%PDF-1.3 1 0 obj << /Type /Catalog /Outlines 2 0 R /Pages 3 0 R >> endobj 2 0 obj << /Type /Outlines /Count 0 >> endobj 3 0 obj << /Type /Pages /Kids [6 0 R 92 0 R 107 0 R 151 0 R 175 0 R 191 0 R 241 0 R 370 0 R 372 0 R ] /Count 9 /Resources << /ProcSet 4 0 R /Font << /F1 8 0 R /F2 9 0 R /F3 10 0 R /F4 11 0 R /F5 153 0 R >> /XObject << /I1 12 0 R /I2 13 0 R /I3 96 0 R /I4 156 0 R /I5 157 0 R /I6 160 0 R /I7 163 0 R /I8 164 0 R /I9 169 0 R /I10 170 0 R /I11 173 0 R /I12 174 0 R /I13 179 0 R /I14 182 0 R /I15 285 0 R >> >> /MediaBox [0.000 0.000 612.000 792.000] >> endobj 4 0 obj [/PDF /Text /ImageC ] endobj 5 0 obj << /Creator (DOMPDF) /CreationDate (D:20180721151655+00'00') /ModDate (D:20180721151655+00'00') /Title (Qualitative Analysis of Surveyed Emergency Responders and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents PLOS Currents Disasters) >> endobj 6 0 obj << /Type /Page /Parent 3 0 R /Annots [ 14 0 R 16 0 R 18 0 R 20 0 R 22 0 R 24 0 R 26 0 R 28 0 R 30 0 R 32 0 R 34 0 R 36 0 R 38 0 R 40 0 R 42 0 R 44 0 R 46 0 R 48 0 R 50 0 R 52 0 R 54 0 R 56 0 R 58 0 R 60 0 R 62 0 R 64 0 R 66 0 R 68 0 R 70 0 R 72 0 R 74 0 R 76 0 R 78 0 R 80 0 R 82 0 R 84 0 R 86 0 R 88 0 R 90 0 R ] /Contents 7 0 R >> endobj 7 0 obj << /Length 25169 >> stream q 375.000 0 0 39.000 222.000 738.000 cm /I2 Do Q q 15.000 659.406 577.500 78.594 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Qualitative Analysis of Surveyed Emergency Responders and )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(the Identified Factors That Affect First Stage of Primary )] TJ ET BT 15.000 668.146 Td /F2 21.0 Tf [(Triage Decision-Making of Mass Casualty Incidents)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 650.140 Td /F3 9.8 Tf [(August 19, 2016)] TJ ET BT 83.523 650.140 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 88.398 650.140 Td /F3 9.8 Tf [(Disasters)] TJ ET BT 26.250 638.299 Td /F1 9.8 Tf [(Kelly R. Klein)] TJ ET 0.271 0.267 0.267 rg BT 84.224 642.187 Td /F1 8.7 Tf [(1)] TJ ET BT 89.042 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 94.463 638.299 Td /F1 9.8 Tf [(Frederick M. Burkle Jr.)] TJ ET 0.271 0.267 0.267 rg BT 192.519 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 197.940 638.299 Td /F1 9.8 Tf [(Raymond Swienton)] TJ ET 0.271 0.267 0.267 rg BT 282.472 642.187 Td /F1 8.7 Tf [(2)] TJ ET BT 287.291 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 292.712 638.299 Td /F1 9.8 Tf [(Richard V. King)] TJ ET 0.271 0.267 0.267 rg BT 360.445 642.187 Td /F1 8.7 Tf [(2)] TJ ET BT 365.264 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 370.685 638.299 Td /F1 9.8 Tf [(Thomas Lehman)] TJ ET 0.271 0.267 0.267 rg BT 443.839 642.187 Td /F1 8.7 Tf [(3)] TJ ET BT 448.658 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 454.079 638.299 Td /F1 9.8 Tf [(Carol S. North)] TJ ET 0.271 0.267 0.267 rg BT 515.845 642.187 Td /F1 8.7 Tf [(4)] TJ ET BT 26.250 627.127 Td /F4 9.0 Tf [(1)] TJ ET BT 31.254 627.127 Td /F1 9.0 Tf [( UT Southwestern Medical Center at Dallas, )] TJ ET BT 208.815 627.127 Td /F4 9.0 Tf [(2)] TJ ET BT 213.819 627.127 Td /F1 9.0 Tf [( University of Texas Southwestern Medical Center, )] TJ ET BT 418.389 627.127 Td /F4 9.0 Tf [(3)] TJ ET BT 423.393 627.127 Td /F1 9.0 Tf [( NDLS Foundation, )] TJ ET BT 502.431 627.127 Td /F4 9.0 Tf [(4)] TJ ET BT 507.435 627.127 Td /F1 9.0 Tf [( The Altshler )] TJ ET BT 26.250 616.138 Td /F1 9.0 Tf [(Center for Education & Research at Metrocare Services and The University of Texas Southwestern Medical Center, Department of )] TJ ET BT 26.250 605.149 Td /F1 9.0 Tf [(Psychiatry)] TJ ET BT 26.250 593.427 Td /F1 9.8 Tf [(Klein KR, Burkle Jr. FM, Swienton R, King RV, Lehman T, North CS. Qualitative Analysis of Surveyed Emergency Responders )] TJ ET BT 26.250 581.523 Td /F1 9.8 Tf [(and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents. PLOS )] TJ ET BT 26.250 569.618 Td /F1 9.8 Tf [(Currents Disasters. 2016 Aug 19 . Edition 1. doi: 10.1371/currents.dis.d69dafcfb3ad8be88b3e655bd38fba84.)] TJ ET q 15.000 29.829 577.500 537.408 re W n 0.271 0.267 0.267 rg BT 26.250 540.515 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 520.561 Td /F1 9.8 Tf [(Introduction: After all large-scale disasters multiple papers are published describing the shortcomings of the triage methods )] TJ ET BT 26.250 508.656 Td /F1 9.8 Tf [(utilized. This paper uses medical provider input to help describe attributes and patient characteristics that impact triage )] TJ ET BT 26.250 496.752 Td /F1 9.8 Tf [(decisions.)] TJ ET BT 26.250 477.347 Td /F1 9.8 Tf [(Methods: A survey distributed electronically to medical providers with and without disaster experience. Questions asked )] TJ ET BT 26.250 465.442 Td /F1 9.8 Tf [(included what disaster experiences they had, and to rank six attributes in order of importance regarding triage.)] TJ ET BT 26.250 446.037 Td /F1 9.8 Tf [(Results: 403 unique completed surveys were analyzed. 92% practiced a structural triage approach with the rest reporting they )] TJ ET BT 26.250 434.133 Td /F1 9.8 Tf [(used gestalt.\(gut feeling\) Twelve per cent were identified as having placed patients in an expectant category during triage. )] TJ ET BT 26.250 422.228 Td /F1 9.8 Tf [(Respiratory status, ability to speak, perfusion/pulse were all ranked in the top three. Gut feeling regardless of statistical analysis )] TJ ET BT 26.250 410.323 Td /F1 9.8 Tf [(was fourth. Supplies were ranked in the top four when analyzed for those who had placed patients in the expectant category.)] TJ ET BT 26.250 390.918 Td /F1 9.8 Tf [(Conclusion: Primary triage decisions in a mass casualty scenario are multifactorial and encompass patient mobility, life saving )] TJ ET BT 26.250 379.014 Td /F1 9.8 Tf [(interventions, situational instincts, and logistics.)] TJ ET BT 26.250 342.411 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 322.457 Td /F1 9.8 Tf [(The authors received no specific funding for this work.)] TJ ET BT 26.250 293.354 Td /F4 12.0 Tf [(INTRODUCTION)] TJ ET BT 26.250 273.400 Td /F1 9.8 Tf [(A mass casualty incident \(MCI\) is defined as an event which generates more patients at one time than locally available )] TJ ET BT 26.250 261.495 Td /F1 9.8 Tf [(resources can manage using routine procedures.)] TJ ET 0.267 0.267 0.267 rg BT 238.137 263.003 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 242.956 261.495 Td /F1 9.8 Tf [( The goal of triage systems, protocols and algorithms, at every level of care, )] TJ ET BT 26.250 249.591 Td /F1 9.8 Tf [(is to ensure the best possible opportunity for survival of all the victims served. Advancements within emergency medical )] TJ ET BT 26.250 237.686 Td /F1 9.8 Tf [(services \(EMS\) have had considerable impact on the manner in which MCIs are triaged and initially managed.)] TJ ET BT 26.250 218.281 Td /F1 9.8 Tf [(Primary triage occurs at the first contact with the EMS medical personnel at which point victims are assigned an acuity level )] TJ ET BT 26.250 206.376 Td /F1 9.8 Tf [(based on injury severity. Secondary triage, or a reevaluation of the victims condition after initial medical care, may also occur at )] TJ ET BT 26.250 194.472 Td /F1 9.8 Tf [(the scene of the MCI following EMS interventions or during transport to an emergency department or secondary collection )] TJ ET BT 26.250 182.567 Td /F1 9.8 Tf [(station.)] TJ ET 0.267 0.267 0.267 rg BT 57.684 184.074 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 62.503 182.567 Td /F1 9.8 Tf [( The decision-making processes involved in primary triage and patient hospital distribution are influenced by both )] TJ ET BT 26.250 170.662 Td /F1 9.8 Tf [(reactive \(ad hoc\) and proactive \(based on situational awareness\) factors.)] TJ ET 0.267 0.267 0.267 rg BT 340.551 172.169 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 345.370 170.662 Td /F1 9.8 Tf [( An ideal triage protocol system would result in )] TJ ET BT 26.250 158.757 Td /F1 9.8 Tf [(minimal under-triage or patients classified less acute than what they really are, and over-triage, which has been shown to )] TJ ET BT 26.250 146.853 Td /F1 9.8 Tf [(increase mortality as more people are labeled as a higher acuity than they really are.)] TJ ET BT 26.250 127.448 Td /F1 9.8 Tf [(To date, no single triage tool algorithm can demonstrate sufficient scientific evidence to justify national adoption. In 2006 the )] TJ ET BT 26.250 115.543 Td /F1 9.8 Tf [(National Association of EMS Physicians \(NAEMSP\) and the Centers for Disease Control and Prevention \(CDC\) funded the )] TJ ET BT 26.250 103.638 Td /F1 9.8 Tf [(SALT workgroup. The goal was to exam published triage systems and make recommendations based on available science for )] TJ ET BT 26.250 91.734 Td /F1 9.8 Tf [(the adoption of one standard mass casualty triage system. The initial result of the workgroup effort showed that there was no )] TJ ET BT 26.250 79.829 Td /F1 9.8 Tf [(published triage system that could be adopted. Secondary outcomes were two fold; the first was the development a new triage )] TJ ET BT 26.250 67.924 Td /F1 9.8 Tf [(system, the Sort-Assess-Lifesaving Interventions-Treatment/Triage \(SALT\). This a non-proprietary free system developed from )] TJ ET BT 26.250 56.019 Td /F1 9.8 Tf [(available research, with widely accepted best practices of existing mass triage systems, and consensus opinion from the )] TJ ET BT 26.250 44.115 Td /F1 9.8 Tf [(workgroup. The second outcome, because of resistance from local, state and federal agencies to change current triage )] TJ ET Q q 15.000 659.406 577.500 78.594 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Qualitative Analysis of Surveyed Emergency Responders and )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(the Identified Factors That Affect First Stage of Primary )] TJ ET BT 15.000 668.146 Td /F2 21.0 Tf [(Triage Decision-Making of Mass Casualty Incidents)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 650.140 Td /F3 9.8 Tf [(August 19, 2016)] TJ ET BT 83.523 650.140 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 88.398 650.140 Td /F3 9.8 Tf [(Disasters)] TJ ET BT 26.250 638.299 Td /F1 9.8 Tf [(Kelly R. Klein)] TJ ET 0.271 0.267 0.267 rg BT 84.224 642.187 Td /F1 8.7 Tf [(1)] TJ ET BT 89.042 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 94.463 638.299 Td /F1 9.8 Tf [(Frederick M. Burkle Jr.)] TJ ET 0.271 0.267 0.267 rg BT 192.519 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 197.940 638.299 Td /F1 9.8 Tf [(Raymond Swienton)] TJ ET 0.271 0.267 0.267 rg BT 282.472 642.187 Td /F1 8.7 Tf [(2)] TJ ET BT 287.291 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 292.712 638.299 Td /F1 9.8 Tf [(Richard V. King)] TJ ET 0.271 0.267 0.267 rg BT 360.445 642.187 Td /F1 8.7 Tf [(2)] TJ ET BT 365.264 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 370.685 638.299 Td /F1 9.8 Tf [(Thomas Lehman)] TJ ET 0.271 0.267 0.267 rg BT 443.839 642.187 Td /F1 8.7 Tf [(3)] TJ ET BT 448.658 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 454.079 638.299 Td /F1 9.8 Tf [(Carol S. North)] TJ ET 0.271 0.267 0.267 rg BT 515.845 642.187 Td /F1 8.7 Tf [(4)] TJ ET BT 26.250 627.127 Td /F4 9.0 Tf [(1)] TJ ET BT 31.254 627.127 Td /F1 9.0 Tf [( UT Southwestern Medical Center at Dallas, )] TJ ET BT 208.815 627.127 Td /F4 9.0 Tf [(2)] TJ ET BT 213.819 627.127 Td /F1 9.0 Tf [( University of Texas Southwestern Medical Center, )] TJ ET BT 418.389 627.127 Td /F4 9.0 Tf [(3)] TJ ET BT 423.393 627.127 Td /F1 9.0 Tf [( NDLS Foundation, )] TJ ET BT 502.431 627.127 Td /F4 9.0 Tf [(4)] TJ ET BT 507.435 627.127 Td /F1 9.0 Tf [( The Altshler )] TJ ET BT 26.250 616.138 Td /F1 9.0 Tf [(Center for Education & Research at Metrocare Services and The University of Texas Southwestern Medical Center, Department of )] TJ ET BT 26.250 605.149 Td /F1 9.0 Tf [(Psychiatry)] TJ ET BT 26.250 593.427 Td /F1 9.8 Tf [(Klein KR, Burkle Jr. FM, Swienton R, King RV, Lehman T, North CS. Qualitative Analysis of Surveyed Emergency Responders )] TJ ET BT 26.250 581.523 Td /F1 9.8 Tf [(and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents. PLOS )] TJ ET BT 26.250 569.618 Td /F1 9.8 Tf [(Currents Disasters. 