TRIAGE AND EMERGENCY MEDICAL SERVICES IN EUROPE

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

MEDICAL ACADEMY

Faculty of Medicine,

Emergency Department

Darío Martínez Cánovas

TRIAGE AND EMERGENCY MEDICAL

SERVICES IN EUROPE

Final Master Thesis

Medicine

Supervisor: Prof.

Kęstutis Stašaitis

Consultant: Vytautas Aukštakalnis

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1. SUMMARY

Dario Martinez. General overview of emergency services and triage in prehospital setting. The aim of this research is to establish basic knowledge about triage, emergency services and its components in Europe.

In order to study the different aspects that will give an insight on what triage and emergency response consist of, four objectives are established:

- To review historical background that led to the creation of triage and emergency medical response.

- To acknowledge disaster classification and preparation for it. - To determine basic concepts of triage in prehospital setting.

- To provide a general insight of human components and resources used in prehospital setting.

The methodology used in this study was a literature review of the available scientific studies, published within the last 10 years, with the exception of four articles that were published in previous years. The databases used in this review are PubMed, Annual Reviews, Google Scholar, and ResearchGate.

After this review, it can be concluded that: It wasn´t until the 1859, when for the first time injured soldiers were treated independently of military graduation or nationality.

Failure to develop protocols may lead to over-triage or under-triage.

Under-triage results in an of increase morbidity and mortality among patients with treatable injuries.

Disasters and emergencies can be caused by natural phenomena, humans or technology. When a disasters occurs the alert state is activated, emergency stage is established, and adequate response is given by the action teams.

The response given in a disaster need to cover the following areas: security and order, diminishing the causative agent and its effects, ensuring the need material and supplies, carrying out technological studies about vital techniques and methods in order to confront disasters and its risks in a specific way, and providing medical assistance.

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facilities; to help, together with security teams, to identify the injured ones and deceased ones; drug administration and to assess the risk regarding the availability of food supplies and drinkable water.

Three types of measures can be taken in order to be prepared for a disaster. Prevention: protocols development and actuation guides. Mitigation: administrative, economic and legal measures. Preparation: education of the action teams and the general population.

During a disaster, it is important to classify, manage and evacuate the affected population. As well as searching and rescuing of the injured.

In the post-disaster, it is important to the rehabilitation and reconstruction measures. The integrants of a medical assistance team are dependent on: the ambulance type and the countries legislations. According to the European Union regulations, there are 3 types of ambulance, based on the type of assistance that can be provided. Selecting the appropriate ambulance for each situation, helps to avoid the use and waste of over-prepared resources. The most commonly used triage model is the S.T.A.R.T., a tetrapolar model that classifies the victims according to four simple premises: walking ability, respiration, perfusión, and mental status. With the purpose of being objective, an international colour system is used,

independently from the triage model used, to classify and give priority to the victims: RED, critical, priority 1; YELLOW, severe, priority 2; GREEN, mild, priority; BLACK, deceased, priority 4.

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3. ABBREVIATIONS LIST

AC After Christ

ALS Advanced Life Support BC Before Christ

BLS Basic Life Support

EMT Emergency Medical Technician ER Emergency Room

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4. INTRODUCTION

Triage is the classification of patients in different priority levels in which the signs and symptoms evaluation is carried out, prioritizing those victims more urgent from those with less priority, that don't need an immediate assistance and/or mobilization resources. The emergency response services are continuously evolving and adapting to the latest scientific updates, because adapting the protocols to the newest data is key in order to have good outcomes.Therefore, the teams involved in the emergency services, every medical personnel involved in hospital and prehospital setting, are under continuous training. In this literature review we are focusing on prehospital setting environment which can become very complex and requires a high level formation for all different components of emergency response teams not only regarding assistance but also taking charge of

organizational functions.

Therefore this literature review was made in order to gather the current available data regarding triage and emergency response services.

The aim of this study is to establish basic knowledge about triage, emergency services and its components.

5. AIM AND OBJECTIVES OF THE THESIS

This study is focused towards the summarization of the current available data regarding triage and emergency response services and its role relevance in any possible scenario.

It has been summarized and considered all the factors that take a role in the establishment of an actuation plan, from the historical background ,to the models used nowadays.

The aim of this literature review is to establish basic knowledge about triage, emergency services and its components.

In order to accomplish this, four objectives are established:

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- To acknowledge disaster classification and preparation for it.

- To determine basic concepts of triage in the prehospital setting in Europe.

- To provide a general insight of human components and resources used in prehospital setting.

