Trauma Scoring System Takes the "Subjective" Out of Triage

Each provider received 45 cards representing trauma victims. Included were descriptions of their injuries and some basic vital signs. The providers' mission: Triage the "patients," using any method they liked, and determine which should receive priority treatment. The results? All over the map.

"The only consistent aspect was that it was chaotic," says EMS veteran Bob Waddell of the exercise. "All the groups picked different patients. One group picked patients No. 22 and 30 as their first patients to go out, and the other groups picked them as their last or next-to-last. What it showed is that you were going to live or die depending on which group picked you."

That exercise underscored the inexact art of triage, demonstrating the need for a better way to determine which patients in a mass-casualty incident need the most immediate help. EMS may have found that way: the Sacco Triage and Constrained Resource Methodology, developed by trauma expert Dr. Bill Sacco.

Sacco, a mathematician by trade, has authored more than 80 peer-reviewed papers on trauma and trauma management, and has developed or codeveloped many of the major trauma scoring and management systems used worldwide. His new outcome-driv­en method has been described as the "first evidence-based triage [system] in history."

"Compared to what's currently used-START and START-like programs are the most common-the Sacco method uses the same vital sign measurements: respiratory rate, pulse rate and best motor response," explains Waddell, vice president of emergency preparedness and response for ThinkSharp, a company cofounded by Sacco that is promoting the system. "The difference is, START and START-like programs just look at those vital signs as kind of an overview. With this method, they're actually given scores, and the sum of those scores tells you how critical the patient is."

The formula also accounts for the resources available in the area where it's used.

"None of the other triage methodologies really look objectively at resources," says Waddell. "You cannot apply any triage model to San Diego and Cheyenne, WY, in exactly the same way. They're too different. There are no Level I trauma centers in the entire state of Wyoming. In Washington, DC, they have 16 Level Is and IIs in a 30-mile radius. That's one of the big differences."

The Sacco method was tested in a large military trial at Camp Pendleton, and its outcomes validated using the Pennsylvania Trauma Outcome Registry. The scores it produced even appeared to correlate to eventual hospital discharge. The system received its first rollout last December in Okaloosa County, FL, and several other jurisdictions are weighing implementation/pilot projects.

The bottom line, say the method's proponents, is imposing an objectivity to the triage process that has heretofore been lacking.

"Our objective-which is definable, measurable and reproducible-is maximizing the number of survivors," says Waddell. "The START objective of doing the greatest good for the greatest number sounds good and makes us feel good, but you can't teach it the same way to everyone, and you can't apply it the same way everyplace."

For more information, visit www.sharpthinkers.com.

-JE