Original Research

Utility of Vital Signs in Mass Casualty-Disaster Triage

David E. Hogan, DO, MPH* * Oklahoma State University, Department of Emergency Medicine, Oklahoma City,
Travis Brown, DO† Oklahoma
†
Duncan Regional Hospital, Department of Emergency Medicine, Duncan, Oklahoma

Supervising Section Editor: Christopher Kang, MD

Submission history: Submitted January 26, 2014; Revision received May 1, 2014; Accepted August 20, 2014
Electronically published September 24, 2014
Full text available through open access at http://escholarship.org/uc/uciem_westjem
DOI: 10.5811/westjem.2014.8.21375
[West J Emerg Med. 2014;15(75):732–735.]

INTRODUCTION separate local institutional review board- (IRB) approved

The triage of patients during a mass casualty – disaster studies of casualties during mass casualty – disaster (MCD)
(MCD) event presents the emergency healthcare provider with conditions (a terrorist bombing and an F-5 tornado).5,6
a complex and difficult issue. The task of evaluating casualties Additional approval of a protocol to study the two anonymous
rapidly, using primarily the skills of physical examination, database collections was granted from the local facility IRB.
while still accurately identifying casualties likely to have We queried the database collections for cases with complete
critical injury or illness, may be impossible to achieve in data points to include: initial clinical triage category, initial
practice. Yet at the same time it is known that accurate triage vital sign documentation, emergency department (ED)
under MCD conditions improves outcomes not only for the diagnosis, and final patient disposition.
individual critically ill casualty, but also for the entire cohort Clinical triage categorization is defined as the initial
of casualties presenting for care.1,2 triage category assigned to the casualty by the triage officer
To improve the accuracy of MCD triage, further scientific at the level of the ED and documented in the medical
investigations must be conducted to determine what elements record. To assess the agreement of the clinical triage
of the physical examination (determining specific anatomic categorization with a standard, we applied a revised triage
and physiologic factors) correlate best with the probability of category to each case. This revised category is termed
critical injury and illness. These investigations should be – when disposition triage category, and is based on ED disposition
possible – carried out under conditions that closely approximate as an indicator of the severity of injury/illness for the case
the MCD environment. In addition, studies must be carried out as as utilized in previous studies.5-7 This does not relate to
to the utility of new technologies that may be applied to the MCD the level of documentation found in the chart but rather to
triage process to improve and extend the ability of the triage individual decisions of admission vs discharge. In addition,
officer in rapidly determining the condition of the casualty. Some decisions as to where the casualty is admitted (taken to the
recent studies have reported on data collected under actual MCD operating room, intensive care unit, ward bed, etc.) are well
conditions, as well as using computer simulation to approximate preserved in most medical records after MCD event and are
the conditions of the MCD environment.3,4 These studies are thought to relate directly with the level of casualty injury or
encouraging and hopefully represent an emerging area of research illness. Under this protocol the ED disposition relates with
into this area of emergency healthcare. disposition triage categorization as follows:
One question frequently posed is that of the utility of vital Category I (Immediate)-Operating Room or Critical
signs, or specific physiologic parameters reflective of formal Care Admission; Category II (Delayed)-Noncritical Care
vital signs, in the performance of MCD triage. Study of this Admission; Category III (Minimal)-Discharge Home;
question has been hampered by multiple factors, including the Category IV (Expectant)-Excluded From Analysis.
difficulty in collecting such detailed data under actual MCD The disposition triage category is used as a standard for
conditions.1 This paper provides an analysis of the potential calculation of overtriage (OT) and undertriage (UT) rates of
impact of abnormal vital signs on clinical triage categorization the clinical triage category assignment.
in comparison to triage categorization derived from actual Recorded vital signs are scored as normal or abnormal
dispositions of casualties from two separate MCD events. using the standard adult and age-adjusted vital signs for
children as recommended in Steadman’s Medical Dictionary.8
METHODS The Glasgow Coma Score (GCS) is recorded in the database
This is a protocol-driven cohort study of data from two as a total score without scoring of the individual parameters.