6. LITERATURE REVIEW

6.1 TRIAGE

6.1.1 DEFINITION

Triage is the term applied to the process of classifying patients at the scene according to the severity of their injuries to determine how quickly they need care.

Careful triage is needed to ensure that the resources available in a community are properly matched to each victims needs. Formal algorithms or protocols need to be developed to ensure that community resources are used properly to care for patients.

These algorithms must exist for both the prehospital and hospital setting.[1]

Failure to develop protocols may lead to over-triage or under-triage.

Over-triage occurs when non critical patients are sent to facilities offering the highest care level.[2]

Under-triage occurs when critically injured patients are treated at the local level or sent to facilities that are not properly equipped to meet their needs.[3] This may result in an increased morbidity and mortality among patients with treatable injuries.

6.1.2 HISTORICAL BACKGROUND

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This type of assistance started in Egipt, by Imhotep (27th century BC), considered to be the first doctor in history [4], treating mainly fractures located in head and forearm, which later would lead to classification of injured soldiers.

In ancient Greece, in the context of armed conflicts also existed medical assistance. The most important figure of this period was Hippocrates (6th-5th century BC), who focused on the study of different epidemies and set the basis for medical ethics.[5]

The most important doctor during Roman times was Galeno (2nd century AC), who had a great impact on the medicine history with his work, but he denied to be part of the military campaigns. Nevertheless, emperors realized that the majority of deaths were caused by untreated injuries among soldiers. This fact promoted the creation of assistance teams in order to reduce the number of fatalities.

Continuing along with history, the Arabs (1st-2th century AC) translated Greek and Roman manuscripts,which they studied, improved and modernized.

But it wasn't until 1792 when Baron Dominique Larrey created the first ambulance during napoleonic wars.

This happened during Valmy battle in September 20 th of 1792 when Larry created a fast evacuation system based on a horse carriage which provided cover and comfort during transportation.

Also, after this innovation, Larry realized that this method wasn't enough and this conclusion led to the creation of a evacuation system based on the severity of the injuries indepently of military graduation or nationality.[6]

One of the biggest movement created in the medical assistance comes from Henry Dunant in 19th century, specifically in 1863 when the Red Cross International Committee was created. The creation of this committee was promoted by the Solferino battle on June 24th of 1859, when Dunant was speechless after witnessing how thousands of injured soldiers were

unassisted, leading to their deaths, which pushed Dunant and many nurses, regardless of their own safety, to attend the injured soldiers indepently of military graduation or nationality.[7]

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6.2 DISASTERS AND EMERGENCIES

6.2..1 CLASSIFICATION

Disasters and emergencies are categorized by the type of risk or accident that provokes them. There are three main types of risk, classified as follows:

- Natural risks: those which are triggered by geological, biological, extraterrestrial, meteorological and climatic factors.[8]

- Antropic risks: those triggered by human actions.[9]

- Technological risks: those triggered by human activities closely related to technologies, its development and applications.

6.2.2 ASSISTANCE

By the time the alert state is activated, the emergency stage must be established in order to have an adequate response from the different teams and resources.

Interventions are determined by actuation plans established by local or national authorities. These actuation plans are carried out by the different action groups whose organization is divided by functions, being established as follows:[10]

- Security teams - Intervention teams - Logistic teams

- Technical support teams - Medical teams

Security teams_{are responsible for providing security and maintaining order in the population.} Intervention teams_{are responsible to act in order to diminish the causative agent and its} effects .

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Technical support team_{s are responsible to carry out all necessary studies about vital}

techniques and methods in order to confront disasters and its risks in a specific way, aiming to diminish its effects and clarify causative factors.[10]

Lastly, _{medical teams which are responsible to provide medicalized attention to the affected} ones and decide all the necessary measures. Some of those assignments are:

To define the action area, classification of the area and evacuation from the area. To provide first aid and triage.

To transport the injured people to the medical facilities .

To help, together with the security teams, to identify the injured ones and deceased ones. Drug administration.

To assess the risk regarding the availability of food supplies and drinkable water.

6.2.3 STAGING

Staging a disaster is a necessary action in order to activate and carry out the adequate measures ensuring efficient, fast and specific actions.

The previously mentioned staging process is classified as follows:[11,12]

- Pre-disaster: in this stage the aim is to reduce the impact by applying three different action levels:

+ Prevention: protocols development and actuation guides, risk maps and medical education must be carried out.

+ Mitigation: its aimed to reduce the impact on population and it is closely related to administrative, economic, and legal aspects.

