EMJ Podcast May 2019

Authors

• Amy Hughes
• Susie Roy

What this paper adds

Provides a great overview of the presentation of Measles in the Emergency Department in addition to highlighting approaches to diagnoses (which may be challenging), diagnoses and management. The paper also provides a comprehensive oversight to vaccination relevant to Measles.

The Paper

Could this be Measles?

ODonnell S, Davies F, Vardhan M, et al; Could this be measles? Emerg Med J 2019;36:310-314.

Available:

emj.bmj.com

dx.doi.org

Study Design

Case based discussion and review

RCEM curriculum coverage

CAP 28: Rash

HAP 14: Fever

HAP 28: Rash life threatening rashes

Online Learning

1. RCEM Learning: Guidelines: Measles Part 1 and Part 2 (Podcast); August 2018
2. Measles: PHE Guidance
3. World Health Organization
4. European Centre for Disease Prevention and Control: Communicable Disease Threats Report, 28 April-4 May 2019, Week 18:
5. Images of Measles rash

Authors

• Andrew Tabner
• Graham Johnson

What is already known on this subject

The key to success in major incident triage is identifying patients in need of life-saving interventions (LSIs). Currently, the UK and many other countries use a two-stage approach to major incident triage.

As a secondary triage process, the Triage Sort aims to refine the triage decisions previously made by primary triage tools. It has previously demonstrated good success at predicting mortality from injury.

However, in studies in the military environment, the Triage Sort has shown limited ability to predict the need for LSI.

What this study adds

Applying the Triage Sort retrospectively to a civilian trauma database (UK TARN), this study has demonstrated that the Triage Sort has poor sensitivity in identifying patients in need of LSI, and had lower sensitivity than two primary triage methods, the National Ambulance Resilience Unit (NARU) Sieve and the Modified Physiological Triage Tool-24 (MPTT-24).

The Paper

Major incident triage and the evaluation of the Triage Sort as a secondary triage method

James Vassallo, Jason Smith

Emerg Med J,2019;36:281286.

Available here

Study Design

Retrospective database review.

What was assessed?

The sensitivity and specificity of Triage Sort, NARU and MPTT-24 for predicting the need for Life-saving Interventions (LSI) in trauma patients

Outcomes

• 127,233 patients included (nearly 50% excluded due to missing data)
• Triage Sort sensitivity 15.7%, specificity 98.6% for LSI
• NARU sensitivity 29.5%, specificity 93.6%
• MPTT-24 sensitivity 53.5%, highest rate of over-triage

Authors’ Conclusion

Within a civilian trauma registry population, the Triage Sort demonstrated the poorest performance at identifying patients in need of LSI. Its use as a secondary triage tool should be reviewed, with an urgent need for further research to determine the optimum method of secondary triage.

Limitations (includes authors and our own)

• Database study rather than real world analysis
• TARN database includes all trauma modalities, not specifically major incident situations
• Some patients excluded by TARN (e.g. low ISS) may well lead to over-estimation of specificity
• Deaths on scene and those not conveyed to hospital for any reason were excluded due to TARN characteristics

Our take-home

Existing methods of major incident triage are flawed; Triage Sort has poor sensitivity for the need for LSI and is out-performed in this study cohort by other tools. Triage Sort is still in use, but will likely be replaced by an alternative in the future.

RCEM curriculum coverage

HAP 20: Major Incident management

#FOAMed Resources

Major Incident Management Jamie Sillett

Minor musings on a Major Incident PEMgeek

Major incident archives St. Emlyns

RCEM Learning

1. Getting started in research Part 1 Graham Johnson and Andrew Tabner
2. Getting started in research Part 2 Graham Johnson and Andrew Tabner
3. Major Incidents Part 1 Jonathon Hurley
4. Major Incidents 2: Incident Plans Jonathon Hurley

Supporting References

1. Delphi Study

Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident.

Vassallo J, Smith JE, Bruijns SR, Wallis LA.

Injury. 2016 Sep;47(9):1898-902.

2. Derivation Study of the MPTT

Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT).

Vassallo J, Beavis J, Smith JE, Wallis LA.

Injury. 2017 May;48(5):992-999.

3. MPTT-24 Article

Major incident triage and the implementation of a new triage tool, the MPTT-24.

Vassallo J, Smith JE, Wallis LA.

J R Army Med Corps. 2018 May;164(2):103-106.

4. Original study that started it all off!

UK triage–an improved tool for an evolving threat.

Horne S, Vassallo J, Read J, Ball S.

Injury. 2013 Jan;44(1):23-8.

SPSS Resources (both require purchasing)

1. Andy Field: Discovering statistics Using IBM statistics
2. Laerd Statistics guides available here.