2016 Aug 19 . Edition 1. doi: 10.1371/currents.dis.d69dafcfb3ad8be88b3e655bd38fba84.)] TJ ET q 15.000 29.829 577.500 537.408 re W n 0.271 0.267 0.267 rg BT 26.250 540.515 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 520.561 Td /F1 9.8 Tf [(Introduction: After all large-scale disasters multiple papers are published describing the shortcomings of the triage methods )] TJ ET BT 26.250 508.656 Td /F1 9.8 Tf [(utilized. This paper uses medical provider input to help describe attributes and patient characteristics that impact triage )] TJ ET BT 26.250 496.752 Td /F1 9.8 Tf [(decisions.)] TJ ET BT 26.250 477.347 Td /F1 9.8 Tf [(Methods: A survey distributed electronically to medical providers with and without disaster experience. Questions asked )] TJ ET BT 26.250 465.442 Td /F1 9.8 Tf [(included what disaster experiences they had, and to rank six attributes in order of importance regarding triage.)] TJ ET BT 26.250 446.037 Td /F1 9.8 Tf [(Results: 403 unique completed surveys were analyzed. 92% practiced a structural triage approach with the rest reporting they )] TJ ET BT 26.250 434.133 Td /F1 9.8 Tf [(used gestalt.\(gut feeling\) Twelve per cent were identified as having placed patients in an expectant category during triage. )] TJ ET BT 26.250 422.228 Td /F1 9.8 Tf [(Respiratory status, ability to speak, perfusion/pulse were all ranked in the top three. Gut feeling regardless of statistical analysis )] TJ ET BT 26.250 410.323 Td /F1 9.8 Tf [(was fourth. Supplies were ranked in the top four when analyzed for those who had placed patients in the expectant category.)] TJ ET BT 26.250 390.918 Td /F1 9.8 Tf [(Conclusion: Primary triage decisions in a mass casualty scenario are multifactorial and encompass patient mobility, life saving )] TJ ET BT 26.250 379.014 Td /F1 9.8 Tf [(interventions, situational instincts, and logistics.)] TJ ET BT 26.250 342.411 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 322.457 Td /F1 9.8 Tf [(The authors received no specific funding for this work.)] TJ ET BT 26.250 293.354 Td /F4 12.0 Tf [(INTRODUCTION)] TJ ET BT 26.250 273.400 Td /F1 9.8 Tf [(A mass casualty incident \(MCI\) is defined as an event which generates more patients at one time than locally available )] TJ ET BT 26.250 261.495 Td /F1 9.8 Tf [(resources can manage using routine procedures.)] TJ ET 0.267 0.267 0.267 rg BT 238.137 263.003 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 242.956 261.495 Td /F1 9.8 Tf [( The goal of triage systems, protocols and algorithms, at every level of care, )] TJ ET BT 26.250 249.591 Td /F1 9.8 Tf [(is to ensure the best possible opportunity for survival of all the victims served. Advancements within emergency medical )] TJ ET BT 26.250 237.686 Td /F1 9.8 Tf [(services \(EMS\) have had considerable impact on the manner in which MCIs are triaged and initially managed.)] TJ ET BT 26.250 218.281 Td /F1 9.8 Tf [(Primary triage occurs at the first contact with the EMS medical personnel at which point victims are assigned an acuity level )] TJ ET BT 26.250 206.376 Td /F1 9.8 Tf [(based on injury severity. Secondary triage, or a reevaluation of the victims condition after initial medical care, may also occur at )] TJ ET BT 26.250 194.472 Td /F1 9.8 Tf [(the scene of the MCI following EMS interventions or during transport to an emergency department or secondary collection )] TJ ET BT 26.250 182.567 Td /F1 9.8 Tf [(station.)] TJ ET 0.267 0.267 0.267 rg BT 57.684 184.074 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 62.503 182.567 Td /F1 9.8 Tf [( The decision-making processes involved in primary triage and patient hospital distribution are influenced by both )] TJ ET BT 26.250 170.662 Td /F1 9.8 Tf [(reactive \(ad hoc\) and proactive \(based on situational awareness\) factors.)] TJ ET 0.267 0.267 0.267 rg BT 340.551 172.169 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 345.370 170.662 Td /F1 9.8 Tf [( An ideal triage protocol system would result in )] TJ ET BT 26.250 158.757 Td /F1 9.8 Tf [(minimal under-triage or patients classified less acute than what they really are, and over-triage, which has been shown to )] TJ ET BT 26.250 146.853 Td /F1 9.8 Tf [(increase mortality as more people are labeled as a higher acuity than they really are.)] TJ ET BT 26.250 127.448 Td /F1 9.8 Tf [(To date, no single triage tool algorithm can demonstrate sufficient scientific evidence to justify national adoption. In 2006 the )] TJ ET BT 26.250 115.543 Td /F1 9.8 Tf [(National Association of EMS Physicians \(NAEMSP\) and the Centers for Disease Control and Prevention \(CDC\) funded the )] TJ ET BT 26.250 103.638 Td /F1 9.8 Tf [(SALT workgroup. The goal was to exam published triage systems and make recommendations based on available science for )] TJ ET BT 26.250 91.734 Td /F1 9.8 Tf [(the adoption of one standard mass casualty triage system. The initial result of the workgroup effort showed that there was no )] TJ ET BT 26.250 79.829 Td /F1 9.8 Tf [(published triage system that could be adopted. Secondary outcomes were two fold; the first was the development a new triage )] TJ ET BT 26.250 67.924 Td /F1 9.8 Tf [(system, the Sort-Assess-Lifesaving Interventions-Treatment/Triage \(SALT\). This a non-proprietary free system developed from )] TJ ET BT 26.250 56.019 Td /F1 9.8 Tf [(available research, with widely accepted best practices of existing mass triage systems, and consensus opinion from the )] TJ ET BT 26.250 44.115 Td /F1 9.8 Tf [(workgroup. The second outcome, because of resistance from local, state and federal agencies to change current triage )] TJ ET Q q 15.000 659.406 577.500 78.594 re W n 0.267 0.267 0.267 rg BT 15.000 718.042 Td /F2 21.0 Tf [(Qualitative Analysis of Surveyed Emergency Responders and )] TJ ET BT 15.000 693.094 Td /F2 21.0 Tf [(the Identified Factors That Affect First Stage of Primary )] TJ ET BT 15.000 668.146 Td /F2 21.0 Tf [(Triage Decision-Making of Mass Casualty Incidents)] TJ ET Q 0.271 0.267 0.267 rg BT 15.000 650.140 Td /F3 9.8 Tf [(August 19, 2016)] TJ ET BT 83.523 650.140 Td /F3 9.8 Tf [()] TJ ET 0.267 0.267 0.267 rg BT 88.398 650.140 Td /F3 9.8 Tf [(Disasters)] TJ ET BT 26.250 638.299 Td /F1 9.8 Tf [(Kelly R. Klein)] TJ ET 0.271 0.267 0.267 rg BT 84.224 642.187 Td /F1 8.7 Tf [(1)] TJ ET BT 89.042 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 94.463 638.299 Td /F1 9.8 Tf [(Frederick M. Burkle Jr.)] TJ ET 0.271 0.267 0.267 rg BT 192.519 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 197.940 638.299 Td /F1 9.8 Tf [(Raymond Swienton)] TJ ET 0.271 0.267 0.267 rg BT 282.472 642.187 Td /F1 8.7 Tf [(2)] TJ ET BT 287.291 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 292.712 638.299 Td /F1 9.8 Tf [(Richard V. King)] TJ ET 0.271 0.267 0.267 rg BT 360.445 642.187 Td /F1 8.7 Tf [(2)] TJ ET BT 365.264 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 370.685 638.299 Td /F1 9.8 Tf [(Thomas Lehman)] TJ ET 0.271 0.267 0.267 rg BT 443.839 642.187 Td /F1 8.7 Tf [(3)] TJ ET BT 448.658 638.299 Td /F1 9.8 Tf [(, )] TJ ET 0.267 0.267 0.267 rg BT 454.079 638.299 Td /F1 9.8 Tf [(Carol S. North)] TJ ET 0.271 0.267 0.267 rg BT 515.845 642.187 Td /F1 8.7 Tf [(4)] TJ ET BT 26.250 627.127 Td /F4 9.0 Tf [(1)] TJ ET BT 31.254 627.127 Td /F1 9.0 Tf [( UT Southwestern Medical Center at Dallas, )] TJ ET BT 208.815 627.127 Td /F4 9.0 Tf [(2)] TJ ET BT 213.819 627.127 Td /F1 9.0 Tf [( University of Texas Southwestern Medical Center, )] TJ ET BT 418.389 627.127 Td /F4 9.0 Tf [(3)] TJ ET BT 423.393 627.127 Td /F1 9.0 Tf [( NDLS Foundation, )] TJ ET BT 502.431 627.127 Td /F4 9.0 Tf [(4)] TJ ET BT 507.435 627.127 Td /F1 9.0 Tf [( The Altshler )] TJ ET BT 26.250 616.138 Td /F1 9.0 Tf [(Center for Education & Research at Metrocare Services and The University of Texas Southwestern Medical Center, Department of )] TJ ET BT 26.250 605.149 Td /F1 9.0 Tf [(Psychiatry)] TJ ET BT 26.250 593.427 Td /F1 9.8 Tf [(Klein KR, Burkle Jr. FM, Swienton R, King RV, Lehman T, North CS. Qualitative Analysis of Surveyed Emergency Responders )] TJ ET BT 26.250 581.523 Td /F1 9.8 Tf [(and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents. PLOS )] TJ ET BT 26.250 569.618 Td /F1 9.8 Tf [(Currents Disasters. 2016 Aug 19 . Edition 1. doi: 10.1371/currents.dis.d69dafcfb3ad8be88b3e655bd38fba84.)] TJ ET q 15.000 29.829 577.500 537.408 re W n 0.271 0.267 0.267 rg BT 26.250 540.515 Td /F4 12.0 Tf [(Abstract)] TJ ET BT 26.250 520.561 Td /F1 9.8 Tf [(Introduction: After all large-scale disasters multiple papers are published describing the shortcomings of the triage methods )] TJ ET BT 26.250 508.656 Td /F1 9.8 Tf [(utilized. This paper uses medical provider input to help describe attributes and patient characteristics that impact triage )] TJ ET BT 26.250 496.752 Td /F1 9.8 Tf [(decisions.)] TJ ET BT 26.250 477.347 Td /F1 9.8 Tf [(Methods: A survey distributed electronically to medical providers with and without disaster experience. Questions asked )] TJ ET BT 26.250 465.442 Td /F1 9.8 Tf [(included what disaster experiences they had, and to rank six attributes in order of importance regarding triage.)] TJ ET BT 26.250 446.037 Td /F1 9.8 Tf [(Results: 403 unique completed surveys were analyzed. 92% practiced a structural triage approach with the rest reporting they )] TJ ET BT 26.250 434.133 Td /F1 9.8 Tf [(used gestalt.\(gut feeling\) Twelve per cent were identified as having placed patients in an expectant category during triage. )] TJ ET BT 26.250 422.228 Td /F1 9.8 Tf [(Respiratory status, ability to speak, perfusion/pulse were all ranked in the top three. Gut feeling regardless of statistical analysis )] TJ ET BT 26.250 410.323 Td /F1 9.8 Tf [(was fourth. Supplies were ranked in the top four when analyzed for those who had placed patients in the expectant category.)] TJ ET BT 26.250 390.918 Td /F1 9.8 Tf [(Conclusion: Primary triage decisions in a mass casualty scenario are multifactorial and encompass patient mobility, life saving )] TJ ET BT 26.250 379.014 Td /F1 9.8 Tf [(interventions, situational instincts, and logistics.)] TJ ET BT 26.250 342.411 Td /F4 12.0 Tf [(Funding Statement)] TJ ET BT 26.250 322.457 Td /F1 9.8 Tf [(The authors received no specific funding for this work.)] TJ ET BT 26.250 293.354 Td /F4 12.0 Tf [(INTRODUCTION)] TJ ET BT 26.250 273.400 Td /F1 9.8 Tf [(A mass casualty incident \(MCI\) is defined as an event which generates more patients at one time than locally available )] TJ ET BT 26.250 261.495 Td /F1 9.8 Tf [(resources can manage using routine procedures.)] TJ ET 0.267 0.267 0.267 rg BT 238.137 263.003 Td /F4 8.7 Tf [(1)] TJ ET 0.271 0.267 0.267 rg BT 242.956 261.495 Td /F1 9.8 Tf [( The goal of triage systems, protocols and algorithms, at every level of care, )] TJ ET BT 26.250 249.591 Td /F1 9.8 Tf [(is to ensure the best possible opportunity for survival of all the victims served. Advancements within emergency medical )] TJ ET BT 26.250 237.686 Td /F1 9.8 Tf [(services \(EMS\) have had considerable impact on the manner in which MCIs are triaged and initially managed.)] TJ ET BT 26.250 218.281 Td /F1 9.8 Tf [(Primary triage occurs at the first contact with the EMS medical personnel at which point victims are assigned an acuity level )] TJ ET BT 26.250 206.376 Td /F1 9.8 Tf [(based on injury severity. Secondary triage, or a reevaluation of the victims condition after initial medical care, may also occur at )] TJ ET BT 26.250 194.472 Td /F1 9.8 Tf [(the scene of the MCI following EMS interventions or during transport to an emergency department or secondary collection )] TJ ET BT 26.250 182.567 Td /F1 9.8 Tf [(station.)] TJ ET 0.267 0.267 0.267 rg BT 57.684 184.074 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 62.503 182.567 Td /F1 9.8 Tf [( The decision-making processes involved in primary triage and patient hospital distribution are influenced by both )] TJ ET BT 26.250 170.662 Td /F1 9.8 Tf [(reactive \(ad hoc\) and proactive \(based on situational