Western Journal of Emergency Medicine 732 Volume XV, NO. 7 : November 2014
Hogan and Brown Utility of Vital Signs in Mass Casualty-Disaster Triage

Any score less than 15 is considered abnormal. variables found a significant but small agreement with GCS:
Because the triage data thus obtained are ordinal (ranked) r=0.1425 (95% CI: 0.0937 to 0.1913) p<0.0001. Substitution
in nature, agreement between clinical and disposition triage of the disposition triage categories for y in the same
categories is assessed using the weighted kappa test and is regression demonstrated similar small agreement with both
reported as raw agreement, κ with the 95% confidence interval GCS [r=0.06994 (95% CI: 0.01829 to 0.12160) p=0.0085]
and probability. In addition, agreement using the Kendall tau and systolic blood pressure [r=0.00895 (95% CI: 0.00309 to
statistic is performed and reported as τ and probability. Linear 0.01481) p=0.0031]. The vital signs of abnormal pulse rate
regression is also performed using first the clinical triage and abnormal respiratory rate are not noted to have significant
categories as the dependent variable then the disposition- levels of agreement with disposition triage categories.
adjusted triage categories against the independent variables of
Glasgow Coma Score, pulse, respiration, and systolic blood DISCUSSION
pressure. The results of correlation are reported as r with 95% In general small numbers of cases were found with
confidence interval and probability. We performed statistical documentation of clinical triage categorizations and initial
analysis with Microsoft Office Excel® (version 11.5612.5606) vital signs in the two study databases. This is consistent with
and the statistical add-on package Analyze-it® (version 2.05). the usual level of documentation that occurs during MCD
events.9 This is one of the issues making the study of the
RESULTS actual process of triage during MCD conditions so difficult.
Out of a total of 535 cases in the two database sets (388 The low numbers can make the impact of any variable such as
bombing, 147 tornadodo) 103 (19.25%) cases met case vital signs on triage categorization more difficult to resolve.
criteria; 46 male, 57 female; mean age 35yr (range 86 – 1 Undertriage, defined as the triage of a critical casualty as
years). The clinical triage categories and event sources of noncritical and overtriage, defined as the triage of a noncritical
cases are demonstrated in Figure 1. There are no significant casualty as critical, are consistent problems encountered in
differences between the cases meeting inclusion criteria and MCD triage.1 Overtriage has been reported to have an adverse
those excluded in age or sex, p=0.765. Three category IV impact on the outcomes of critical casualty cohort due to a
(expectant) cases were excluded from further analysis (all 3 misdirection and dilution of critical care resources away from
expectant casualties had no signs of life on presentation to truly critical casualties.2,10 Undertriage primarily impacts the
the ED) leaving 100 cases fit for analysis, Category I; 23, individual casualty by delaying his/her critical care interventions.
Category II; 11, Category III; 66. Rates for Undertriage (UT) Undertriage rates of 5% or less and overtriage rates of up to
and Overtriage (OT) comparing the clinical triage categories 50% have been generally agreed to be acceptable in prior
to disposition triage categories are UT=35% and OT=1%. publications.10-13 The difficulties of studying activities of triage
Evaluation of agreement between clinical and disposition during MCD conditions are multiple and persistent.1,14 The nature
triage categories provided a raw agreement of 0.540 and of these difficulties makes it even more challenging to evaluate
κ=0.33 (95% CI: 0.21 to 0.45) p<0.0001 indicating a “fair” the MCD triage process for the impacts of individual process
level of agreement. Linear regression using the clinical triage elements (such as physiologic parameters). To our knowledge,
categories as the dependent variable and GCS, heart rate, this study includes some of the only data reported regarding a
respiratory rate, and systolic blood pressure as the independent potential impact of vital signs on triage categorization collected
under actual MCD conditions. As such, even with generally low
numbers, there is value in their analysis, as long as that value is
taken in the context of the study limitations.
Improvement of the MCD triage process is an important
goal of emergency healthcare providers. The process of triage
must obtain sufficient information regarding the anatomic
and physiologic state of the casualty to avoid high levels of
mistriage, which are known to adversely impact the entire
cohort of injured/ill casualties.2 At the same time the triage
evaluation itself must remain nimble and abbreviated to
prevent a bogging down of the process. As such, any elements
of evaluation included in a “standardized” triage process
should be validated as much as possible scientifically.
The data of this study demonstrate a small but significant
level of agreement with increasing severity of triage
categorization for mental status (based on the GCS) and
Figure. Distribution of mass casualty-disaster cases by clinical systolic blood pressure. This suggests that a rapid mental
triage category and event type. status evaluation (such as the Mental status Alert, responsive

