Open Access Open Access  Restricted Access Subscription Access

A review of the literature on the validity of mass casualty triage systems with a focus on chemical exposures

Joan M. Culley, PhD, MPH, RN, CWOCN, Erik Svendsen, PhD, MS


Introduction: Mass casualty incidents (MCIs) include natural (eg, earthquake) or human (eg, terrorism or technical) events. They produce an imbalance between medical needs and resources necessitating the use of triage strategies. Triage of casualties must be performed accurately and efficiently if providers are to do the greatest good for the greatest number. There is limited research on the validation of triage system efficacy in determining the priority of care for victims of MCI, particularly those involving chemicals.

Objective: To review the literature on the validation of current triage systems to assign onsite treatment status codes to victims of mass casualties, particularly those involving chemicals, using actual patient outcomes.

Methods: The focus of this article is a systematic review of the literature to describe the influences of MCIs, particularly those involving chemicals, on current triage systems related to the onsite assignment of treatment status codes to a victim and the validation of the assigned code using actual patient outcomes.

Results: There is extensive literature published on triage systems used for MCI but only four articles used actual outcome data to validate mass casualty triage outcomes including three for chemical events. Currently, the amount and type of data collected are not consistent or standardized and definitions are not universal.

Conclusions: Current literature does not provide needed evidence on the validity of triage systems for MCI in particular those involving chemicals. Well-designed studies are needed to validate the reliability, sensitivity, and specificity of triage systems used for MCI including those involving chemicals.


mass casualty incidents, chemical mass casualty incidents, evidence-based medicine, mass casualty triage systems, validation

Full Text:



Shaluf IM: An overview on the technological disasters. Disaster Prev Manag. 2007; 16(3): 380-390.

Auf der Heide E: The importance of evidence-based disaster planning. Ann Emerg Med. 2006; 47(1): 34-49.

Cone DC, MacMillan DS: Mass-casualty triage systems: A hint of science. Acad Emerg Med. 2005; 12(8): 739-741.

Sundnes KO, Birnbaum ML (eds.), the Task Force for Quality Control of Disaster Management: Health disaster management: Guidelines for evaluation and research in the Utstein style. Prehosp Disaster Med. 2003; 17(suppl 3): 1-177.

Birnbaum M: Disaster medicine: Status, roles, responsibilities, and needs. Prehosp Disaster Med. 2002; (3): 117-118.

Birnbaum M: Disaster research: Why how and when? Prehosp Disaster Med. 2000; 15(3): s88.

Frykberg ER: Triage principles and practice. Scand J Surg. 2005; 94: 272-278.

Sasser S, Varghese M, Joshipura M, et al.: Preventing Death and Disability Through the Timely Provision of Prehospital Trauma Care. Geneva, Switzerland: World Health Organization, 2006. Available at Accessed April 3, 2014.

Frykberg ER: Terrorist bombings in Madrid. Crit Care. 2005; 9: 20-22.

Armstrong JH, Hammond J, Hirshberg A, et al.: Is overtriage associated with increased mortality? The evidence says “yes.” Med Pubic Health Prep. 2008; 2(1): 4-5.

Frykberg E: Medical management of disaster and mass casualties from terrorist bombings: How can we cope? J Trauma. 2002; 53(2): 201-212.

Frykberg E: Principles of mass casualty management following terrorist disasters. Ann Surg. 2004; 239(3): 319-321.

Hoey GA, Schwab CW: Level I center triage and mass casualties. Clin Orthop Relat Res. 2004; (4)22: 23-29.

Parker M: Critical care and disaster management. Crit Care Med. 2006; 34(3 Suppl): S52-S55.

Sharma R: Development of pre-hospital trauma-care-system—An overview. Injury. 2005; 36(5): 579-587.

Lerner EB: Studies evaluating current field triage: 1966-2005. Prehosp Emerg Care. 2006; 10(3): 303-307.

Benson M, Koenig KL, Schultz CH: Disaster triage: START, then SAVE—A new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med. 1996; 11(2): 117-124.

Culley J: Validation of a mass casualty model [dissertation]. Tucson, AZ: University of Arizona, 2007.

Neal DJ, Barbera JA, Harrald JR: -PLUS Prehospital mass-casualty triage: A strategy for addressing unusual injury mechanisms. Prehosp Disaster Med. 2010; 25(3): 227-236.

Knopp R, Yanagi A, Kallsen G, et al.: Mechanisms of injury and anatomic injury as criteria for prehospital trauma triage. Ann Emerg Med. 1988; 17(9): 895-902.

Ihlenfeld JT: A primer on triage and mass casualty events. Dimens Crit Care Nurs. 2003; 22(5): 204-207.