+ Preparation: when it is not possible to eliminate a risk, it is important to plan and coordinate the necessary measures in case a disaster takes place. Actuation teams and population must be under preparation and prevention programs to grant an effective response.[13]

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- Disaster: essential activities include classification, attention and evacuation of affected population, as well as to search and to rescue the injured ones..

All the previously mentioned actions are determined by the needs, resources and material available.

- Post-disaster: the activities following a disaster aim to promote recuperation of the affected area. Two different action levels can be differentiated:

+ Rehabilitation: those actions aiming to establish basic services within the community like water, electricity, telecommunications, etc.

+ Reconstruction: aiming to reconstruct the affected area, as well as the social and economical wellness.

6.3 ASSISTENCIAL TEAMS AND TRANSPORTATION TYPES

6.3.1 ASSISTENCIAL TEAMS

Management of the victims in disasters is a complex process which requires good coordination between all the team members and between the different teams. The use of protocols is needed to achieve this goal.

In the protocols, it is described the integrants of the medical teams. Generally, they are composed of a doctor, a nurse, and an Emergency Medical Technician (EMT). Although, the integrants of the medical assistance team can vary from one ambulance type to another and also depending on the different countries legislations.

Mainly, they are responsible to carry out two main functions during a disaster or emergency:

- Organizative: these actions focus on scenario control, establishment of the limits within the area, risk evaluation, human resources organization _{in situ, and to assess the number of} victims, to determine the accident nature and to distribute Personal Protective Equipment (PPE).

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6.3.2 TRANSPORTATION TYPES

There are diverse types of medical transportation that can be activated in order to provide adequate assistance and evacuation.

The transportation vehicles can be used to either assist, triage and evacuate or to assist and triage, in order to facilitate the management of mass casualty scenario. Also different types of vehicles ensure an efficient approach _{via air, land or sea. The European Union have}

established a classification of the different type of ambulances based on three different categories:

- Category A: Only transport, aimed to transport patients from point A to B without ability to provide medical care. Composed of EMT.

- Category B: Basic Life Support (BLS), prepared for basic medical assistance. Composed of nurse and EMT.

- Category C: Advanced Life Support (ALS), aimed to patients which require intensive treatment. Composed of doctor, nurse, and EMT.[14]

It must be mentioned the existence of terrestrial vehicles not aimed for evacuation, instead their function is focused on assistance and triage _{in situ, as an example, it can be mentioned} the fast intervention vehicles.

Also, there are aerial equivalents for ALS as medicalized planes and helicopters, bringing in to focus the enormous importance of helicopters during search and rescue operations, especially in difficult access and remote areas.[15,16]

Lastly, there are specialized vehicles for disasters responsible to provide all the necessary equipment as triage material, deployable hospitals, tents, signaling elements, field

communication centers, etc.

6.4. TRIAGE IN PREHOSPITAL SETTING

Triage can be divided in two main groups:

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- Hospital triage, usually realized in the emergency room (ER) of the hospitals.

In some situations, an area previous to the ER can be designated for this function in order to regulate patient influx.

Nonetheless, in this literature review we are focussing in prehospital triage which can be classified in different stages and models.

6.4.1 TRIAGE STAGES

Traditionally prehospital triage can be classified in the following stages:

- Basic triage: this triage is carried out by available personnel in the scene using fast, basic and simple methods and not using more than 30 seconds to identify deceased ones, 1 minute for mild conditions and 3 minutes for critical victims.

This method is not precise and usually tends to overtriage, but the aim is to allow critical victims, which will die within the next minutes, to be quickly classified and get the medical help..

During basic triage, only two maneuvers are allowed[17]:

+ Airway opening as mandibular traction, orofaringeal cannula insertion, recovery position, head tilt chin lift maneuver. [18]

+ Hemorrhage control as direct compression or compression bandages.

- Advance triage: this triage is carried out by the medical personnel, in the advance medical post. More specialized methods are used to classify victims aiming to establish an evacuation order.

Advance triage is much more complex than basic triage, focusing in prognosis estimation and the immediate need of hospitalary care.

6.4.2 TRIAGE MODELS

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Classification under pressure must be simple at first. The following models can be used in the prehospital setting:

- Bipolar model: it is a fast and exceptional method when resources are very limited or when there is an imminent threat, such as chemical or nuclear incidents.

The classification is very simple. For example: dead or alive; walking or not walking.

- Tripolar model: it is a classical option in situations that require fast intervention towards an ongoing incident but having certain margin for action. For example: critical, severe, mild; deceased, critical, severe.