Volume XV, NO. 7 : November 2014 733 Western Journal of Emergency Medicine
Utility of Vital Signs in Mass Casualty-Disaster Triage Hogan and Brown

to Verbal or Painful Stimuli or Unresponsive method or GCS) reliability).20 The same statistic of agreement may be used to
as well as an evaluation for a radial pulse (as a surrogate evaluate agreement between two measurements or outcomes
for systolic blood pressure measurement) may be useful in on the same individual.21 In this study the initial clinical triage
improving the accuracy of MCD triage. categorization may be compared with the actual disposition of
The presence of a radial pulse (as well as the strength and the casualty–and the implied triage category associated with
character of a radial pulse) has been associated with systolic that disposition.
blood pressure in previous studies.15,16 In addition, both mental Measurement of raw agreement alone is unsatisfactory in
status and systolic blood pressure have been studied in the this case due to the potential for some level of agreement from
context of trauma systems triage and have been incorporated random chance. Therefore, a statistical approach must be used
into various trauma scoring systems in that context.17 An to determine any agreement not associated with chance. The
absent or weak radial pulse assessment by palpation may be most commonly used is the kappa statistic that reports a value
considered an indicator of hypotension suggesting a level I between 0=no agreement and 1=perfect agreement.22 The
(immediate) triage categorization. The data from this study kappa statistic, however, is based on the assumption that the
suggest a link between these physiologic parameters and the data are nominal in nature. Triage data in the form of triage
patient dispositions under actual MCD triage conditions and categories is ordinal (ranked). As such, either the weighted
should spur further prospective studies in this area. kappa statistic or the Kendell’s tau-b statistic must be used
to evaluate agreement.22 Both of these values are provided in
LIMITATIONS this study. Agreement in this case, when present to a sufficient
The reported overtriage and undertriage rates detected degree, suggests a potential association, but it does not prove
in this analysis are unusual, and thought to be a result of an association. The authors selected this method of analysis as
the process of case selection. The inclusion of only cases sufficient for the robustness of the data and its level of bias.
with complete sets of vital sign data points reduces the total
case numbers considerably. Most of the cases removed from CONCLUSION
analysis for incomplete vital signs were also discharged Movement toward a standardization of MCD triage
home. As such, the large numbers of excluded cases represent protocols intensifies the need for scientific analysis of the
“correct” triage decisions where clinical and disposition triage elements of that process. This study suggests a role of the
categories would agree. In addition, the cases most likely to physiologic parameters of mental status and systolic blood
have complete vital signs documented would logically be pressure in improving triage accuracy. These elements could be
the more ill and injured casualties. For reasons discussed, incorporated into a rapid triage evaluation formally or through
such cases are more likely to have disagreement between a quick mental status examination and palpation for a radial
clinical and disposition triage categories. This will skew the pulse. The fact that any strong agreement between physiologic
triage data towards the more critical cases in the numerator parameters and triage categorization was found suggests that
while eliminating less critical cases from the denominator. further prospective data collection under MCD conditions
Therefore, as expected the undertriage rate will likely be should be performed to illuminate any potential association.
falsely exaggerated and the overtriage rate falsely minimized. In a wider context however, researchers should consider
Estimation of triage sensitivity and specificity based on such what healthcare providers are being asked to do in MCD triage
potentially exaggerated rates has no real value. As such, conditions. Given the temporal and physical limitations of
sensitivity and specificity of triage categories correlated with the MCD triage examination and the limited type and nature
vital signs are not calculated in this study. To do so would of data those constraints allow one to collect, it may not be
promote insensitive measure bias.18 possible to achieve the levels of accuracy that emergency
In addition, the use of the disposition-adjusted triage healthcare providers have set for themselves.
category for a comparative standard makes OT and UT
rates highly sensitive to the decision to admit casualties. In
MCD events where medical resources are stressed but not Address for Correspondence: David E. Hogan, DO, MPH, 5705
completely overwhelmed (as was the case in both of the study Parkhurst Road, Edmond, OK 73034. Email: [email protected].
events) physicians are more likely to admit casualties of lower
acuity as a “safety measure” against missing injuries during Conflicts of Interest: By the WestJEM article submission
the initial chaos of the event.19 Such practice will further agreement, all authors are required to disclose all affiliations,
falsely elevate the UT rate in this study. funding sources and financial or management relationships that
Measurement of the reliability of the triage process is a could be perceived as potential sources of bias. The authors
disclosed none.
difficult proposition. The reliability of any particular process
can often be estimated by evaluation of agreement between
two observers (inter-rater reliability) or of the same observer REFERENCES
on different observations of the same issue (intra-rater 1. Hogan DE, Lairet JR. Triage. (in) Hogan DE, Burstein JL (EDs): Disaster