Schultz DH, Koenig KL, Noji EK: A medical disaster response to reduce immediate mortality after an earthquake. N Engl J Med. 1996; 334(7): 438-444.

Culley J: Mass casualty information decision support. OJNI. 2011; 15 (3).

Culley JM, Effken JA: Development and validation of a mass casualty conceptual model. J Nurs Scholarsh. 2010; 42(1): 66-75.

Nocera A: Australian disaster triage: A colour maze in the Tower of Babel. Aust N Z J Surg. 1999; 69(8): 598-602.

Sacco Triage Method (STM) Web site. Available at Accessed July 6, 2011.

Jenkins J, McCarthy M, Sauer L, et al.: Mass-casualty triage: Time for an evidence-based approach. Prehosp Disaster Med. 2008; 23(1): 3-8.

Neal DJ: Prehospital patient triage in mass casualty incidents: An engineering management analysis and prototype Strategy recommendation [dissertation]. Washington, DC: George Washington University. 1999. Available at Accessed April 3, 2014.

Koenig KL, Goans RE, Hatchett RJ, et al.: Medical treatment of radiological casualties: Current concepts. Ann Emerg Med. 2005; 45: 643-652.

Cone DC, Loenig KL: Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur J Emerg Med. 2005; 12(8): 287-302.

MacKenzie MH, Alcorta EJ, Kelen GD: Compliance with prehospital triage protocols for major trauma patients. J Trauma. 1999; 46(1): 168-175.

Kilner T: Triage decisions of prehospital emergency health care providers, using a multiple casualty scenario paper exercise. Emerg Med J. 2002; 19: 348-353.

Centers for Disease Control and Prevention: CDC acute injury care research agenda: Guiding research for the future. Atlanta, GA: US Department of Health and Human Services, CDC, 2005. Available at Accessed July 6, 2011.

Meredith W, Rutledge R, Hansen AR, et al.: Field triage of trauma patients based upon the ability to follow commands: A study in 29,573 injured patients. J Trauma. 1995; 38: 129-135.

SALT Mass Casualty triage: Concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008; 2(4): 245-246.

Sacco WJ, Mavin DM, Fiedler KE, et al.: Precise formulation and evidence-based application of resource constrained triage. Acad Emerg Med. 2005; 12(8): 759-770.

Killeen JP, Chan TC, Buono C, et al.: A wireless first responder handheld device for rapid triage, patient assessment and documentation during mass casualty incidents. AMIA Annu Symp Proc. 2006; 2006:429-433.

Williams D. TacMedCS (Tactical Medical Coordination System). Naval Health Research Center, Technical Document No. 07-9I. Available at Accessed April 3, 2014.

Chan T, Killeen J, Griswold W, et al.: Information technology and emergency medical care during disasters. Acad Med. 2004; 11(11): 1229-1236.

Task Force on Quality Control of Disaster Management: Health Disaster Management. Guidelines for evaluation and research in the Utstein style: Executive Summary. Prehosp Disaster Med. 1999; 14(2): 43-53.

Burstein JL, Henry MC, Alicandro JM, et al.: Evidence for and impact of selective reporting of trauma triage mechanisms criteria. Acad Med. 1996; 3(110): 1011-1015.

Domres B, Koch M, Mange A, et al.: Ethics and triage. Prehosp Disaster Med. 2001; 16(1): 53-58.

Gebbi K, Merill J: Public health worker competencies for emergency response. J Public Health Manag Pract. 2002; 8(3): 73-81.

Rüter A: Disaster Medicine- Performance Indicators, Information Support and Documentation [dissertation]. 2006. Linköping, Sweden: Linköping University, 2007.

Van Sickle D, Wenck MA, Belflower A, et al.: Acute health effects of chlorine gas exposure in the community. Am J Emerg Med. 2009; 27: 1-7.

Wenck MA, Van Sickle D, Drociuk D, et al.: Rapid assessment of exposure to chlorine released from a train derailment and resulting health impact. Public Health Rep. 2007; 122(6): 784-792.

Medical Management Guidelines for Chlorine. Agency for Toxic Substances and Disease Registry (ATSDR). Available at Accessed April 3, 2014.

Kay J: Special Report: Chlorine accidents rupture life for workers, townspeople. Environmental Health News. Available at Accessed April 3, 2014.

Sax NI, Lewis SRJ: Dangerous Properties of Industrial Chemicals. New York, NY: Van Nostrand Reinhold, 2007: 768.

Evans RB: Chlorine: State of the art. Lung. 2005; 183(3): 151-167.

Bowen HJ, Palmer SR, Fielder HMP, et al.: Community exposures to chemical incidents: Development and evaluation of the first environmental public health surveillance system in Europe. J Epidemiol Community Health. 2000; 54(11): 870-873.