- Tetrapolar model: it is the most used model. Always 4 categories are established according to the international color code system (explained in the section under the name: 4.3 triage, colors importance). The most popular model is S.T.A.R.T (Simple Triage Algorithm and Rapid Treatment) which consider four different parameters [19]:

+ Walking ability + Respiration + Perfusión + Mental status

- Pentapolar model: used at hospital setting.

6.4.3 TRIAGE, COLORS IMPORTANCE

All the classification systems that had been developed, aim to categorized patients according to their attendance priority, transport and definitive medical care.

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- RED, critical, priority 1 - YELLOW, severe, priority 2 - GREEN, mild, priority 3 - BLACK, deceased, priority 4

Once the victims´ priority has been identified, a triage tag is placed in which color and priority will be specified.[20,21]

7. RESEARCH METHODOLOGY AND METHODS

The research methodology has consisted of a literature review based on the following data bases on which Lithuanian University of Health Sciences is subscribed to: PubMed, Annual Reviews, also outside from university subscriptions Google Scholar and ResearchGate have been used.

Information gathering and thesis planning has been based on the following books: Prehospital Emergency Care in Acute Trauma Conditions and Disaster Risk Management Systems

Analysis.

In order to search and select the literature, these specific terms were used: “Disaster”, ”Triage”, ”Prehospital Care”, ”Emergency”, ”Ambulance”.

Also filters were applied, using only articles that were written in English and Spanish

language and those articles that were published within the last ten years, with the exception of four articles previously published to the mentioned period.

The literature references that are listed at the end of this study are cited according to the Vancouver system.

The aim of this literature review is to establish basic knowledge about triage, emergency services and its components.

In order to organize all the gathered material the study has been divided in four different chapters:

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disasters and emergencies.

- In the third chapter it is described the different assistencial teams and transportation types. - In the fourth chapter it is described triage stages, models and color classification

importance.

8. CONCLUSIONS

After gathering and analyzing the current available data, it can be concluded: 1. It wasn´t until the 1859, when for the first time injured soldiers were treated

independently of military graduation or nationality.

2. Failure to develop protocols may lead to over-triage or under-triage.

Under-triage results in an of increase morbidity and mortality among patients with treatable injuries.

3. Disasters and emergencies can be caused by natural phenomena, humans or

technology. When a disasters occurs the alert state is activated, emergency stage is established, and adequate response is given by the action teams.

The response given in a disaster need to cover the following areas: security and order, diminishing the causative agent and its effects, ensuring the need material and

supplies, carrying out technological studies about vital techniques and methods in order to confront disasters and its risks in a specific way, and providing medical assistance.

The medical assistance in a disaster consists of: defining the action area; classification of the evacuation area; providing first aid and triage; transporting the injured people to medical facilities; to help, together with security teams, to identify the injured ones and deceased ones; drug administration and to assess the risk regarding the

availability of food supplies and drinkable water.

Three types of measures can be taken in order to be prepared for a disaster.

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During a disaster, it is important to classify, manage and evacuate the affected population. As well as searching and rescuing of the injured.

In the post-disaster, it is important to the rehabilitation and reconstruction measures.

4. The integrants of a medical assistance team are dependent on: the ambulance type and the countries legislations. According to the European Union regulations, there are 3 types of ambulance, based on the type of assistance that can be provided. Selecting the appropriate ambulance for each situation, helps to avoid the use and waste of over-prepared resources.

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9. LITERATURE LIST

1. Kenneth V. Iserson, MD, MBA John C. Moskop, PhD, 2007. Triage in Medicine, Part I: Concept, History, and Types.

https://www.acep.org/globalassets/sites/acep/media/disaster-medicine/niche-groups/ethics-in-disasters/triage-ethics-part-1.pdf

2. Craig D. Newgard, Kristan Staudenmayer, Renee Y. Hsia, N. Clay Mann, Eileen M. Bulger,James F. Holmes, _{Ross Fleischman, Kyle Gorman, Jason Haukoos, K. John} McConnell, 2013. The cost of overtriage: more than one third of low risk injured patients were taken to mayor trauma centers.