awareness\) factors.)] TJ ET 0.267 0.267 0.267 rg BT 340.551 172.169 Td /F4 8.7 Tf [(2)] TJ ET 0.271 0.267 0.267 rg BT 345.370 170.662 Td /F1 9.8 Tf [( An ideal triage protocol system would result in )] TJ ET BT 26.250 158.757 Td /F1 9.8 Tf [(minimal under-triage or patients classified less acute than what they really are, and over-triage, which has been shown to )] TJ ET BT 26.250 146.853 Td /F1 9.8 Tf [(increase mortality as more people are labeled as a higher acuity than they really are.)] TJ ET BT 26.250 127.448 Td /F1 9.8 Tf [(To date, no single triage tool algorithm can demonstrate sufficient scientific evidence to justify national adoption. In 2006 the )] TJ ET BT 26.250 115.543 Td /F1 9.8 Tf [(National Association of EMS Physicians \(NAEMSP\) and the Centers for Disease Control and Prevention \(CDC\) funded the )] TJ ET BT 26.250 103.638 Td /F1 9.8 Tf [(SALT workgroup. The goal was to exam published triage systems and make recommendations based on available science for )] TJ ET BT 26.250 91.734 Td /F1 9.8 Tf [(the adoption of one standard mass casualty triage system. The initial result of the workgroup effort showed that there was no )] TJ ET BT 26.250 79.829 Td /F1 9.8 Tf [(published triage system that could be adopted. Secondary outcomes were two fold; the first was the development a new triage )] TJ ET BT 26.250 67.924 Td /F1 9.8 Tf [(system, the Sort-Assess-Lifesaving Interventions-Treatment/Triage \(SALT\). This a non-proprietary free system developed from )] TJ ET BT 26.250 56.019 Td /F1 9.8 Tf [(available research, with widely accepted best practices of existing mass triage systems, and consensus opinion from the )] TJ ET BT 26.250 44.115 Td /F1 9.8 Tf [(workgroup. The second outcome, because of resistance from local, state and federal agencies to change current triage )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(1)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 8 0 obj << /Type /Font /Subtype /Type1 /Name /F1 /BaseFont /Helvetica /Encoding /WinAnsiEncoding >> endobj 9 0 obj << /Type /Font /Subtype /Type1 /Name /F2 /BaseFont /Times-Bold /Encoding /WinAnsiEncoding >> endobj 10 0 obj << /Type /Font /Subtype /Type1 /Name /F3 /BaseFont /Times-Italic /Encoding /WinAnsiEncoding >> endobj 11 0 obj << /Type /Font /Subtype /Type1 /Name /F4 /BaseFont /Helvetica-Bold /Encoding /WinAnsiEncoding >> endobj 12 0 obj << /Type /XObject /Subtype /Image /Width 500 /Height 52 /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 1 /Columns 500 /BitsPerComponent 8>> /ColorSpace /DeviceGray /BitsPerComponent 8 /Length 144>> stream x1 0 'ݲ؎"e{dzAdzAdzAdzAdzAdzAdzAdzAdzAdzAdzAdzAtlM0\ endstream endobj 13 0 obj << /Type /XObject /Subtype /Image /Width 500 /Height 52 /SMask 12 0 R /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 3 /Columns 500 /BitsPerComponent 8>> /ColorSpace /DeviceRGB /BitsPerComponent 8 /Length 3627>> stream x?b!/w N BU!@rܥ>L%|"ɾeB~qbϧG0 0 0 ü<,a ,a ,a /)܋( daKnW>'IR2 0x1ͽ{0 Z4= 4M޶mY}'IĖ2 0ָML}GQ48Iy>i("u>s6ne0 YfB;S}b 5ba,ZP՚ћuFڶ= 0{ǤbA!>m{wwW׵ApssDZdU,K:fs_׿___qykQbfMii{$̂>}JdB um{Lh'پy2c\ifZypE|,Uݝ,h4ڶ],R*\U-rQ9l PUUQ#G80aef_-mI*gߋlil-d:5ec]RUa0\ͼ$ ֌8jE%4BH\m=ϣfY )!vDL^)4axt=3*E<' _?>>.7DYt]׆0gqwр,ajmۢ(HMB$ [ U5;gfw`2R]u]GQD0g[Tt:a1J#,AU}0hwb>&8V~*ȀIH fuiah aMl7\:\>|,L5w(YqOFsoBy|<3^=6.ym۾%)~`XHnݰ‹IDs'oZ7In}wV|C%H{lDsDQ6]4jcЊͭ;*ٶv&A.09e(ji2btXɄy4?!ZEI"+Yɲy%'hZch@C+q,U1TA+FEe_R18;z.􃰢c ( H| $I.hy {ss&` 26:#(RuGQmZtJӅ˲csоj$}3#rl& j }>  ]x] ъ|G[1lfu ϛIaVz0-mvy2h܉ေA^XD`b"W#ֵU{(Y BAaDL]z_ex6 (nMOÈ%֐m`04Ԝ0aℓ.*"^=KeY~-'iM``v,Z꺞fRf1c+! 85BX,HeEљ @N^ԚG`5p |!L]U).?"l5eFQŞu]ɍK'eW/o҆&(i VM_ = E/J,;sqq0 W>rM=gdќ陞qѼ:2X;.˲j#Ņ뺮fbi\ו.u݋1mgXEQꋋ q@P%~VL0%b`eF4M}'@Sp8v;FߊdY]@u[5 (96 V0~1Gj Ňg֏= >\'ͪ$yX`!dhq%I0fF5x]t,hRˮb"3鈰@'5ؽE2>GI@ KȲLrÿ*1ȰT5ffܱYjuqqC3v(uEsI'c^چ#X,hAk"ZH6`XPW,>}fY6t^C8,Fi#nica Jzlf0 >سX,)m_Bs' c oN c>TT'%x&ߘ fi$W܇g[@ mDZ7]:RQjƘ.ğ$:؝, s{HzxqZKmF|Ϗ~p7@ {1$Xu}p(ĉzZaJ%i&0L@#\}GaT~tTQ,asEOxhy.?,aC9oqE=MS9I%8~WmdG:agO\\$,yHg^Ab%Ĩ7Z}џd2!YmN0X-#*ڈ/&W4MAYT?3;f udJ 6%ag9IxINlȦ|[+ ٘{R0' uT?NP%A wD&1=4L&ĵg-G)+0*V} 62T75yiۣrѰڳ>$'?B'IeY0K1WH]NkiR m<˭XF.xaijT==}~&;ہHA7| \( s\? ~_{ޒ{ O?^AVtї~g~~mVfS XtU6wMUv8|xxG-ü[A܆m!g۾勜*N5,sP=0 cibCub=2xa? 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As of 2011, 15 of the 24 MUCC essential elements are being )] TJ ET BT 26.250 62.716 Td /F1 9.8 Tf [(used by existing triage systems; SALT is totally compliant with all 24 criteria.)] TJ ET 0.267 0.267 0.267 rg BT 354.611 64.223 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 26.250 43.311 Td /F1 9.8 Tf [(In recognition that current classification systems may not be accurate enough or properly mitigate subjectivity, several studies )] TJ ET Q q 15.000 29.026 577.500 747.974 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(practices which, would allow interoperability among existing triage tool algorithms, the SALT workgroup, developed the Model )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(Uniform Core Criteria \(MUCC\) for Mass Casualty Triage. The MUCC consists of 24 criteria of recommended elements of a MCI )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(triage system \(Table 1\).)] TJ ET 0.965 0.965 0.965 rg 26.250 103.549 555.000 630.236 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 733.786 m 581.250 733.786 l 581.250 733.036 l 26.250 733.036 l f 26.250 103.549 m 581.250 103.549 l 581.250 104.299 l 26.250 104.299 l f q 450.000 0 0 582.000 35.250 142.036 cm /I3 Do Q q 35.250 114.799 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 125.047 Td /F4 9.8 Tf [(Table 1: Model Uniform Core Criteria for Mass Casualty \(MUCC\) triage)] TJ ET Q BT 26.250 86.526 Td /F1 9.8 Tf [(The criteria, if adopted into existing triage systems, would allow more for uniformity and interoperability between EMS )] TJ ET BT 26.250 74.621 Td /F1 9.8 Tf [(responders from different jurisdictions upon arrival at an MCI site. As of 2011, 15 of the 24 MUCC essential elements are being )] TJ ET BT 26.250 62.716 Td /F1 9.8 Tf [(used by existing triage systems; SALT is totally compliant with all 24 criteria.)] TJ ET 0.267 0.267 0.267 rg BT 354.611 64.223 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 26.250 43.311 Td /F1 9.8 Tf [(In recognition that current classification systems may not be accurate enough or properly mitigate subjectivity, several studies )] TJ ET Q q 15.000 29.026 577.500 747.974 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(practices which, would allow interoperability among existing triage tool algorithms, the SALT workgroup, developed the Model )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(Uniform Core Criteria \(MUCC\) for Mass Casualty Triage. The MUCC consists of 24 criteria of recommended elements of a MCI )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(triage system \(Table 1\).)] TJ ET 0.965 0.965 0.965 rg 26.250 103.549 555.000 630.236 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 733.786 m 581.250 733.786 l 581.250 733.036 l 26.250 733.036 l f 26.250 103.549 m 581.250 103.549 l 581.250 104.299 l 26.250 104.299 l f q 450.000 0 0 582.000 35.250 142.036 cm /I3 Do Q q 35.250 114.799 537.000 21.236 re W n 0.271 0.267 0.267 rg BT 35.250 125.047 Td /F4 9.8 Tf [(Table 1: Model Uniform Core Criteria for Mass Casualty \(MUCC\) triage)] TJ ET Q BT 26.250 86.526 Td /F1 9.8 Tf [(The criteria, if adopted into existing triage systems, would allow more for uniformity and interoperability between EMS )] TJ ET BT 26.250 74.621 Td /F1 9.8 Tf [(responders from different jurisdictions upon arrival at an MCI site. As of 2011, 15 of the 24 MUCC essential elements are being )] TJ ET BT 26.250 62.716 Td /F1 9.8 Tf [(used by existing triage systems; SALT is totally compliant with all 24 criteria.)] TJ ET 0.267 0.267 0.267 rg BT 354.611 64.223 Td /F4 8.7 Tf [(3)] TJ ET 0.271 0.267 0.267 rg BT 26.250 43.311 Td /F1 9.8 Tf [(In recognition that current classification systems may not be accurate enough or properly mitigate subjectivity, several studies )] TJ ET Q q 450.000 0 0 582.000 35.250 142.036 cm /I3 Do Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(2)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 94 0 obj << /Type /Annot /Subtype /Link /A 95 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 142.0358 485.2500 724.0358 ] >> endobj 95 0 obj << /Type /Action /S /URI /URI (https://currents.plos.org/disasters/files/2016/04/Table-1-5.jpg) >> endobj 96 0 obj << /Type /XObject /Subtype /Image /Width 600 /Height 776 /ColorSpace /DeviceRGB /Filter /DCTDecode /BitsPerComponent 8 /Length 204877>> stream JFIF``;CREATOR: gd-jpeg v1.0 (using IJG JPEG v80), quality = 90 C     C   X" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?R1F( Q(b(1F( Q(b(1F( Q(b(1F( Q(b(1F( Q(b(1F( Q(b(1F( Q(b(1F( Q(b(1F( Q(b(1EPEQRdQ@ E&EQ&A"Z)2(-dPIQhhN(hȣ"L7 Z)21FE-dZ)2(BE-dPIFE-Q@ E&ERdPH"@ E&ERdQ@ E&EQPERq@ EQRqKRQ@ E&E/QGRdR@qGQGq@qGQGq@qGQGPGj( O躏4tfrд74+H:2䃍G7!: JAlKK}dc$- ϙwmKFEY4{0!AaP L;xU-5Ko I喋SV6 V=w/'$.xtgin--5K]bn-mΊːF7^jkݔ76w:4~6qĩ m]|o nM=4{ž;־#+a_[Cwl6Z6VtIQ Cd\^y5_nj>|ׯi|a殷0Z>axUWb Z/|+xvo3lҙ'%L1rA]1\=Ÿ 4WV Yxb[ =dco0] ke@ih/'Mk5VZ;7mܪ#lgY|mC\]BP/z`!id]Yyq\ ϰjZ7/#4ևci׶2\Z+:y{ULս_K{Pҥ{fvԮWyc!x8i|Z)SIeP%7c[NnC 4nPrQgoM։ivNmR@ -3 R9T5>-D X,ພ Bnms-\[9)'yrbv炵?<y9N\!F\(v?1BZPmPy7XbSOK˸mSbE*5͹dÜ_#%έi|o}JeVOssTE .=hPvfHgD1DJЪʸ{W 0xv_Zz :-vF)Qa-݅!|ZOF>$|5BKy%.C$n_B*ݶC{iW?.qo|IrUKR#(#<»g&w¾!<"֮-M.l$MȂP8ߜ@&IAT'|jB1$$8-[ּA_[EGJ:, s2)ٌڇ0a+=xW$cU˿ \OLeR3B8'98 ^# s3w+ۀgAeI.«WÖmԗiom&W2J|2O͸Dօ_d&v_ky6-1ݍ8:e =A"x|{6?Ve#kw.#A2i9Wf0C puqI\՚7l,ͬ)m<31$$T#_j:o57wpb)./oHOEIX+Jծ53&I[`HRb߽ !P\('[F=D.te`'FD&GI$uVnjYK( EK9#E2X-4,.ntRi[V9QBt)q9Ӿ|+ľM6zΟtų$Z e;FY@*AR<|e׼kibD4o=]fhcĊL79#\g5UhQyb[}>$_6"FyTaEb+1;UÚvWc`[R_:k& "Q$>QV ;Fo.MokG4=ܶܲ3Jҫ.(傅u^$VgkzF֮n/ Xےg#Ēxq]/! 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45.750 289.372 Td /F1 9.8 Tf [(Triage system used in both non-disaster and disaster practice \(ESI, CDP-Noble, MASS, SAVE, START, SALT, STM )] TJ ET BT 45.750 277.467 Td /F1 9.8 Tf [(informal gut feeling, or other\))] TJ ET 40.337 264.780 m 40.337 265.227 40.154 265.671 39.838 265.987 c 39.522 266.303 39.078 266.487 38.631 266.487 c 38.185 266.487 37.741 266.303 37.425 265.987 c 37.109 265.671 36.925 265.227 36.925 264.780 c 36.925 264.334 37.109 263.890 37.425 263.574 c 37.741 263.258 38.185 263.074 38.631 263.074 c 39.078 263.074 39.522 263.258 39.838 263.574 c 40.154 263.890 40.337 264.334 40.337 264.780 c f BT 45.750 261.813 Td /F1 9.8 Tf [(Disaster triage experience \(yes/no\))] TJ ET 40.337 249.126 m 40.337 249.572 40.154 250.016 39.838 250.332 c 39.522 250.648 39.078 250.832 38.631 250.832 c 38.185 250.832 37.741 250.648 37.425 250.332 c 37.109 250.016 36.925 249.572 36.925 249.126 c 36.925 248.679 37.109 248.235 37.425 247.919 c 37.741 247.603 38.185 247.419 38.631 247.419 c 39.078 247.419 39.522 247.603 39.838 247.919 c 40.154 248.235 40.337 248.679 40.337 249.126 c f BT 45.750 246.158 Td /F1 9.8 Tf [(Experience of triaging a live patient to an expectant category \(yes/no\))] TJ ET 40.337 233.471 m 40.337 233.917 40.154 234.361 39.838 234.677 c 39.522 234.993 39.078 235.177 38.631 235.177 c 38.185 235.177 37.741 234.993 37.425 234.677 c 37.109 234.361 36.925 233.917 36.925 233.471 c 36.925 233.024 37.109 232.580 37.425 232.264 c 37.741 231.948 38.185 231.765 38.631 231.765 c 39.078 231.765 39.522 231.948 39.838 232.264 c 40.154 232.580 40.337 233.024 40.337 233.471 c f BT 45.750 230.503 Td /F1 9.8 Tf [(Specific disaster deployments if applicable)] TJ ET BT 26.250 207.348 Td /F1 9.8 Tf [(Patient attributes contributing to triage placement: Six patient and disaster attributes were to be ranked in the order of )] TJ ET BT 26.250 195.444 Td /F1 9.8 Tf [(importance to the respondent \(1-6 with 1 being the most important\); to help that would determine the preferred ranking of these )] TJ ET BT 26.250 183.539 Td /F1 9.8 Tf [(attributes by the respondent.)] TJ ET 40.337 167.102 m 40.337 167.548 40.154 167.992 39.838 168.308 c 39.522 168.624 39.078 168.808 38.631 168.808 c 38.185 168.808 37.741 168.624 37.425 168.308 c 37.109 167.992 36.925 167.548 36.925 167.102 