Mrvos R, Dean BS, Krenzelok EO: Home exposures to chlorine/chloramine gas: Review of 216 cases. South Med J. 1993; 86(6): 654-657.

Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, et al.: 2001 Annual report of the American association of poison control centers toxic exposure surveillance system. Am J Emerg Med. 2002; 20(5): 391-452.

Litovitz TL, Klein-Schwartz W, White S, et al.: 2000 Annual report of the American association of poison control centers toxic exposure surveillance system. Am J Emerg Med. 2001; 19(5): 337-395.

Watson W, Litovitz TL, Klein-Schwartz W, et al.: 2003 Annual report of the American association of poison control centers toxic exposure surveillance system. Am J Emerg Med. 2004; 22(5): 335-404.

Watson WA, Litovitz TL, Rodgers GC Jr, et al.: 2004 Annual report of the American association of poison control centers toxic exposure surveillance system. Am J Emerg Med. 2005; 23(5): 589-666.

Watson WA, Litovitz TL, Rodgers GC Jr, et al. 2002 Annual report of the American association of poison control centers toxic exposure surveillance system. Am J Emerg Med. 2003; 21(5): 353-421.

Kleindorfer PR, Paul R, James C, et al.: Accident epidemiology and the U.S. chemical industry: Accident history and worst-case data from RMP*Info. Risk Anal. 2003; 23(5): 865-881.

Henneberger PK, Metayer C, Layne LA, et al.: Nonfatal work-related inhalations: Surveillance data from hospital emergency departments, 1995-1996. Am J Ind Med. 2000; 38(2): 140-148.

The Homeland Security Council: Planning Scenarios: Executive Summaries. 2004. Available at Accessed April 3, 2014.

Centers for Disease Control and Prevention: Guidelines for field triage of injured patients, recommendations of the national expert panel on field triage. MMWR. 2009; 58 (1): 1-35.

START Web site. Available at Accessed April 3, 2014.

Garner A, Lee A, Harrison K, et al.: Comparative analysis of multiple casualty incident triage algorithms. Ann Emerg Med. 2001; 8: 541-548.

Mulholland S, Gabbe B, Cameron P, et al.: Is paramedic judgment useful in prehospital trauma triage? Injury. 2005; 36(11): 1298-1305.

Lerner EB, Schwartz RB, Coule ES: Mass casualty triage: An evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008; 2(Suppl 1): S25-S34.

Gebhart ME, Pence R: START triage: Does it work? Disaster Manag Response. 2007; 5(3): 68-73.

Kahn C, Schultz C, Miller K, et al.: Does START triage work?. An outcomes level assessment of use at a mass casualty event. Acad Emerg Med. 2009; 53(3): 424-430.

Homepage. JumpSTART Pediatric MCI Triage Tool Web site. Available at Accessed April 3, 2014.

Romig L: The JumpSTART Pediatric MCI Triage Tool. 2008. Available at Accessed April 3, 2014.

Gilboy N, Tanabe P, Travers D, et al.: Emergency Severity Index, Version 4: Implementation Handbook. AHRQ Publication No. 05-0046-2. Rockville, MD: AHRQ, 2005.

Eitel D, Travers D, Rosenau A, et al.: The emergency severity index triage algorithm version 2 is reliable and valid. Acad Emerg Med. 2003; 10(10): 1070-1080.

Tanabe R, Travers D, Gilboy N, et al.: Refining emergency severity index triage criteria. Acad Emerg Med. 2005; 12(6): 497-501.

Wuerz R, Travers D, Gilboy N, et al.: Implementation and refinement of the emergency severity index. Acad Emerg Med. 2001; 8(2): 170-176.

Gimbel T, Yarnold P, Adams J: The emergency severity index (version 3) 5-level triage system scores predict D resource consumption. J Emerg Nurs. 2004; 30(1): 22-29.

Lee CH: Disaster and Mass Casualty Triage. Virtual Mentor. 2010; 12(6): 466-470.

Cone DC, MacMillan DS, Parwani V, et al: Pilot test of a proposed chemical/biological/radiation/nuclear-capable mass casualty triage system. Prehosp Emerg Care. 2008; 12(2): 236-240.

Hines S, Payne A, Edmondson J, et al.: Bombs under London. The EMS response plan that worked. JEMS. 2005; 30: 58-67.

Wallis LA, Carley S: Validation of the paediatric triage tape. Emerg Med J. 2006; 23: 47-50.

Engum SA, Mitchell MK, Scherer LR, et al.: Prehospital triage in the injured pediatric patient. J Pediatr Surg. 2002; 35(1): 82-87.

