ABSTRACT
OBJECTIVE: Evaluate the resource-constrained, evidence-based, and outcome-driven Sacco Triage method (STM) for military-age victims of blunt, penetrating, and blast overpressure-like trauma. METHODS: STM is based on a mathematical model of resource-constrained triage. Its objective is to maximize expected survivors given constraints on transport and treatment resources. STM uses estimates of time-dependent victim survival probabilities and expected deteriorations. A respiration, pulse, and best motor response (RPM) score predicts survivability. Logistic function-generated survival probability estimates from 99,369 military-age victims were assessed using calibration and discrimination statistics. The consensus building Delphi method was used to provide aggregate expert opinion on victim deterioration rates. The models were solved using linear programming. Rule-based (not requiring software) protocols were determined using a greedy algorithm for Iraqi combat scenarios, and simulations enabled comparison of STM to the widely known Simple Triage and Rapid Treatment (START) method. RESULTS: RPM was an accurate predictor of survival probability, equivalent to the Revised Trauma Score and exceeding the Injury Severity Score. In 18 simulations, STM and STM rule-based protocols increased survivorship over START from 20% to an 18-fold increase. CONCLUSIONS: STM offers lifesaving and operational advantages for military-age victims of blunt, penetrating, and blast overpressure-like trauma.
Subject(s)
Military Medicine/methods , Models, Theoretical , Triage/methods , Wounds and Injuries/classification , Wounds and Injuries/mortality , Algorithms , Delphi Technique , Evidence-Based Medicine , Female , Humans , Logistic Models , Male , Outcome and Process Assessment, Health Care , Registries , Survival Rate , Trauma Severity Indices , Wounds and Injuries/therapyABSTRACT
BACKGROUND: Resource-constrained triage occurs when the number of trauma patients exceeds the capacity for simultaneous transport and treatment. The objective of this article is to apply a new resource-constrained triage method (denoted Sacco triage method [STM]) to victims of penetrating trauma and compare it with existing methods. METHODS: STM is a mathematical model of resource-constrained triage. Its objective is to maximize expected survivors given constraints on the timing and availability of resources. The model incorporates estimates of time-dependent victim survival probabilities based on initial assessments and expected deteriorations. For application to penetrating trauma, an "RPM" score based on respiratory rate, pulse rate, and best motor response was used to predict survivability. Logistic function-generated survival probability estimates for scene values of RPM were determined from 7,274 penetrating injury patients from the Pennsylvania Trauma Outcome Study. The Delphi Method provided expert consensus on victim deterioration rates, and the model was solved using linear programming. The accuracy of predicting survivability was assessed using calibration and discrimination statistics. STM was compared with START (Simple Triage and Rapid Treatment)-like triage methods with respect to process and outcomes (assessed by expected number of survivors in simulated resource-constrained casualty incidents). RESULTS: RPM was shown to be an accurate predictor of survival probability for penetrating trauma, equivalent to the Revised Trauma Score and exceeding that of the Injury Severity Score, as measured by calibration and discrimination statistics. In the simulations, STM had substantially more expected survivors than did current triage methods. CONCLUSIONS: Resource-constrained triage is modeled as an evidence-based, outcome-driven method (STM) that maximizes expected survivors in consideration of resources. STM offers lifesaving and operational advantages over current methods.
Subject(s)
Cause of Death , Models, Theoretical , Triage/methods , Wounds, Penetrating/classification , Wounds, Penetrating/mortality , Evidence-Based Medicine , Female , Humans , Injury Severity Score , Logistic Models , Male , Predictive Value of Tests , Probability , Sensitivity and Specificity , Survival Analysis , Wounds, Penetrating/therapyABSTRACT
OBJECTIVES: To develop a precise mathematical formulation of resource-constrained triage, denoted the Sacco triage method (STM), to develop an evidence-based application to blunt trauma, and to compare the STM with the simple triage and rapid treatment (START) method. METHODS: Resource-constrained triage is modeled mathematically as a classic resource allocation problem. The objective is to maximize expected survivors given constraints on the timing and availability of resources. The model incorporates estimates of time-dependent victim survival probabilities based on an initial assessment and expected deterioration. For application to blunt trauma, an "RPM" score, based on respiratory rate, pulse rate, and motor response, was used to predict survivability. Logistic function-generated survival probability estimates for scene values of RPM were determined from 76,459 blunt-injured patients from the Pennsylvania Trauma Outcome Study (PTOS). The Delphi method provided expert consensus on victim deterioration rates, and the model was solved using linear programming. STM was compared with START across various criteria of process and outcome. Outcome was measured by expected number of survivors in simulated resource-constrained casualty incidents. RESULTS: In this mathematical simulation, RPM was a more accurate predictor of survivability from blunt trauma than the Injury Severity Score and the Revised Trauma Score, as measured by calibration and discrimination statistics. STM resulted in greater expected survivorship than START in all simulations. CONCLUSIONS: Resource-constrained triage is modeled precisely as an evidence-based, outcome-driven method that maximizes expected survivors in consideration of resources. The lifesaving potential and operational advantages over current methods warrant scrutiny and further research.