c 36.925 166.655 37.109 166.211 37.425 165.895 c 37.741 165.579 38.185 165.396 38.631 165.396 c 39.078 165.396 39.522 165.579 39.838 165.895 c 40.154 166.211 40.337 166.655 40.337 167.102 c f BT 45.750 164.134 Td /F1 9.8 Tf [(Ability of the patient to speak to you)] TJ ET 40.337 151.447 m 40.337 151.894 40.154 152.338 39.838 152.654 c 39.522 152.969 39.078 153.153 38.631 153.153 c 38.185 153.153 37.741 152.969 37.425 152.654 c 37.109 152.338 36.925 151.894 36.925 151.447 c 36.925 151.000 37.109 150.556 37.425 150.240 c 37.741 149.925 38.185 149.741 38.631 149.741 c 39.078 149.741 39.522 149.925 39.838 150.240 c 40.154 150.556 40.337 151.000 40.337 151.447 c f BT 45.750 148.479 Td /F1 9.8 Tf [(Age)] TJ ET 40.337 135.792 m 40.337 136.239 40.154 136.683 39.838 136.999 c 39.522 137.315 39.078 137.499 38.631 137.499 c 38.185 137.499 37.741 137.315 37.425 136.999 c 37.109 136.683 36.925 136.239 36.925 135.792 c 36.925 135.346 37.109 134.902 37.425 134.586 c 37.741 134.270 38.185 134.086 38.631 134.086 c 39.078 134.086 39.522 134.270 39.838 134.586 c 40.154 134.902 40.337 135.346 40.337 135.792 c f BT 45.750 132.825 Td /F1 9.8 Tf [(Gut feeling, by the responder performing triage, of the severity of injury)] TJ ET 40.337 120.138 m 40.337 120.584 40.154 121.028 39.838 121.344 c 39.522 121.660 39.078 121.844 38.631 121.844 c 38.185 121.844 37.741 121.660 37.425 121.344 c 37.109 121.028 36.925 120.584 36.925 120.138 c 36.925 119.691 37.109 119.247 37.425 118.931 c 37.741 118.615 38.185 118.431 38.631 118.431 c 39.078 118.431 39.522 118.615 39.838 118.931 c 40.154 119.247 40.337 119.691 40.337 120.138 c f BT 45.750 117.170 Td /F1 9.8 Tf [(Perfusion-peripheral pulse)] TJ ET 40.337 104.483 m 40.337 104.929 40.154 105.373 39.838 105.689 c 39.522 106.005 39.078 106.189 38.631 106.189 c 38.185 106.189 37.741 106.005 37.425 105.689 c 37.109 105.373 36.925 104.929 36.925 104.483 c 36.925 104.036 37.109 103.592 37.425 103.276 c 37.741 102.960 38.185 102.777 38.631 102.777 c 39.078 102.777 39.522 102.960 39.838 103.276 c 40.154 103.592 40.337 104.036 40.337 104.483 c f BT 45.750 101.515 Td /F1 9.8 Tf [(Respiratory status)] TJ ET 40.337 88.828 m 40.337 89.275 40.154 89.719 39.838 90.035 c 39.522 90.350 39.078 90.534 38.631 90.534 c 38.185 90.534 37.741 90.350 37.425 90.035 c 37.109 89.719 36.925 89.275 36.925 88.828 c 36.925 88.381 37.109 87.937 37.425 87.621 c 37.741 87.306 38.185 87.122 38.631 87.122 c 39.078 87.122 39.522 87.306 39.838 87.621 c 40.154 87.937 40.337 88.381 40.337 88.828 c f BT 45.750 85.860 Td /F1 9.8 Tf [(Supplies or resource availability)] TJ ET BT 26.250 62.706 Td /F1 9.8 Tf [(In addition, for those who claim prior disaster response experience, a comment box was added to allow for additional )] TJ ET BT 26.250 50.801 Td /F1 9.8 Tf [(observations to be added besides the six listed attributes and/or factors that might influence the triage priority of patients.)] TJ ET Q q 15.000 40.920 577.500 736.080 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(including those by ethicists and critical care specialists have suggested that, due to social, medical, and logistical variables, that )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(only an experienced provider or a triage team approach should be utilized during the most difficult triage decisions.)] TJ ET 0.267 0.267 0.267 rg BT 519.932 757.079 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 524.750 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 527.159 757.079 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 531.978 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 534.388 757.079 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 26.250 743.667 Td /F1 9.8 Tf [(Additionally, very few studies have satisfactorily identified, compared, and discussed the actual real time decision-making )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(criteria used by experience-rich providers, in order to create an accurate and usable prioritization algorithm for mass casualty )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(events.)] TJ ET 0.267 0.267 0.267 rg BT 57.684 721.364 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 62.503 723.745 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 64.912 721.364 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 69.731 723.745 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 72.140 721.364 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 76.959 723.745 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 79.368 721.364 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 700.452 Td /F1 9.8 Tf [(To better understand both the reactive and situational awareness factors influencing the primary triage decision-making process )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(among pre-hospital responders, both experienced and not, this study was designed to investigate and analyze those factors that )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(actual medical providers during MCIs perceived that directly and indirectly impacted and influenced how their primary triage )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(priority decisions were processed.)] TJ ET BT 26.250 628.136 Td /F4 12.0 Tf [(METHODS)] TJ ET BT 26.250 608.181 Td /F1 9.8 Tf [(To evaluate how triage decisions are initially processed, this study distributed an electronic survey to EMS and pre-hospital )] TJ ET BT 26.250 596.277 Td /F1 9.8 Tf [(medical providers to help identify and rank the factors that influence primary triage decisions made by those with and without )] TJ ET BT 26.250 584.372 Td /F1 9.8 Tf [(disaster experience. The survey questionnaire was designed by the authors, in English, to ascertain what attributes healthcare )] TJ ET BT 26.250 572.467 Td /F1 9.8 Tf [(workers value and utilize when evaluating a patient for triage and treatment priority. The initial survey was piloted with a small )] TJ ET BT 26.250 560.562 Td /F1 9.8 Tf [(sample of ten healthcare workers who work in an academically affiliated emergency department and have had previous disaster )] TJ ET BT 26.250 548.658 Td /F1 9.8 Tf [(response experience. Based upon the feedback received, the final survey instrument was revised and the modified questions )] TJ ET BT 26.250 536.753 Td /F1 9.8 Tf [(were entered into SurveyMonkey. The survey was available on-line for 2 months \(April-May 2010\). The survey was then )] TJ ET BT 26.250 524.848 Td /F1 9.8 Tf [(distributed electronically via a variety of methods: personal email addresses to disaster responders, emergency medicine and )] TJ ET BT 26.250 512.943 Td /F1 9.8 Tf [(disaster listservs, and a hyperlink on a medical website frequented by prehospital EMS medical professionals )] TJ ET BT 26.250 501.039 Td /F1 9.8 Tf [(\(https://www.jems.com/articles/2010/05/mci-triage-techniques-survey.html\). Respondents were not provided any financial or )] TJ ET BT 26.250 489.134 Td /F1 9.8 Tf [(other incentives for participation. The survey study received approval by our hospitals institutional review board prior to the start )] TJ ET BT 26.250 477.229 Td /F1 9.8 Tf [(of data collection. Surveys that were not completed in their entirety were excluded from the final analysis.)] TJ ET BT 26.250 457.824 Td /F4 9.8 Tf [(Survey Instrument:)] TJ ET BT 26.250 438.420 Td /F1 9.8 Tf [(The introductory paragraph described the intent of the survey, provided assurance of anonymity, and indicated that the )] TJ ET BT 26.250 426.515 Td /F1 9.8 Tf [(approximate time to complete the survey would be less than 20 minutes \(this was based on Beta testing of the survey on )] TJ ET BT 26.250 414.610 Td /F1 9.8 Tf [(SurveyMonkey\). By survey design, all questions were required to be answered and the respondent could not advance without )] TJ ET BT 26.250 402.705 Td /F1 9.8 Tf [(answering; The only exception was for specific stand-alone questions asking for opinion-based write-ins, if these were not )] TJ ET BT 26.250 390.801 Td /F1 9.8 Tf [(answered, the respondents survey was still included.)] TJ ET BT 26.250 371.396 Td /F1 9.8 Tf [(General information required, aside from date of birth and gender included:)] TJ ET 0.271 0.267 0.267 RG 40.337 354.959 m 40.337 355.405 40.154 355.849 39.838 356.165 c 39.522 356.481 39.078 356.665 38.631 356.665 c 38.185 356.665 37.741 356.481 37.425 356.165 c 37.109 355.849 36.925 355.405 36.925 354.959 c 36.925 354.512 37.109 354.068 37.425 353.752 c 37.741 353.436 38.185 353.253 38.631 353.253 c 39.078 353.253 39.522 353.436 39.838 353.752 c 40.154 354.068 40.337 354.512 40.337 354.959 c f BT 45.750 351.991 Td /F1 9.8 Tf [(Primary professional role \(e.g., physician, nurse, EMT \(emergency medical technician, Paramedic\))] TJ ET 40.337 339.304 m 40.337 339.751 40.154 340.195 39.838 340.511 c 39.522 340.826 39.078 341.010 38.631 341.010 c 38.185 341.010 37.741 340.826 37.425 340.511 c 37.109 340.195 36.925 339.751 36.925 339.304 c 36.925 338.857 37.109 338.413 37.425 338.097 c 37.741 337.782 38.185 337.598 38.631 337.598 c 39.078 337.598 39.522 337.782 39.838 338.097 c 40.154 338.413 40.337 338.857 40.337 339.304 c f BT 45.750 336.336 Td /F1 9.8 Tf [(Medical specialty \(e.g., emergency medicine, prehospital care\))] TJ ET 40.337 323.649 m 40.337 324.096 40.154 324.540 39.838 324.856 c 39.522 325.172 39.078 325.356 38.631 325.356 c 38.185 325.356 37.741 325.172 37.425 324.856 c 37.109 324.540 36.925 324.096 36.925 323.649 c 36.925 323.203 37.109 322.759 37.425 322.443 c 37.741 322.127 38.185 321.943 38.631 321.943 c 39.078 321.943 39.522 322.127 39.838 322.443 c 40.154 322.759 40.337 323.203 40.337 323.649 c f BT 45.750 320.682 Td /F1 9.8 Tf [(Years in medical profession \(dichotomized as 10 or fewer years vs. >10 years\))] TJ ET 40.337 307.995 m 40.337 308.441 40.154 308.885 39.838 309.201 c 39.522 309.517 39.078 309.701 38.631 309.701 c 38.185 309.701 37.741 309.517 37.425 309.201 c 37.109 308.885 36.925 308.441 36.925 307.995 c 36.925 307.548 37.109 307.104 37.425 306.788 c 37.741 306.472 38.185 306.288 38.631 306.288 c 39.078 306.288 39.522 306.472 39.838 306.788 c 40.154 307.104 40.337 307.548 40.337 307.995 c f BT 45.750 305.027 Td /F1 9.8 Tf [(Disaster training if any \(military, NDLS, ARC, FEMA, decontamination, CDP-Noble, or other\))] TJ ET 40.337 292.340 m 40.337 292.786 40.154 293.230 39.838 293.546 c 39.522 293.862 39.078 294.046 38.631 294.046 c 38.185 294.046 37.741 293.862 37.425 293.546 c 37.109 293.230 36.925 292.786 36.925 292.340 c 36.925 291.893 37.109 291.449 37.425 291.133 c 37.741 290.817 38.185 290.634 38.631 290.634 c 39.078 290.634 39.522 290.817 39.838 291.133 c 40.154 291.449 40.337 291.893 40.337 292.340 c f BT 45.750 289.372 Td /F1 9.8 Tf [(Triage system used in both non-disaster and disaster practice \(ESI, CDP-Noble, MASS, SAVE, START, SALT, STM )] TJ ET BT 45.750 277.467 Td /F1 9.8 Tf [(informal gut feeling, or other\))] TJ ET 40.337 264.780 m 40.337 265.227 40.154 265.671 39.838 265.987 c 39.522 266.303 39.078 266.487 38.631 266.487 c 38.185 266.487 37.741 266.303 37.425 265.987 c 37.109 265.671 36.925 265.227 36.925 264.780 c 36.925 264.334 37.109 263.890 37.425 263.574 c 37.741 263.258 38.185 263.074 38.631 263.074 c 39.078 263.074 39.522 263.258 39.838 263.574 c 40.154 263.890 40.337 264.334 40.337 264.780 c f BT 45.750 261.813 Td /F1 9.8 Tf [(Disaster triage experience \(yes/no\))] TJ ET 40.337 249.126 m 40.337 249.572 40.154 250.016 39.838 250.332 c 39.522 250.648 39.078 250.832 38.631 250.832 c 38.185 250.832 37.741 250.648 37.425 250.332 c 37.109 250.016 36.925 249.572 36.925 249.126 c 36.925 248.679 37.109 248.235 37.425 247.919 c 37.741 247.603 38.185 247.419 38.631 247.419 c 39.078 247.419 39.522 247.603 39.838 247.919 c 40.154 248.235 40.337 248.679 40.337 249.126 c f BT 45.750 246.158 Td /F1 9.8 Tf [(Experience of triaging a live patient to an expectant category \(yes/no\))] TJ ET 40.337 233.471 m 40.337 233.917 40.154 234.361 39.838 234.677 c 39.522 234.993 39.078 235.177 38.631 235.177 c 38.185 235.177 37.741 234.993 