Ambulance Service in Australia. Between the flags defines a set of vital sign parameters with the intention of identifying the sick or deteriorating patient and prompt appropriate action (Figure 2; used with permission by the Ambulance Service of New South Wales). 20 Using the between the flags initiative, paramedics are assisted in the recognition of the sick or deteriorating patient and are able to better communicate the patient’s condition with other health care professionals. Standard physiological parameters ensure consistency and objectivity in the application of the between the flags initiative. Additionally, between the flags ensures all members of the multi-disciplinary health care team are communicating using a common framework.

Figure 2. NSW Ambulance “Clinical Review and Emergency Response Escalation Criteria (Adult)” utilized the NSW Health “Between the Flags” Vital Sign Parameters in the Prehospital Context. 20 Note: USED WITH PERMISSION by Ambulance Service NSW, Australia. Abbreviation: NSW, New South Wales.

St John Ambulance Australia (Sydney, New South Wales, Australia), a major health service provider within the mass-gathering environment with volunteer and paid first responders and health care professionals, has implemented the between the flags initiative in their clinical practice guidelines. As such, the proposed Australian mass-gathering triage tool has incorporated the between the flags parameters and criteria.

The Target Population of First Responders

The proposed Australian mass-gathering triage tool recognizes that the tool will be used by both first responders and health care professionals (doctors, nurses, and paramedics). As such, to make the proposed triage tool appropriate for use by both cohorts, it was designed to be as simple as possible, with strong elements of objective data, such as vital sign parameters. Vital signs can be obtained by first responders and applied to this mass-gathering tool to guide decision making.

Limitations

This Australian mass-gathering triage tool has been developed using tools that are readily available to Australian health care providers, and it is expected to be easy and safe for first responders to apply. The authors have strived to create a model which can be applied internationally. However, the tool is yet to be tested in a mass-gathering event. This model has been developed based on the context of applicability to the Australian Health System. It is designed to be simple so that volunteer first responders can apply it safely. The next phase of this research intends to test this model in a real-life setting at major events in New South Wales, Australia.

Conclusion

This is the first paper to discuss the development of a mass-gathering triage tool for the Australian context. The tool is based on the principles of triage, previous mass-gathering triage tools, existing Australian triage tools, Australian contextual considerations, and the target population of first responders. The proposed Australian mass-gathering triage tool has not yet been tested in a mass-gathering event. Further research should be conducted to test the validity and reliability of this Australian mass-gathering triage tool. In the absence of any other triage tool for the Australian mass-gathering environment, this triage tool should be considered for implementation for future clinical practice at Australian mass gatherings where first responders are providing clinical assessment and management of patients presenting for on-site care.

References

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Figure 0

Figure 1 Proposed Triage Tool for the Australian Context used by First Responders.

Figure 1

Table 1 Australasian Triage Scale14

Figure 2

Figure 2. NSW Ambulance “Clinical Review and Emergency Response Escalation Criteria (Adult)” utilized the NSW Health “Between the Flags” Vital Sign Parameters in the Prehospital Context.20 Note: USED WITH PERMISSION by Ambulance Service NSW, Australia. Abbreviation: NSW, New South Wales.