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2012.1142

3. Barbara Haas,MD, David Gómez,MD, Brandon Zagorski,MS, Therese A.Stukel,PhD, Gordon D.Rubenfeld MD, MS, Avery B.Nathens MD, PhD, 2010.Survival of the Fittest: The Hidden Cost of Undertriage of Major Trauma.

https://www.sciencedirect.com/science/article/abs/pii/S1072751510010124

4. Guenter B. Risse, MD, PhD, 1986. Imhotep and medicine--a reevaluation.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1306737/?page=1

5. César Sierra Martín, 2012. Fundamentos médico-filosóficos en los discursos historico-politicos de la Grecia antigua.

https://ddd.uab.cat/pub/tesis/2012/hdl_10803_117600/csm1de1.pdf#page=319

6. Salomon Jasqui Remba, Joseph Varon, Alma Rivera, George L. Sternbach, 2009.

Dominique-Jean Larrey: The effects of therapeutic hypothermia and the rst ambulance.

https://www.researchgate.net/publication/40784800_Dominique-Jean_Larrey_The_effects_of _therapeutic_hypothermia_and_the_first_ambulance

7. Christy Shucksmith, 2015. The International Committee of the Red Cross and its mandate to protect and assist: law and practice.

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8. S.C. Wirasinghe , H.J. Caldera , S.W. Durage and J.Y. Ruwanpura. 2013. Preliminary Analysis and Classification of Natural Disasters.

https://www.researchgate.net/publication/236325920_Preliminary_Analysis_and_Classificati on_of_Natural_Disasters

9.Patrick F. Clarkin, 2019. The Embodiment of War: Growth, Development, and Armed Conflict. https://www.annualreviews.org/doi/full/10.1146/annurev-anthro-102218-011208

10. Ibrahim Arziman, 2016. Field Organization and Disaster Medical Assistance Teams.

https://www.sciencedirect.com/science/article/pii/S2452247316600584

11. Lorenzo Bruzzone, Francesca Bovolo, 2010. Remote Sensing and GIS for Natural Hazards Assessment Disaster Risk Management.

https://www.researchgate.net/publication/224201465_A_conceptual_framework_for_change _detection_in_very_high_resolution_remote_sensing_images

12. _{Kathrin Poser, Doris Dransch, 2010. Volunteered Geographic Information for Disaster} Management with Application to Rapid Flood Damage Estimation.

https://www.researchgate.net/publication/265619198_Volunteered_Geographic_Information_ for_Disaster_Management_with_Application_to_Rapid_Flood_Damage_Estimation

13. _{Katharine Wulff, Darrin Donato, Nicole Lurie, 2015. What Is Health Resilience and How} Can We Build It?

https://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-031914-122829

14. Dr. Mircea Beuran, S. Paun, B. Gaspar, M. Vartic, S. Hostiuc, A. Chiotoroiu, I. Negoi, 2012. Prehospital Trauma Care: a Clinical Review.

http://revistachirurgia.ro/pdfs/2012-5-564.pdf

15. Kelvin Williamson, Ramaiah Ramesh, Andreas Grabinsky, 2011. Advances in prehospital trauma care. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3209988/

16. Thibaut Desmettre, Jean-Michel Yeguiayan, Hervé Coadou, Claude Jacquot, Mathieu

Raux, Benoit Vivien, Claude Martin, Claire Bonithon-Kopp, Marc Freysz, 2012. Impact of

emergency medical helicopter transport directly to a university hospital trauma center on mortality of severe blunt trauma patients until discharge.

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17. Pedro Arcos González, Rafael Castro Delgado, Tatiana Cuartas Alvarez, Gracia Garijo Gonzalo, Carlos Martinez Monzon, Nieves Pelaez Corres, Alberto Rodriguez Soler, Fernando Turegano Fuentes, 2016. The development and features of the Spanish prehospital advanced triage method (META) for mass casualty incidents.

https://sjtrem.biomedcentral.com/articles/10.1186/s13049-016-0255-y

18. Meirav Mor, M.D. and Yehezkel Waisman, M.D, 2002. Triage principles in multiple casualty situations involving children: the Israeli experience.

http://researchinpem.homestead.com/files/triage.pdf

19. Mary Colleen Bhalla, MD, Jennifer Frey PhD, Cody Rider, DO, Michael Nord, DO, Mitch

Hegerhorst, DO, 2015. Simple Triage Algorithm and Rapid Treatment and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation mass casualty triage methods for sensitivity, specificity, and predictive values.

https://www.sciencedirect.com/science/article/abs/pii/S0735675715006877

20. Rocío Cándida Romero González, 2014. Triage en Emergencias Extrahospitalarias.

http://www.index-f.com/para/n20/pdf/095.pdf

21. Ashley Kay Childers, 2010. Prioritizing Patients for Emergency Evacuation From a Healthcare Facility.