37.425 234.677 c 37.109 234.361 36.925 233.917 36.925 233.471 c 36.925 233.024 37.109 232.580 37.425 232.264 c 37.741 231.948 38.185 231.765 38.631 231.765 c 39.078 231.765 39.522 231.948 39.838 232.264 c 40.154 232.580 40.337 233.024 40.337 233.471 c f BT 45.750 230.503 Td /F1 9.8 Tf [(Specific disaster deployments if applicable)] TJ ET BT 26.250 207.348 Td /F1 9.8 Tf [(Patient attributes contributing to triage placement: Six patient and disaster attributes were to be ranked in the order of )] TJ ET BT 26.250 195.444 Td /F1 9.8 Tf [(importance to the respondent \(1-6 with 1 being the most important\); to help that would determine the preferred ranking of these )] TJ ET BT 26.250 183.539 Td /F1 9.8 Tf [(attributes by the respondent.)] TJ ET 40.337 167.102 m 40.337 167.548 40.154 167.992 39.838 168.308 c 39.522 168.624 39.078 168.808 38.631 168.808 c 38.185 168.808 37.741 168.624 37.425 168.308 c 37.109 167.992 36.925 167.548 36.925 167.102 c 36.925 166.655 37.109 166.211 37.425 165.895 c 37.741 165.579 38.185 165.396 38.631 165.396 c 39.078 165.396 39.522 165.579 39.838 165.895 c 40.154 166.211 40.337 166.655 40.337 167.102 c f BT 45.750 164.134 Td /F1 9.8 Tf [(Ability of the patient to speak to you)] TJ ET 40.337 151.447 m 40.337 151.894 40.154 152.338 39.838 152.654 c 39.522 152.969 39.078 153.153 38.631 153.153 c 38.185 153.153 37.741 152.969 37.425 152.654 c 37.109 152.338 36.925 151.894 36.925 151.447 c 36.925 151.000 37.109 150.556 37.425 150.240 c 37.741 149.925 38.185 149.741 38.631 149.741 c 39.078 149.741 39.522 149.925 39.838 150.240 c 40.154 150.556 40.337 151.000 40.337 151.447 c f BT 45.750 148.479 Td /F1 9.8 Tf [(Age)] TJ ET 40.337 135.792 m 40.337 136.239 40.154 136.683 39.838 136.999 c 39.522 137.315 39.078 137.499 38.631 137.499 c 38.185 137.499 37.741 137.315 37.425 136.999 c 37.109 136.683 36.925 136.239 36.925 135.792 c 36.925 135.346 37.109 134.902 37.425 134.586 c 37.741 134.270 38.185 134.086 38.631 134.086 c 39.078 134.086 39.522 134.270 39.838 134.586 c 40.154 134.902 40.337 135.346 40.337 135.792 c f BT 45.750 132.825 Td /F1 9.8 Tf [(Gut feeling, by the responder performing triage, of the severity of injury)] TJ ET 40.337 120.138 m 40.337 120.584 40.154 121.028 39.838 121.344 c 39.522 121.660 39.078 121.844 38.631 121.844 c 38.185 121.844 37.741 121.660 37.425 121.344 c 37.109 121.028 36.925 120.584 36.925 120.138 c 36.925 119.691 37.109 119.247 37.425 118.931 c 37.741 118.615 38.185 118.431 38.631 118.431 c 39.078 118.431 39.522 118.615 39.838 118.931 c 40.154 119.247 40.337 119.691 40.337 120.138 c f BT 45.750 117.170 Td /F1 9.8 Tf [(Perfusion-peripheral pulse)] TJ ET 40.337 104.483 m 40.337 104.929 40.154 105.373 39.838 105.689 c 39.522 106.005 39.078 106.189 38.631 106.189 c 38.185 106.189 37.741 106.005 37.425 105.689 c 37.109 105.373 36.925 104.929 36.925 104.483 c 36.925 104.036 37.109 103.592 37.425 103.276 c 37.741 102.960 38.185 102.777 38.631 102.777 c 39.078 102.777 39.522 102.960 39.838 103.276 c 40.154 103.592 40.337 104.036 40.337 104.483 c f BT 45.750 101.515 Td /F1 9.8 Tf [(Respiratory status)] TJ ET 40.337 88.828 m 40.337 89.275 40.154 89.719 39.838 90.035 c 39.522 90.350 39.078 90.534 38.631 90.534 c 38.185 90.534 37.741 90.350 37.425 90.035 c 37.109 89.719 36.925 89.275 36.925 88.828 c 36.925 88.381 37.109 87.937 37.425 87.621 c 37.741 87.306 38.185 87.122 38.631 87.122 c 39.078 87.122 39.522 87.306 39.838 87.621 c 40.154 87.937 40.337 88.381 40.337 88.828 c f BT 45.750 85.860 Td /F1 9.8 Tf [(Supplies or resource availability)] TJ ET BT 26.250 62.706 Td /F1 9.8 Tf [(In addition, for those who claim prior disaster response experience, a comment box was added to allow for additional )] TJ ET BT 26.250 50.801 Td /F1 9.8 Tf [(observations to be added besides the six listed attributes and/or factors that might influence the triage priority of patients.)] TJ ET Q q 15.000 40.920 577.500 736.080 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(including those by ethicists and critical care specialists have suggested that, due to social, medical, and logistical variables, that )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(only an experienced provider or a triage team approach should be utilized during the most difficult triage decisions.)] TJ ET 0.267 0.267 0.267 rg BT 519.932 757.079 Td /F4 8.7 Tf [(4)] TJ ET 0.271 0.267 0.267 rg BT 524.750 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 527.159 757.079 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 531.978 759.460 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 534.388 757.079 Td /F4 8.7 Tf [(6)] TJ ET 0.271 0.267 0.267 rg BT 26.250 743.667 Td /F1 9.8 Tf [(Additionally, very few studies have satisfactorily identified, compared, and discussed the actual real time decision-making )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(criteria used by experience-rich providers, in order to create an accurate and usable prioritization algorithm for mass casualty )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(events.)] TJ ET 0.267 0.267 0.267 rg BT 57.684 721.364 Td /F4 8.7 Tf [(7)] TJ ET 0.271 0.267 0.267 rg BT 62.503 723.745 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 64.912 721.364 Td /F4 8.7 Tf [(8)] TJ ET 0.271 0.267 0.267 rg BT 69.731 723.745 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 72.140 721.364 Td /F4 8.7 Tf [(9)] TJ ET 0.271 0.267 0.267 rg BT 76.959 723.745 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 79.368 721.364 Td /F4 8.7 Tf [(10)] TJ ET 0.271 0.267 0.267 rg BT 26.250 700.452 Td /F1 9.8 Tf [(To better understand both the reactive and situational awareness factors influencing the primary triage decision-making process )] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(among pre-hospital responders, both experienced and not, this study was designed to investigate and analyze those factors that )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(actual medical providers during MCIs perceived that directly and indirectly impacted and influenced how their primary triage )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(priority decisions were processed.)] TJ ET BT 26.250 628.136 Td /F4 12.0 Tf [(METHODS)] TJ ET BT 26.250 608.181 Td /F1 9.8 Tf [(To evaluate how triage decisions are initially processed, this study distributed an electronic survey to EMS and pre-hospital )] TJ ET BT 26.250 596.277 Td /F1 9.8 Tf [(medical providers to help identify and rank the factors that influence primary triage decisions made by those with and without )] TJ ET BT 26.250 584.372 Td /F1 9.8 Tf [(disaster experience. The survey questionnaire was designed by the authors, in English, to ascertain what attributes healthcare )] TJ ET BT 26.250 572.467 Td /F1 9.8 Tf [(workers value and utilize when evaluating a patient for triage and treatment priority. The initial survey was piloted with a small )] TJ ET BT 26.250 560.562 Td /F1 9.8 Tf [(sample of ten healthcare workers who work in an academically affiliated emergency department and have had previous disaster )] TJ ET BT 26.250 548.658 Td /F1 9.8 Tf [(response experience. Based upon the feedback received, the final survey instrument was revised and the modified questions )] TJ ET BT 26.250 536.753 Td /F1 9.8 Tf [(were entered into SurveyMonkey. The survey was available on-line for 2 months \(April-May 2010\). The survey was then )] TJ ET BT 26.250 524.848 Td /F1 9.8 Tf [(distributed electronically via a variety of methods: personal email addresses to disaster responders, emergency medicine and )] TJ ET BT 26.250 512.943 Td /F1 9.8 Tf [(disaster listservs, and a hyperlink on a medical website frequented by prehospital EMS medical professionals )] TJ ET BT 26.250 501.039 Td /F1 9.8 Tf [(\(https://www.jems.com/articles/2010/05/mci-triage-techniques-survey.html\). Respondents were not provided any financial or )] TJ ET BT 26.250 489.134 Td /F1 9.8 Tf [(other incentives for participation. The survey study received approval by our hospitals institutional review board prior to the start )] TJ ET BT 26.250 477.229 Td /F1 9.8 Tf [(of data collection. Surveys that were not completed in their entirety were excluded from the final analysis.)] TJ ET BT 26.250 457.824 Td /F4 9.8 Tf [(Survey Instrument:)] TJ ET BT 26.250 438.420 Td /F1 9.8 Tf [(The introductory paragraph described the intent of the survey, provided assurance of anonymity, and indicated that the )] TJ ET BT 26.250 426.515 Td /F1 9.8 Tf [(approximate time to complete the survey would be less than 20 minutes \(this was based on Beta testing of the survey on )] TJ ET BT 26.250 414.610 Td /F1 9.8 Tf [(SurveyMonkey\). By survey design, all questions were required to be answered and the respondent could not advance without )] TJ ET BT 26.250 402.705 Td /F1 9.8 Tf [(answering; The only exception was for specific stand-alone questions asking for opinion-based write-ins, if these were not )] TJ ET BT 26.250 390.801 Td /F1 9.8 Tf [(answered, the respondents survey was still included.)] TJ ET BT 26.250 371.396 Td /F1 9.8 Tf [(General information required, aside from date of birth and gender included:)] TJ ET 0.271 0.267 0.267 RG 40.337 354.959 m 40.337 355.405 40.154 355.849 39.838 356.165 c 39.522 356.481 39.078 356.665 38.631 356.665 c 38.185 356.665 37.741 356.481 37.425 356.165 c 37.109 355.849 36.925 355.405 36.925 354.959 c 36.925 354.512 37.109 354.068 37.425 353.752 c 37.741 353.436 38.185 353.253 38.631 353.253 c 39.078 353.253 39.522 353.436 39.838 353.752 c 40.154 354.068 40.337 354.512 40.337 354.959 c f BT 45.750 351.991 Td /F1 9.8 Tf [(Primary professional role \(e.g., physician, nurse, EMT \(emergency medical technician, Paramedic\))] TJ ET 40.337 339.304 m 40.337 339.751 40.154 340.195 39.838 340.511 c 39.522 340.826 39.078 341.010 38.631 341.010 c 38.185 341.010 37.741 340.826 37.425 340.511 c 37.109 340.195 36.925 339.751 36.925 339.304 c 36.925 338.857 37.109 338.413 37.425 338.097 c 37.741 337.782 38.185 337.598 38.631 337.598 c 39.078 337.598 39.522 337.782 39.838 338.097 c 40.154 338.413 40.337 338.857 40.337 339.304 c f BT 45.750 336.336 Td /F1 9.8 Tf [(Medical specialty \(e.g., emergency medicine, prehospital care\))] TJ ET 40.337 323.649 m 40.337 324.096 40.154 324.540 39.838 324.856 c 39.522 325.172 39.078 325.356 38.631 325.356 c 38.185 325.356 37.741 325.172 37.425 324.856 c 37.109 324.540 36.925 324.096 36.925 323.649 c 36.925 323.203 37.109 322.759 37.425 322.443 c 37.741 322.127 38.185 321.943 38.631 321.943 c 39.078 321.943 39.522 322.127 39.838 322.443 c 40.154 322.759 40.337 323.203 40.337 323.649 c f BT 45.750 320.682 Td /F1 9.8 Tf [(Years in medical profession \(dichotomized as 10 or fewer years vs. >10 years\))] TJ ET 40.337 307.995 m 40.337 308.441 40.154 308.885 39.838 309.201 c 39.522 309.517 39.078 309.701 38.631 309.701 c 38.185 309.701 37.741 309.517 37.425 309.201 c 37.109 308.885 36.925 308.441 36.925 307.995 c 36.925 307.548 37.109 307.104 37.425 306.788 c 37.741 306.472 38.185 306.288 38.631 306.288 c 39.078 306.288 39.522 306.472 39.838 306.788 c 40.154 307.104 40.337 307.548 40.337 307.995 c f BT 45.750 305.027 Td /F1 9.8 Tf [(Disaster training if any \(military, NDLS, ARC, FEMA, decontamination, CDP-Noble, or other\))] TJ ET 40.337 292.340 m 40.337 292.786 40.154 293.230 39.838 293.546 c 39.522 293.862 39.078 294.046 38.631 294.046 c 38.185 294.046 37.741 293.862 37.425 293.546 c 37.109 293.230 36.925 292.786 36.925 292.340 c 36.925 291.893 37.109 291.449 37.425 291.133 c 37.741 290.817 38.185 290.634 38.631 290.634 c 39.078 290.634 39.522 290.817 39.838 291.133 c 40.154 291.449 40.337 291.893 40.337 292.340 c f BT 45.750 289.372 Td /F1 9.8 Tf [(Triage system used in both non-disaster and disaster practice \(ESI, CDP-Noble, MASS, SAVE, START, SALT, STM )] TJ ET BT 45.750 277.467 Td /F1 9.8 Tf [(informal gut feeling, or other\))] TJ ET 40.337 264.780 m 40.337 265.227 40.154 265.671 39.838 265.987 c 39.522 266.303 39.078 266.487 38.631 266.487 c 38.185 266.487 37.741 266.303 37.425 265.987 c 37.109 265.671 36.925 265.227 