Larsen KT, Uleberg O, Skogvoll E: Differences in trauma team activation criteria among Norwegian hospitals. Scand J Trauma Resusc Emerg Med. 2010; 18: 21.

Olchin L, Krutz A: Nurses as first responders in a mass casualty: Are you prepared? J Trauma Nurs. 2012; 19(2): 122-129.

American Academy of Pediatrics, American College of Emergency Physicians, American College of Emergency Physicians, et al.: Model uniform core criteria for mass casualty triage. Disaster Med Public Health Prep. 2011; 5(2): 125-128.

Lerner EB, Cone DC, Weinstein ES, et al.: Mass casualty triage: An evaluation of the science and refinement of a national guideline. Disaster Med Public Health Prep. 2011; 5(2): 129-137.

Lerner EB, Schwartz RB, Coule PL, et al.: Use of SALT triage in a simulated mass casualty incident. Prehosp Emerg Care. 2010; 14(1): 21-25.

Navin DM, Sacco WM, Waddell R: Operational comparison of the Simple Triage and Rapid Treatment method and the Sacco Triage Method in mass casualty exercises. J Trauma. 2010; 69(1): 215-225.

Navin M, Sacco W, McGill G: Application of a new resource constrained triage method to military-aged victims. Mil Med. 2009; 174: 1247-1255.

Hupert N, Hollingsworth E, Xiong W: Is over-triage associated with increased mortality?. Insights from a simulation model of mass casualty trauma care. Disaster Med Public Health Prep. 2007; 1(1 Suppl): S14-S24.

Navin M, Waddell R: Triage is broken. EMS Magazine. 2005. Available at$1740. Accessed April 3, 2014.

Peral Gutierrez de Ceballos J, Turégano-Fuentes F, Perez-Diaz D, et al.: 11 March 2004: the terrorist bomb explosions in Madrid, Spain-analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care. 2004; 9: 104-111.

Armstrong JE, Frykberg E, Burnis D: Toward a national standard in primary mass casualty triage. Disaster Med Public Health Prep. 2008; 2(1): S8.

Fernandes CP, Tanabe N, Gilbo L, et al.: Five-level triage: A report from the ACEP/ENA five-level triage task force. J Emerg Nurs. 2005; 31(1): 39-50.

Burstein JL: Mostly dead: Can science help with disaster triage? Ann Emerg Med. 2009; 54(3): 431.

Fry EF, Lenert LA: MASCAL: RFID tracking of patients, staff and equipment to enhance hospital response to mass casualty events. AMIA Annu Symp Proc. 2005; 2005: 261-265.

Zhao X, Rafiq A, Ding-Yu Fei RH, et al.: Integration of Information, #wireless |networks, and personal digital assistants for triage and casualty. Telemed J E Health. 2006; 12(4): 466-474.

Hrdina CM, Coleman CN, Bogucki S, et al.: The “RTR” medical response system for nuclear and radiological mass-casualty incidents: A functional TRiage-TReatment-TRansport medical response model. Prehosp Disaster Med. 2009; 24(3): 167-178.

Amram O, Schuurman N, Hedley N, et al.: A web-based model to support patient-to-hospital allocation in mass casualty incidents. J Trauma Acute Care Surg. 2012; 72(5): 1323-1328.

Yu X: MiTRE: Mixed reliability triage and evaluation game for mass casualty information system design, testing and training. Paper presented at the 33rd Annual International Conference of the IEE EMPS, Boston, MA, 2011.

Jederberg W: Issues with the integration of technical information in planning for and responding to nontraditional disasters. J Toxicol Environ Health A. 2005; 68(11-12): 877-888.

Centers for Disease Control and Prevention (CDC): Advancing the Nation's Health: A Guide for Public Health Research Needs, 2006-2015. 2006. Available at Accessed April 3, 2014.

Institute of Medicine (IOM): Research priorities in emergency preparedness and response for public health systems: A letter report. Washington, DC: The National Academies Press, 2008. Available at Accessed April 3, 2014.

Agency for Healthcare Research and Quality (AHRQ): Altered Standards of Care in Mass Casualty Events: Bioterrorism and Other Public Health Emergencies. AHRQ Publication No. 05-0043. April 2005. Agency for Healthcare Research and Quality, Rockville, MD. Available at Accessed April 3, 2014.

Ball LJ, Dworak J: Disaster in Graniteville. S C Nurse. 2005; 12(2): 1.

Devereaqux AV, Dichter JR, Christian MD, et al.: Definitive care for the critically ill during a disaster: A framework for allocation of scarce resources in mass critical care. Chest. 2008; 133: 51S-66S.

Neil PA: The ABC's of disaster response. Scand J Surg. 2005; 94(4): 259-266.



  • There are currently no refbacks.