Western Journal of Emergency Medicine 734 Volume XV, NO. 7 : November 2014
Hogan and Brown Utility of Vital Signs in Mass Casualty-Disaster Triage

Medicine 2nd Edition Philadelphia. Lippincott Williams & Wilkins. 2007. Categorization of trauma victims. Bull Coll Surg. 1986;71:17-21.
2. Frykberg ER, Tepas JJ, Alexander RH. The 1983 Beirut airport 13. IDFMC. Trauma Division Report, Terrorist Suicide Bombings in Israel:
terrorist bombing. Injury patterns and implications for disaster 1994–1996, Medical Summary. Tel Aviv, Israel. Israel Defense Forces
management. Am Surg. 1989;55:134-141. Medical Corps. 1997:10-13.
3. Kahn CA, Schultz CH, Miller KT, et al. Does START Triage work? 14. Burkle FM, Orebaugh S, Barendse BR. Emergency medicine in
An outcomes assessment after a disaster. Ann Emerg Med. the Persian Gulf War – Part 1: Preparations for triage and combat
2009;54:424-430. casualty care. Ann Emerg Med. 1994;23:742-747.
4. Hirshberg A, Frykberg ER, Mattox KL, et al.: Triage and trauma 15. ACS. ATLS Advanced Trauma Life Support for Doctors: Faculty
workload in mass casualty: a complex model. J Trauma. 2010. Course Manual. 8th Edition. Chicago, IL. American College of
5. Hogan DE, Lillibridge SR, Waeckerle J, et al. Emergency department Surgeons. 2008.
impact of the Oklahoma City terrorist bombing. Ann Emerg Med. 16. Burkle FM, Newland C, Orebaugh S, et al. Emergency medicine
1999;34:160-167. in the Persian Gulf War – Part 2: Triage methodology and lessons
6. May BM, Hogan DE, Feighner K. Impact of a tornado on a community learned. Ann Emerg Med. 1994;23:748-754.
hospital. JAOA. 2002;102:225-228. 17. Hardern RD. Critical appraisal of papers describing triage systems.
7. Mallonee S, Shariat S, Stennies G, et al. The epidemiology of Acad Emerg Med. 1999;6:1166-1171.
physical injuries associated with the Oklahoma City bombing. JAMA. 18. Hogan DE. Research for Emergency Medicine Residents (3rd Edition)
1996;276:382-387. TeamHealth Emergency Medicine. 2013 Oklahoma City, Oklahoma.
8. Steadmans Medical Dictionary (28th Edition). Baltimore. Lippincott, 19. Hogan DE. The Oklahoma City Terrorist Blast: A case study
Williams and Wilikins. 2005. in disaster. Environment of Care. Oakbrook Terrace, IL. Joint
9. Barnhart S, Cody PM, Hogan DE. Multiple information sources in the Commission on Hospital Accreditation Publication. 1997 pp. 3-217.
analysis of a disaster. Am J Disaster Med. 2009;4(1):41-47. 20. Aschengrau A, Seage GR III. Essentials of Epidemiology in Public
10. Frykberg ER, Tepas JJ. Terrorist bombings: lessons learned from Health (2nd Edition) Boston: Jones and Bartlett Publishers, 2008.
Belfast to Beirut. Ann Surg. 1988;208:569-576. 21. Crichton NJ. Information point: Spearman’s rank correlation. J Clin
11. Wesson DE, Scorpio R. Field triage: help or hindrance? Can J Surg. Nurs. 1999;8:763.
1992;35:19-21. 22. Le CT. Health and Numbers: A Problems Based Introduction to
12. American College of Surgeons Committee on Trauma. Field Biostatistics (2nd Edition). New York: Wiley-Liss. 2001.

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