36.925 264.780 c 36.925 264.334 37.109 263.890 37.425 263.574 c 37.741 263.258 38.185 263.074 38.631 263.074 c 39.078 263.074 39.522 263.258 39.838 263.574 c 40.154 263.890 40.337 264.334 40.337 264.780 c f BT 45.750 261.813 Td /F1 9.8 Tf [(Disaster triage experience \(yes/no\))] TJ ET 40.337 249.126 m 40.337 249.572 40.154 250.016 39.838 250.332 c 39.522 250.648 39.078 250.832 38.631 250.832 c 38.185 250.832 37.741 250.648 37.425 250.332 c 37.109 250.016 36.925 249.572 36.925 249.126 c 36.925 248.679 37.109 248.235 37.425 247.919 c 37.741 247.603 38.185 247.419 38.631 247.419 c 39.078 247.419 39.522 247.603 39.838 247.919 c 40.154 248.235 40.337 248.679 40.337 249.126 c f BT 45.750 246.158 Td /F1 9.8 Tf [(Experience of triaging a live patient to an expectant category \(yes/no\))] TJ ET 40.337 233.471 m 40.337 233.917 40.154 234.361 39.838 234.677 c 39.522 234.993 39.078 235.177 38.631 235.177 c 38.185 235.177 37.741 234.993 37.425 234.677 c 37.109 234.361 36.925 233.917 36.925 233.471 c 36.925 233.024 37.109 232.580 37.425 232.264 c 37.741 231.948 38.185 231.765 38.631 231.765 c 39.078 231.765 39.522 231.948 39.838 232.264 c 40.154 232.580 40.337 233.024 40.337 233.471 c f BT 45.750 230.503 Td /F1 9.8 Tf [(Specific disaster deployments if applicable)] TJ ET BT 26.250 207.348 Td /F1 9.8 Tf [(Patient attributes contributing to triage placement: Six patient and disaster attributes were to be ranked in the order of )] TJ ET BT 26.250 195.444 Td /F1 9.8 Tf [(importance to the respondent \(1-6 with 1 being the most important\); to help that would determine the preferred ranking of these )] TJ ET BT 26.250 183.539 Td /F1 9.8 Tf [(attributes by the respondent.)] TJ ET 40.337 167.102 m 40.337 167.548 40.154 167.992 39.838 168.308 c 39.522 168.624 39.078 168.808 38.631 168.808 c 38.185 168.808 37.741 168.624 37.425 168.308 c 37.109 167.992 36.925 167.548 36.925 167.102 c 36.925 166.655 37.109 166.211 37.425 165.895 c 37.741 165.579 38.185 165.396 38.631 165.396 c 39.078 165.396 39.522 165.579 39.838 165.895 c 40.154 166.211 40.337 166.655 40.337 167.102 c f BT 45.750 164.134 Td /F1 9.8 Tf [(Ability of the patient to speak to you)] TJ ET 40.337 151.447 m 40.337 151.894 40.154 152.338 39.838 152.654 c 39.522 152.969 39.078 153.153 38.631 153.153 c 38.185 153.153 37.741 152.969 37.425 152.654 c 37.109 152.338 36.925 151.894 36.925 151.447 c 36.925 151.000 37.109 150.556 37.425 150.240 c 37.741 149.925 38.185 149.741 38.631 149.741 c 39.078 149.741 39.522 149.925 39.838 150.240 c 40.154 150.556 40.337 151.000 40.337 151.447 c f BT 45.750 148.479 Td /F1 9.8 Tf [(Age)] TJ ET 40.337 135.792 m 40.337 136.239 40.154 136.683 39.838 136.999 c 39.522 137.315 39.078 137.499 38.631 137.499 c 38.185 137.499 37.741 137.315 37.425 136.999 c 37.109 136.683 36.925 136.239 36.925 135.792 c 36.925 135.346 37.109 134.902 37.425 134.586 c 37.741 134.270 38.185 134.086 38.631 134.086 c 39.078 134.086 39.522 134.270 39.838 134.586 c 40.154 134.902 40.337 135.346 40.337 135.792 c f BT 45.750 132.825 Td /F1 9.8 Tf [(Gut feeling, by the responder performing triage, of the severity of injury)] TJ ET 40.337 120.138 m 40.337 120.584 40.154 121.028 39.838 121.344 c 39.522 121.660 39.078 121.844 38.631 121.844 c 38.185 121.844 37.741 121.660 37.425 121.344 c 37.109 121.028 36.925 120.584 36.925 120.138 c 36.925 119.691 37.109 119.247 37.425 118.931 c 37.741 118.615 38.185 118.431 38.631 118.431 c 39.078 118.431 39.522 118.615 39.838 118.931 c 40.154 119.247 40.337 119.691 40.337 120.138 c f BT 45.750 117.170 Td /F1 9.8 Tf [(Perfusion-peripheral pulse)] TJ ET 40.337 104.483 m 40.337 104.929 40.154 105.373 39.838 105.689 c 39.522 106.005 39.078 106.189 38.631 106.189 c 38.185 106.189 37.741 106.005 37.425 105.689 c 37.109 105.373 36.925 104.929 36.925 104.483 c 36.925 104.036 37.109 103.592 37.425 103.276 c 37.741 102.960 38.185 102.777 38.631 102.777 c 39.078 102.777 39.522 102.960 39.838 103.276 c 40.154 103.592 40.337 104.036 40.337 104.483 c f BT 45.750 101.515 Td /F1 9.8 Tf [(Respiratory status)] TJ ET 40.337 88.828 m 40.337 89.275 40.154 89.719 39.838 90.035 c 39.522 90.350 39.078 90.534 38.631 90.534 c 38.185 90.534 37.741 90.350 37.425 90.035 c 37.109 89.719 36.925 89.275 36.925 88.828 c 36.925 88.381 37.109 87.937 37.425 87.621 c 37.741 87.306 38.185 87.122 38.631 87.122 c 39.078 87.122 39.522 87.306 39.838 87.621 c 40.154 87.937 40.337 88.381 40.337 88.828 c f BT 45.750 85.860 Td /F1 9.8 Tf [(Supplies or resource availability)] TJ ET BT 26.250 62.706 Td /F1 9.8 Tf [(In addition, for those who claim prior disaster response experience, a comment box was added to allow for additional )] TJ ET BT 26.250 50.801 Td /F1 9.8 Tf [(observations to be added besides the six listed attributes and/or factors that might influence the triage priority of patients.)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(3)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 109 0 obj << /Type /Annot /Subtype /Link /A 110 0 R /Border [0 0 0] /H /I /Rect [ 519.9315 756.2769 524.7502 765.0952 ] >> endobj 110 0 obj << /Type /Action >> endobj 111 0 obj << /Type /Annot /Subtype /Link /A 112 0 R /Border [0 0 0] /H /I /Rect [ 527.1595 756.2769 531.9782 765.0952 ] >> endobj 112 0 obj << /Type /Action >> endobj 113 0 obj << /Type /Annot /Subtype /Link /A 114 0 R /Border [0 0 0] /H /I /Rect [ 534.3875 756.2769 539.2062 765.0952 ] >> endobj 114 0 obj << /Type /Action >> endobj 115 0 obj << /Type /Annot /Subtype /Link /A 116 0 R /Border [0 0 0] /H /I /Rect [ 57.6840 720.5627 62.5027 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R >> endobj 152 0 obj << /Length 15609 >> stream 0.271 0.267 0.267 rg 0.271 0.267 0.267 RG q 15.000 -27.470 577.500 804.470 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(RESULTS)] TJ ET BT 26.250 730.324 Td /F4 9.8 Tf [(Data Analysis)] TJ ET BT 26.250 710.919 Td /F1 9.8 Tf [(A total of 495 surveys were returned, with 92 deemed incomplete and thusly excluded from data analysis. The 403 completed )] TJ ET BT 26.250 699.015 Td /F1 9.8 Tf [(surveys were analyzed using SAS 9.3 for Windows. Descriptive findings are presented as numbers, proportions, means, )] TJ ET BT 26.250 687.110 Td /F1 9.8 Tf [(frequencies, and standard deviations. Respondents, for further analysis, were classified into three groups based on their )] TJ ET BT 26.250 675.205 Td /F1 9.8 Tf [(disaster triage experience: no disaster triage experience \()] TJ ET BT 274.436 675.205 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 303.696 675.205 Td /F1 9.8 Tf [(\), performance of disaster triage without the expectant )] TJ ET BT 26.250 663.300 Td /F1 9.8 Tf [(category \()] TJ ET BT 69.599 663.300 Td /F5 9.8 Tf [(ExpNoExpectant)] TJ ET BT 142.216 663.300 Td /F1 9.8 Tf [(\) experience, and performing disaster triage with an expectant category, those people who are not )] TJ ET BT 26.250 651.396 Td /F1 9.8 Tf [(expected to survive based upon logistical and or skill limitations. Those with expectant category \()] TJ ET BT 449.459 651.396 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 478.718 651.396 Td /F1 9.8 Tf [(\) experience \(n=47\) )] TJ ET BT 26.250 639.491 Td /F1 9.8 Tf [(were classified as the most triage experienced respondents of the three groups. Wilcoxon \(non-parametric\) tests compared )] TJ ET BT 26.250 627.586 Td /F1 9.8 Tf [(mean rankings between the different triage experience groups. Bonferroni adjustments to the alpha level were made for 12 )] TJ ET BT 26.250 615.681 Td /F1 9.8 Tf [(comparisons, and for these comparisons, alpha level was set at p)] TJ ET BT 308.581 615.681 Td /F1 9.8 Tf [(<)] TJ ET BT 314.275 615.681 Td /F1 9.8 Tf [(.004 \(.05/12\). Chi-square statistics were used to compare the )] TJ ET BT 26.250 603.777 Td /F1 9.8 Tf [(dichotomous top four vs. lowest two rank order of the supplies/resource availability factor and of the patient age factor between )] TJ ET BT 26.250 591.872 Td /F1 9.8 Tf [(the )] TJ ET BT 42.513 591.872 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 71.773 591.872 Td /F1 9.8 Tf [( vs. )] TJ ET BT 89.654 591.872 Td /F5 9.8 Tf [(ExpNoExpectant)] TJ ET BT 162.272 591.872 Td /F1 9.8 Tf [( groups and between the )] TJ ET BT 272.301 591.872 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 314.021 591.872 Td /F1 9.8 Tf [( and )] TJ ET BT 335.705 591.872 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 364.965 591.872 Td /F1 9.8 Tf [( groups.)] TJ ET BT 26.250 572.467 Td /F1 9.8 Tf [(Fifty three percent of the 403 respondents were pre-hospital providers \(Table 2\).)] TJ ET 0.965 0.965 0.965 rg 26.250 387.364 555.000 175.223 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 562.586 m 581.250 562.586 l 581.250 561.836 l 26.250 561.836 l f 26.250 387.364 m 581.250 387.364 l 581.250 388.114 l 26.250 388.114 l f q 225.000 0 0 113.250 35.250 439.586 cm /I5 Do Q q 35.250 398.614 537.000 34.973 re W n 0.271 0.267 0.267 rg BT 35.250 422.597 Td /F4 9.8 Tf [(Table 2. Self reported medical occupations of respondents, all of who worked in emergency management areas. )] TJ ET BT 35.250 408.861 Td /F4 9.8 Tf [(\(N=403\))] TJ ET Q BT 26.250 370.340 Td /F1 9.8 Tf [(Nearly all indicated that they practiced a structured triage approach \(i.e., START, MASS, SAVE, STM, ESI\) with 8% \(32/403\) )] TJ ET BT 26.250 358.435 Td /F1 9.8 Tf [(reporting that they utilized an informal gut feeling triage methodology. The )] TJ ET BT 353.567 358.435 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 382.827 358.435 Td /F1 9.8 Tf [( group comprised the majority, 60% )] TJ ET BT 26.250 346.530 Td /F1 9.8 Tf [(\(240/403\), 29% \(116/403\) were in the )] TJ ET BT 190.459 346.530 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 232.180 346.530 Td /F1 9.8 Tf [( group, and 12% \(47/403\) were in the )] TJ ET BT 395.853 346.530 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 425.113 346.530 Td /F1 9.8 Tf [( group. Those in both the )] TJ ET BT 536.224 346.530 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 26.250 334.626 Td /F1 9.8 Tf [(and )] TJ ET BT 45.224 334.626 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 74.483 334.626 Td /F1 9.8 Tf [( groups, were able to expound on their personal disaster experiences. These included deployments to military )] TJ ET BT 26.250 322.721 Td /F1 9.8 Tf [(conflicts, Oklahoma City bombing, 9/11 for both World Trade Center and Pentagon sites, and protracted disaster events such as )] TJ ET BT 26.250 310.816 Td /F1 9.8 Tf [(hurricanes Katrina and Ike.)] TJ ET BT 26.250 291.411 Td /F1 9.8 Tf [(The mean \(SD\) ranking of each of the six-triage factors by the three experience groups is displayed in Figure 1.)] TJ ET 0.965 0.965 0.965 rg 26.250 -27.470 555.000 309.000 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 281.530 m 581.250 281.530 l 581.250 280.780 l 26.250 280.780 l f q 450.000 0 0 293.250 35.250 -21.470 cm /I6 Do Q q 35.250 -27.470 537.000 0.000 re W n Q Q q 15.000 -27.470 577.500 804.470 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(RESULTS)] TJ ET BT 26.250 730.324 Td /F4 9.8 Tf [(Data Analysis)] TJ ET BT 26.250 710.919 Td /F1 9.8 Tf [(A total of 495 surveys were returned, with 92 deemed incomplete and thusly excluded from data analysis. The 403 completed )] TJ ET BT 26.250 699.015 Td /F1 9.8 Tf [(surveys were analyzed using SAS 9.3 for Windows. Descriptive findings are presented as numbers, proportions, means, )] TJ ET BT 26.250 687.110 Td /F1 9.8 Tf [(frequencies, and standard deviations. Respondents, for further analysis, were classified into three groups based on their )] TJ ET BT 26.250 675.205 Td /F1 9.8 Tf [(disaster triage experience: no disaster triage experience \()] TJ ET BT 274.436 675.205 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 303.696 675.205 Td /F1 9.8 Tf [(\), performance of disaster triage without the expectant )] TJ ET BT 26.250 663.300 Td /F1 9.8 Tf [(category \()] TJ ET BT 69.599 663.300 Td /F5 9.8 Tf [(ExpNoExpectant)] TJ ET BT 142.216 663.300 Td /F1 9.8 Tf [(\) experience, and performing disaster triage with an expectant