Page 39 - Journal of Special Operations Medicine - Spring 2014

Such techniques, which have found many applications The authors are of the opinion that, for a number of rea-
in many industries, have not been successfully applied sons that are fundamentally related to the complexity of
to patient prioritization during emergencies. the problem, infancy of research in this area, and lack
of data, developing very specific prioritization methods
To our knowledge, the only existing work that has de- that would be universally valid is not a realistic goal at
veloped a new method to make resource-based patient this stage. Nevertheless, to demonstrate the potential
5,6
prioritization decisions is by Sacco et al. So far, the benefits of the results of this report, we have developed
method, which is named Sacco Triage Method (STM), a specific prescription that describes what action to take
has not found wide acceptance because complex cal- in the field when prioritizing patients. We name this
culations are required and because so many different new method Resource-based START ( ReSTART). As
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triage classifications are introduced. Importantly, how- the name suggests, ReSTART is a patient prioritization
ever, the authors propose that first responders and tri- protocol that can be added to the START classification
age personnel begin including resource availability in criteria (or similar color-coded classification system),
their transport decisions. Like Sacco et al., we will il- allowing providers to work within a familiar frame-
lustrate the benefit of making triage allocations based work. As in START, patients are classified as expectant,
on transport and resource availability. However, unlike immediate, delayed, or minor, and patients classified as
Sacco et al., our objective is not to propose a new triage minor and expectant receive the lowest priority. How-
protocol. Rather, the main objective of this report is to ever, ReSTART differs from the standard implementa-
provide general guidance on how resource restrictions tion of START in that whether priority transportation
should be taken into account when determining prior- of the immediate or delayed may change based on the
ity levels for transporting patients in the aftermath of resource availability. ReSTART is based on the solution
mass-casualty incidents. Our results can be used as an of a mathematical optimization problem, but it does
adjunct to commonly adopted triage classification sys- not require performing a complex calculation in real
tem, such as START and SALT (see later). We hope that time following a mass-casualty incident. The solution,
this report will introduce responders to the need that and thus the priorities, can be obtained quickly by us-
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resource availability should be taken into account when ing a simple predetermined formula. Simulation stud-
making decisions on the order in which patients should ies point to significant potential benefits of adopting
be transported. Given the paucity of evidence to support ReSTART or similar prioritization methods over the
the current triage systems and algorithms systems in use, standard practice.
we hope this study will help generate further research
on patient prioritization. More broadly, this study dem-
onstrates the value of applying operations research con- Methods
cepts that are commonly used in industry to provide
decision support in emergency medicine. Modeling Assumptions
Determining priorities in the aftermath of mass-casualty
To illustrate this concept of resource-based patient pri- incidents mainly concerns patients who are classified as
oritization, we have developed a model that can inform immediate or delayed. There is no question that patients
and guide decision-making in the field or support efforts classified as minor or expectant have lower priority than
to develop more sophisticated decision support systems. the others as long as there is no reason to believe that
The illustrative model is based on rigorous mathemati- they might have been misclassified in the first place. The
cal and computational analysis of a mass-casualty pa- key difference between the immediate and the delayed
tient triage and transport problem, which consisted of patients is that while patients from both classes have
the following steps: we first developed a mathematical serious injuries and need to be attended to urgently, the
representation, which captured the fundamental features delayed patients should be able to wait a little longer
of the problem. Then, using various mathematical tech- than the immediate patients. In other words, it is as-
niques, we identified the solution that maximizes the ex- sumed that the chance of surviving (which we refer to
pected number of survivors. Following that, we carried as survival probability) of the immediate patients starts
out an extensive computer simulation study, which con- declining rapidly very soon after the incident, whereas
sidered realistic mass-casualty conditions, and compared the rapid decline in survival probability of the delayed
the expected number of survivors under the current prac- patients starts some time later. While field management
tice versus those using our model. Complete details of may prolong survival of delayed patients, it is expected
this study that serves as the scientific foundation for the that immediate patients will die quickly without defini-
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proposals here have already been published. This cur- tive care, which is assumed to require transport from the
rent report is a product of our translational research ef- mass-casualty scene. Figure 1 is an illustration of this
fort that aims to provide practical insights for medical anticipated difference between the survival probabilities
providers based on the earlier derivation study. for the two classes. This structural difference between

ReSTART: Resource-Based Triage in Mass-Casualty Events 31