Paediatric major incident triage: UK military tool offers best performance in predicting the need for time-critical major surgical and resuscitative intervention

Nabeela S Malik; Saisakul Chernbumroong; Yuanwei Xu; James Vassallo; Justine Lee; Christopher G Moran; Tina Newton; G Suren Arul; Janet M Lord; Antonio Belli; Damian Keene; Mark Foster; Timothy Hodgetts; Douglas M Bowley; Georgios V Gkoutos

doi:10.1016/j.eclinm.2021.101100

Paediatric major incident triage: UK military tool offers best performance in predicting the need for time-critical major surgical and resuscitative intervention

EClinicalMedicine. 2021 Aug 23:40:101100. doi: 10.1016/j.eclinm.2021.101100. eCollection 2021 Oct.

Authors

Nabeela S Malik^{1

2

3}, Saisakul Chernbumroong^{1

4}, Yuanwei Xu⁴, James Vassallo⁵, Justine Lee^{2

6

7}, Christopher G Moran^{7

8}, Tina Newton⁹, G Suren Arul^{3

9}, Janet M Lord^{1

2}, Antonio Belli^{1

2

6}, Damian Keene^{6

10}, Mark Foster^{1

6

10}, Timothy Hodgetts¹¹, Douglas M Bowley^{2

6

10}, Georgios V Gkoutos^{1

4

12

13}

Affiliations

¹ NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom.
² Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom.
³ 212 (Yorkshire) Field Hospital, Endcliffe Hall, Endcliffe Vale Road, Sheffield S10 3EU, United Kingdom.
⁴ Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom.
⁵ Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom.
⁶ University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom.
⁷ NHS England London, Skipton House, 80 London Road, London SE1 6LH, United Kingdom.
⁸ Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, United Kingdom.
⁹ Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom.
¹⁰ Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom.
¹¹ Headquarters Defence Medical Services, Coltman House, Lichfield WS14 9PY, United Kingdom.
¹² Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, United Kingdom.
¹³ MRC Health Data Research UK (HDR UK), Midlands Site, Birmingham B15 2TT, United Kingdom.

Abstract

Background: Children are frequently injured during major incidents (MI), including terrorist attacks, conflict and natural disasters. Triage facilitates healthcare resource allocation in order to maximise overall survival. A critical function of MI triage tools is to identify patients needing time-critical major resuscitative and surgical intervention (Priority 1 (P1) status). This study compares the performance of 11 MI triage tools in predicting P1 status in children from the UK Trauma Audit and Research Network (TARN) registry.

Methods: Patients aged <16 years within TARN (January 2008-December 2017) were included. 11 triage tools were applied to patients' first recorded pre-hospital physiology. Patients were retrospectively assigned triage categories (P1, P2, P3, Expectant or Dead) using predefined intervention-based criteria. Tools' performance in <16s were evaluated within four-yearly age subgroups, comparing tool-predicted and intervention-based priority status.

Findings: Amongst 4962 patients, mortality was 1.1% (n = 53); median Injury Severity Score (ISS) was 9 (IQR 9-16). Blunt injuries predominated (94.4%). 1343 (27.1%) met intervention-based criteria for P1, exhibiting greater intensive care requirement (60.2% vs. 8.5%, p < 0.01) and ISS (median 17 vs 9, p < 0.01) compared with P2 patients. The Battlefield Casualty Drills (BCD) Triage Sieve had greatest sensitivity (75.7%) in predicting P1 status in children <16 years, demonstrating a 38.4-49.8% improvement across all subgroups of children <12 years compared with the UK's current Paediatric Triage Tape (PTT). JumpSTART demonstrated low sensitivity in predicting P1 status in 4 to 8 year olds (35.5%) and 0 to 4 year olds (28.5%), and was outperformed by its adult counterpart START (60.6% and 59.6%).

Interpretation: The BCD Triage Sieve had greatest sensitivity in predicting P1 status in this paediatric trauma registry population: we recommend it replaces the PTT in UK practice. Users of JumpSTART may consider alternative tools. We recommend Lerner's triage category definitions when conducting MI evaluations.