category, those people who are not )] TJ ET BT 26.250 651.396 Td /F1 9.8 Tf [(expected to survive based upon logistical and or skill limitations. Those with expectant category \()] TJ ET BT 449.459 651.396 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 478.718 651.396 Td /F1 9.8 Tf [(\) experience \(n=47\) )] TJ ET BT 26.250 639.491 Td /F1 9.8 Tf [(were classified as the most triage experienced respondents of the three groups. Wilcoxon \(non-parametric\) tests compared )] TJ ET BT 26.250 627.586 Td /F1 9.8 Tf [(mean rankings between the different triage experience groups. Bonferroni adjustments to the alpha level were made for 12 )] TJ ET BT 26.250 615.681 Td /F1 9.8 Tf [(comparisons, and for these comparisons, alpha level was set at p)] TJ ET BT 308.581 615.681 Td /F1 9.8 Tf [(<)] TJ ET BT 314.275 615.681 Td /F1 9.8 Tf [(.004 \(.05/12\). Chi-square statistics were used to compare the )] TJ ET BT 26.250 603.777 Td /F1 9.8 Tf [(dichotomous top four vs. lowest two rank order of the supplies/resource availability factor and of the patient age factor between )] TJ ET BT 26.250 591.872 Td /F1 9.8 Tf [(the )] TJ ET BT 42.513 591.872 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 71.773 591.872 Td /F1 9.8 Tf [( vs. )] TJ ET BT 89.654 591.872 Td /F5 9.8 Tf [(ExpNoExpectant)] TJ ET BT 162.272 591.872 Td /F1 9.8 Tf [( groups and between the )] TJ ET BT 272.301 591.872 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 314.021 591.872 Td /F1 9.8 Tf [( and )] TJ ET BT 335.705 591.872 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 364.965 591.872 Td /F1 9.8 Tf [( groups.)] TJ ET BT 26.250 572.467 Td /F1 9.8 Tf [(Fifty three percent of the 403 respondents were pre-hospital providers \(Table 2\).)] TJ ET 0.965 0.965 0.965 rg 26.250 387.364 555.000 175.223 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 562.586 m 581.250 562.586 l 581.250 561.836 l 26.250 561.836 l f 26.250 387.364 m 581.250 387.364 l 581.250 388.114 l 26.250 388.114 l f q 225.000 0 0 113.250 35.250 439.586 cm /I8 Do Q q 35.250 398.614 537.000 34.973 re W n 0.271 0.267 0.267 rg BT 35.250 422.597 Td /F4 9.8 Tf [(Table 2. Self reported medical occupations of respondents, all of who worked in emergency management areas. )] TJ ET BT 35.250 408.861 Td /F4 9.8 Tf [(\(N=403\))] TJ ET Q BT 26.250 370.340 Td /F1 9.8 Tf [(Nearly all indicated that they practiced a structured triage approach \(i.e., START, MASS, SAVE, STM, ESI\) with 8% \(32/403\) )] TJ ET BT 26.250 358.435 Td /F1 9.8 Tf [(reporting that they utilized an informal gut feeling triage methodology. The )] TJ ET BT 353.567 358.435 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 382.827 358.435 Td /F1 9.8 Tf [( group comprised the majority, 60% )] TJ ET BT 26.250 346.530 Td /F1 9.8 Tf [(\(240/403\), 29% \(116/403\) were in the )] TJ ET BT 190.459 346.530 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 232.180 346.530 Td /F1 9.8 Tf [( group, and 12% \(47/403\) were in the )] TJ ET BT 395.853 346.530 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 425.113 346.530 Td /F1 9.8 Tf [( group. Those in both the )] TJ ET BT 536.224 346.530 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 26.250 334.626 Td /F1 9.8 Tf [(and )] TJ ET BT 45.224 334.626 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 74.483 334.626 Td /F1 9.8 Tf [( groups, were able to expound on their personal disaster experiences. These included deployments to military )] TJ ET BT 26.250 322.721 Td /F1 9.8 Tf [(conflicts, Oklahoma City bombing, 9/11 for both World Trade Center and Pentagon sites, and protracted disaster events such as )] TJ ET BT 26.250 310.816 Td /F1 9.8 Tf [(hurricanes Katrina and Ike.)] TJ ET BT 26.250 291.411 Td /F1 9.8 Tf [(The mean \(SD\) ranking of each of the six-triage factors by the three experience groups is displayed in Figure 1.)] TJ ET 0.965 0.965 0.965 rg 26.250 -27.470 555.000 309.000 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 281.530 m 581.250 281.530 l 581.250 280.780 l 26.250 280.780 l f q 450.000 0 0 293.250 35.250 -21.470 cm /I6 Do Q q 35.250 -27.470 537.000 0.000 re W n Q Q q 15.000 -27.470 577.500 804.470 re W n 0.271 0.267 0.267 rg BT 26.250 750.278 Td /F4 12.0 Tf [(RESULTS)] TJ ET BT 26.250 730.324 Td /F4 9.8 Tf [(Data Analysis)] TJ ET BT 26.250 710.919 Td /F1 9.8 Tf [(A total of 495 surveys were returned, with 92 deemed incomplete and thusly excluded from data analysis. The 403 completed )] TJ ET BT 26.250 699.015 Td /F1 9.8 Tf [(surveys were analyzed using SAS 9.3 for Windows. Descriptive findings are presented as numbers, proportions, means, )] TJ ET BT 26.250 687.110 Td /F1 9.8 Tf [(frequencies, and standard deviations. Respondents, for further analysis, were classified into three groups based on their )] TJ ET BT 26.250 675.205 Td /F1 9.8 Tf [(disaster triage experience: no disaster triage experience \()] TJ ET BT 274.436 675.205 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 303.696 675.205 Td /F1 9.8 Tf [(\), performance of disaster triage without the expectant )] TJ ET BT 26.250 663.300 Td /F1 9.8 Tf [(category \()] TJ ET BT 69.599 663.300 Td /F5 9.8 Tf [(ExpNoExpectant)] TJ ET BT 142.216 663.300 Td /F1 9.8 Tf [(\) experience, and performing disaster triage with an expectant category, those people who are not )] TJ ET BT 26.250 651.396 Td /F1 9.8 Tf [(expected to survive based upon logistical and or skill limitations. Those with expectant category \()] TJ ET BT 449.459 651.396 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 478.718 651.396 Td /F1 9.8 Tf [(\) experience \(n=47\) )] TJ ET BT 26.250 639.491 Td /F1 9.8 Tf [(were classified as the most triage experienced respondents of the three groups. Wilcoxon \(non-parametric\) tests compared )] TJ ET BT 26.250 627.586 Td /F1 9.8 Tf [(mean rankings between the different triage experience groups. Bonferroni adjustments to the alpha level were made for 12 )] TJ ET BT 26.250 615.681 Td /F1 9.8 Tf [(comparisons, and for these comparisons, alpha level was set at p)] TJ ET BT 308.581 615.681 Td /F1 9.8 Tf [(<)] TJ ET BT 314.275 615.681 Td /F1 9.8 Tf [(.004 \(.05/12\). Chi-square statistics were used to compare the )] TJ ET BT 26.250 603.777 Td /F1 9.8 Tf [(dichotomous top four vs. lowest two rank order of the supplies/resource availability factor and of the patient age factor between )] TJ ET BT 26.250 591.872 Td /F1 9.8 Tf [(the )] TJ ET BT 42.513 591.872 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 71.773 591.872 Td /F1 9.8 Tf [( vs. )] TJ ET BT 89.654 591.872 Td /F5 9.8 Tf [(ExpNoExpectant)] TJ ET BT 162.272 591.872 Td /F1 9.8 Tf [( groups and between the )] TJ ET BT 272.301 591.872 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 314.021 591.872 Td /F1 9.8 Tf [( and )] TJ ET BT 335.705 591.872 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 364.965 591.872 Td /F1 9.8 Tf [( groups.)] TJ ET BT 26.250 572.467 Td /F1 9.8 Tf [(Fifty three percent of the 403 respondents were pre-hospital providers \(Table 2\).)] TJ ET 0.965 0.965 0.965 rg 26.250 387.364 555.000 175.223 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 562.586 m 581.250 562.586 l 581.250 561.836 l 26.250 561.836 l f 26.250 387.364 m 581.250 387.364 l 581.250 388.114 l 26.250 388.114 l f q 225.000 0 0 113.250 35.250 439.586 cm /I10 Do Q q 35.250 398.614 537.000 34.973 re W n 0.271 0.267 0.267 rg BT 35.250 422.597 Td /F4 9.8 Tf [(Table 2. Self reported medical occupations of respondents, all of who worked in emergency management areas. )] TJ ET BT 35.250 408.861 Td /F4 9.8 Tf [(\(N=403\))] TJ ET Q BT 26.250 370.340 Td /F1 9.8 Tf [(Nearly all indicated that they practiced a structured triage approach \(i.e., START, MASS, SAVE, STM, ESI\) with 8% \(32/403\) )] TJ ET BT 26.250 358.435 Td /F1 9.8 Tf [(reporting that they utilized an informal gut feeling triage methodology. The )] TJ ET BT 353.567 358.435 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 382.827 358.435 Td /F1 9.8 Tf [( group comprised the majority, 60% )] TJ ET BT 26.250 346.530 Td /F1 9.8 Tf [(\(240/403\), 29% \(116/403\) were in the )] TJ ET BT 190.459 346.530 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 232.180 346.530 Td /F1 9.8 Tf [( group, and 12% \(47/403\) were in the )] TJ ET BT 395.853 346.530 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 425.113 346.530 Td /F1 9.8 Tf [( group. Those in both the )] TJ ET BT 536.224 346.530 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 26.250 334.626 Td /F1 9.8 Tf [(and )] TJ ET BT 45.224 334.626 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 74.483 334.626 Td /F1 9.8 Tf [( groups, were able to expound on their personal disaster experiences. These included deployments to military )] TJ ET BT 26.250 322.721 Td /F1 9.8 Tf [(conflicts, Oklahoma City bombing, 9/11 for both World Trade Center and Pentagon sites, and protracted disaster events such as )] TJ ET BT 26.250 310.816 Td /F1 9.8 Tf [(hurricanes Katrina and Ike.)] TJ ET BT 26.250 291.411 Td /F1 9.8 Tf [(The mean \(SD\) ranking of each of the six-triage factors by the three experience groups is displayed in Figure 1.)] TJ ET 0.965 0.965 0.965 rg 26.250 -27.470 555.000 309.000 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 281.530 m 581.250 281.530 l 581.250 280.780 l 26.250 280.780 l f q 450.000 0 0 293.250 35.250 -21.470 cm /I6 Do Q q 35.250 -27.470 537.000 0.000 re W n Q Q q 225.000 0 0 113.250 35.250 439.586 cm /I12 Do Q q 450.000 0 0 293.250 35.250 -21.470 cm /I6 Do Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(4)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 153 0 obj << /Type /Font /Subtype /Type1 /Name /F5 /BaseFont /Helvetica-Oblique /Encoding /WinAnsiEncoding >> endobj 154 0 obj << /Type /Annot /Subtype /Link /A 155 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 439.5862 260.2500 552.8362 ] >> endobj 155 0 obj << /Type /Action /S /URI /URI (https://currents.plos.org/disasters/files/2016/04/Table-2-Self-reported-medical-occupations-of-respondents.png) >> endobj 156 0 obj << /Type /XObject /Subtype /Image /Width 300 /Height 151 /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 1 /Columns 300 /BitsPerComponent 8>> /ColorSpace /DeviceGray /BitsPerComponent 8 /Length 331>> stream xA 0 =fy9뀟\Z endstream endobj 157 0 obj << /Type /XObject /Subtype /Image /Width 300 /Height 151 /SMask 156 0 R /Filter /FlateDecode /DecodeParms << /Predictor 15 /Colors 3 /Columns 300 /BitsPerComponent 8>> /ColorSpace /DeviceRGB /BitsPerComponent 8 /Length 33757>> stream x}u|Tw5BBB`CCqw(^xb);=X[JV63.iK?̙s̙sf2!B !0Kd|M\|V9cel6mc~|uܜK֩+iYGncFpN,6A7pE} tD3w2 _(M:qӴ6G 04Q8P IsB >:t dď/\XVI,H8 \fipXg@ 9>}B-[YN1y"@}"P H5p؈Nh", _+3 \Pq z)X̭8ۉ#juTt}# BkL%NsM#e DDțQ zЫL/ =E0Љ".8*ܺ 9Ks(~6aFdf% J+֑PE- |UĒk/ALV*Wʊ ng=!CpfB0 ,E[+Y9,L‡KsVIq ؐup+f "Z~; .7яK AWxT`̍v&lxf5;L+?fWv$P'C D^Ә% AZh eBTE::hZ\kA\Ժv Z$`]q0V@HLd_P2 Vf[1y"GX4J';Z^Ђ%P%O X;_+:F*ڄbg7 _׊Brx+܄ VɦÇ?{/mb 33sܸqAAA TQb0?ܧO E uT!Tʲ)J%\YcB XZoˆ;2 /F6J\7' vaٷ@71CtҰ Z@\`H=D*\ u ߘl(+9.5GC ɕ~a ֬:l49? 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The mean rankings for five of the six variables \(all but gut feeling\) differed by experience groups and were all )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(statistically significant depending on disaster experience \(Table 3\).)] TJ ET 0.965 0.965 0.965 rg 26.250 443.908 555.000 253.223 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 697.131 m 581.250 697.131 l 581.250 696.381 l 26.250 696.381 l f 26.250 443.908 m 581.250 443.908 l 581.250 444.658 l 26.250 444.658 l f q 450.000 0 0 191.250 35.250 496.131 cm /I13 Do Q q 35.250 455.158 537.000 34.973 re W n 0.271 0.267 0.267 rg BT 35.250 479.142 Td /F4 9.8 Tf [(Table 3: Ranking differences of criteria separating experienced, black tag with and without disaster experience )] TJ ET BT 35.250 465.406 Td /F4 9.8 Tf [(\(163\) vs. no disaster experience \(240\). \(p<0.05 sig\))] TJ ET Q BT 26.250 426.885 Td /F1 9.8 Tf [(Though there were slight differences in the order of ranking, both groups had the same top and bottom three criteria choices )] TJ ET BT 26.250 414.980 Td /F1 9.8 Tf [(with supplies and age showing strong significance in their ranking placement differences. Further analysis with a series of )] TJ ET BT 26.250 403.075 Td /F1 9.8 Tf [(nonparametric Wilcoxon tests comparing the factor rankings across each of the disaster experience group pairs found the )] TJ ET BT 26.250 391.170 Td /F1 9.8 Tf [(following significant between-group comparisons: the )] TJ ET BT 257.637 391.170 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 286.897 391.170 Td /F1 9.8 Tf [( group ranked the supplies/resource availability factor significantly )] TJ ET BT 26.250 379.266 Td /F1 9.8 Tf [(lower than did the )] TJ ET BT 105.917 379.266 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 147.637 379.266 Td /F1 9.8 Tf [( group who in turn ranked the supplies/resource availability factor significantly lower than did the )] TJ ET BT 26.250 367.361 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 55.510 367.361 Td /F1 9.8 Tf [( group. The Z proportion of each of the three experience groups ranking supplies/resource availability in the top four is )] TJ ET BT 26.250 355.456 Td /F1 9.8 Tf [(demonstrated in Figure 2.)] TJ ET 0.965 0.965 0.965 rg 26.250 2.075 555.000 343.500 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 345.575 m 581.250 345.575 l 581.250 344.825 l 26.250 344.825 l f q 450.000 0 0 327.750 35.250 8.075 cm /I14 Do Q q 35.250 2.075 537.000 0.000 re W n Q Q q 15.000 2.075 577.500 774.925 re W n 0.965 0.965 0.965 rg 26.250 747.845 555.000 29.155 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 747.845 m 581.250 747.845 l 581.250 748.595 l 26.250 748.595 l f q 35.250 759.095 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: Mean rankings of triage factors by respondents disasters experience level.)] TJ ET Q BT 26.250 730.821 Td /F1 9.8 Tf [(Respiratory status, ability to speak, perfusion/pulse, and gut feeling factors were ranked in the top four by the majority of the )] TJ ET BT 26.250 718.917 Td /F1 9.8 Tf [(403 respondents. The mean rankings for five of the six variables \(all but gut feeling\) differed by experience groups and were all )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(statistically significant depending on disaster experience \(Table 3\).)] TJ ET 0.965 0.965 0.965 rg 26.250 443.908 555.000 253.223 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 697.131 m 581.250 697.131 l 581.250 696.381 l 26.250 696.381 l f 26.250 443.908 m 581.250 443.908 l 581.250 444.658 l 26.250 444.658 l f q 450.000 0 0 191.250 35.250 496.131 cm /I13 Do Q q 35.250 455.158 537.000 34.973 re W n 0.271 0.267 0.267 rg BT 35.250 479.142 Td /F4 9.8 Tf [(Table 3: Ranking differences of criteria separating experienced, black tag with and without disaster experience )] TJ ET BT 35.250 465.406 Td /F4 9.8 Tf [(\(163\) vs. no disaster experience \(240\). \(p<0.05 sig\))] TJ ET Q BT 26.250 426.885 Td /F1 9.8 Tf [(Though there were slight differences in the order of ranking, both groups had the same top and bottom three criteria choices )] TJ ET BT 26.250 414.980 Td /F1 9.8 Tf [(with supplies and age showing strong significance in their ranking placement differences. Further analysis with a series of )] TJ ET BT 26.250 403.075 Td /F1 9.8 Tf [(nonparametric Wilcoxon tests comparing the factor rankings across each of the disaster experience group pairs found the )] TJ ET BT 26.250 391.170 Td /F1 9.8 Tf [(following significant between-group comparisons: the )] TJ ET BT 257.637 391.170 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 286.897 391.170 Td /F1 9.8 Tf [( group ranked the supplies/resource availability factor significantly )] TJ ET BT 26.250 379.266 Td /F1 9.8 Tf [(lower than did the )] TJ ET BT 105.917 379.266 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 147.637 379.266 Td /F1 9.8 Tf [( group who in turn ranked the supplies/resource availability factor significantly lower than did the )] TJ ET BT 26.250 367.361 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 55.510 367.361 Td /F1 9.8 Tf [( group. The Z proportion of each of the three experience groups ranking supplies/resource availability in the top four is )] TJ ET BT 26.250 355.456 Td /F1 9.8 Tf [(demonstrated in Figure 2.)] TJ ET 0.965 0.965 0.965 rg 26.250 2.075 555.000 343.500 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 345.575 m 581.250 345.575 l 581.250 344.825 l 26.250 344.825 l f q 450.000 0 0 327.750 35.250 8.075 cm /I14 Do Q q 35.250 2.075 537.000 0.000 re W n Q Q q 15.000 2.075 577.500 774.925 re W n 0.965 0.965 0.965 rg 26.250 747.845 555.000 29.155 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 747.845 m 581.250 747.845 l 581.250 748.595 l 26.250 748.595 l f q 35.250 759.095 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 1: Mean rankings of triage factors by respondents disasters experience level.)] TJ ET Q BT 26.250 730.821 Td /F1 9.8 Tf [(Respiratory status, ability to speak, perfusion/pulse, and gut feeling factors were ranked in the top four by the majority of the )] TJ ET BT 26.250 718.917 Td /F1 9.8 Tf [(403 respondents. The mean rankings for five of the six variables \(all but gut feeling\) differed by experience groups and were all )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(statistically significant depending on disaster experience \(Table 3\).)] TJ ET 0.965 0.965 0.965 rg 26.250 443.908 555.000 253.223 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 697.131 m 581.250 697.131 l 581.250 696.381 l 26.250 696.381 l f 26.250 443.908 m 581.250 443.908 l 581.250 444.658 l 26.250 444.658 l f q 450.000 0 0 191.250 35.250 496.131 cm /I13 Do Q q 35.250 455.158 537.000 34.973 re W n 0.271 0.267 0.267 rg BT 35.250 479.142 Td /F4 9.8 Tf [(Table 3: Ranking differences of criteria separating experienced, black tag with and without disaster experience )] TJ ET BT 35.250 465.406 Td /F4 9.8 Tf [(\(163\) vs. no disaster experience \(240\). \(p<0.05 sig\))] TJ ET Q BT 26.250 426.885 Td /F1 9.8 Tf [(Though there were slight differences in the order of ranking, both groups had the same top and bottom three criteria choices )] TJ ET BT 26.250 414.980 Td /F1 9.8 Tf [(with supplies and age showing strong significance in their ranking placement differences. Further analysis with a series of )] TJ ET BT 26.250 403.075 Td /F1 9.8 Tf [(nonparametric Wilcoxon tests comparing the factor rankings across each of the disaster experience group pairs found the )] TJ ET BT 26.250 391.170 Td /F1 9.8 Tf [(following significant between-group comparisons: the )] TJ ET BT 257.637 391.170 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 286.897 391.170 Td /F1 9.8 Tf [( group ranked the supplies/resource availability factor significantly )] TJ ET BT 26.250 379.266 Td /F1 9.8 Tf [(lower than did the )] TJ ET BT 105.917 379.266 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 147.637 379.266 Td /F1 9.8 Tf [( group who in turn ranked the supplies/resource availability factor significantly lower than did the )] TJ ET BT 26.250 367.361 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 55.510 367.361 Td /F1 9.8 Tf [( group. The Z proportion of each of the three experience groups ranking supplies/resource availability in the top four is )] TJ ET BT 26.250 355.456 Td /F1 9.8 Tf [(demonstrated in Figure 2.)] TJ ET 0.965 0.965 0.965 rg 26.250 2.075 555.000 343.500 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 345.575 m 581.250 345.575 l 581.250 344.825 l 26.250 344.825 l f q 450.000 0 0 327.750 35.250 8.075 cm /I14 Do Q q 35.250 2.075 537.000 0.000 re W n Q Q q 450.000 0 0 191.250 35.250 496.131 cm /I13 Do Q q 450.000 0 0 327.750 35.250 8.075 cm /I14 Do Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(5)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 177 0 obj << /Type /Annot /Subtype /Link /A 178 0 R /Border [0 0 0] /H /I /Rect [ 35.2500 496.1310 485.2500 687.3810 ] >> endobj 178 0 obj << /Type /Action /S /URI /URI (https://currents.plos.org/disasters/files/2016/04/Table-3-2.jpg) >> endobj 179 0 obj << /Type /XObject /Subtype /Image /Width 600 /Height 255 /ColorSpace /DeviceRGB /Filter /DCTDecode /BitsPerComponent 8 /Length 53806>> stream JFIF``;CREATOR: gd-jpeg v1.0 (using IJG JPEG v80), quality = 90 C     C   X" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?Q(kj> ^4/Y5[yc_.d؁0I |+}A=k|zt_1{h>#dѬ)&%w`L{J `miVWu_ڌJ{%p  L{ӳN¿SsE|wcY ҵ^\O՜P4>v]pH0Nyφ>.w]jZMlX W`vc$~*?/9t}Hyb.껱fs_\~^9u?ǣuW0A

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This statistical )] TJ ET BT 26.250 695.107 Td /F1 9.8 Tf [(significance is important when reviewing resource utilization \(supplies/resource availability\) considerations among the three )] TJ ET BT 26.250 683.202 Td /F1 9.8 Tf [(groups. The )] TJ ET BT 80.987 683.202 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 110.246 683.202 Td /F1 9.8 Tf [( group employed resource utilization based factors as important in disaster triage decision-making 62% of )] TJ ET BT 26.250 671.298 Td /F1 9.8 Tf [(the time compared with )] TJ ET BT 129.746 671.298 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 171.466 671.298 Td /F1 9.8 Tf [( and )] TJ ET BT 193.150 671.298 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 222.410 671.298 Td /F1 9.8 Tf [( groups, who employed it 39% and 25% of the time, respectively.)] TJ ET BT 26.250 634.695 Td /F4 12.0 Tf [(LIMITATIONS)] TJ ET BT 26.250 614.741 Td /F1 9.8 Tf [(Surveys are not strong science, with a sampling bias in this case due to the use of specific and limited access listservs, )] TJ ET BT 26.250 602.836 Td /F1 9.8 Tf [(personal email lists, and web site visit. The results were analyzed as professionally pooled and therefore might be skewed )] TJ ET BT 26.250 590.931 Td /F1 9.8 Tf [(toward the larger numbers of physicians, EMTs, and paramedics among the EMS providers surveyed. The electronic survey )] TJ ET BT 26.250 579.027 Td /F1 9.8 Tf [(limited the pool of respondents to those willing and able to use and access the survey using a computer. The true potential )] TJ ET BT 26.250 567.122 Td /F1 9.8 Tf [(response rate is unknown as the actual number of people who received an invitation via email list or listserv is unknown. The )] TJ ET BT 26.250 555.217 Td /F1 9.8 Tf [(use of a convenience sample, such as we used, did not allow for us to have any control over who chose to respond. It is not an )] TJ ET BT 26.250 543.312 Td /F1 9.8 Tf [(ideal method of gathering data, but in this case, it allowed for the survey to be distributed to a much larger geographic )] TJ ET BT 26.250 531.408 Td /F1 9.8 Tf [(population to give a better sense of the triage provider population at large and was not cost prohibitive, as we only had to pay )] TJ ET BT 26.250 519.503 Td /F1 9.8 Tf [(for the SurveyMonkey annual fee of $400 U.S.. In addition, the top three ranked attributes \(airway, circulation, and )] TJ ET BT 26.250 507.598 Td /F1 9.8 Tf [(neurological status\) are seen in START triage, possibly skewing their priority ranking due to the Hawthorne affect, where )] TJ ET BT 26.250 495.693 Td /F1 9.8 Tf [(participants change behavior because they are aware of being observed. Moreover, the survey did not inquire whether triage )] TJ ET BT 26.250 483.789 Td /F1 9.8 Tf [(decisions were made individually, or with assistance such as a team and this triage aspect will be included in subsequent )] TJ ET BT 26.250 471.884 Td /F1 9.8 Tf [(studies.)] TJ ET BT 26.250 435.281 Td /F4 12.0 Tf [(DISCUSSION)] TJ ET BT 26.250 415.327 Td /F1 9.8 Tf [(Only in a perfect world would the ideal MCI triage system exist that accurately identified each casualty by severity and type of )] TJ ET BT 26.250 403.422 Td /F1 9.8 Tf [(injury/illness, ensures that victims received the proper treatment and transport prioritization, and are delivered to appropriate )] TJ ET BT 26.250 391.518 Td /F1 9.8 Tf [(medical care quickly and efficiently. Admittedly, in every mass casualty event patients who are able to leave the scene often do )] TJ ET BT 26.250 379.613 Td /F1 9.8 Tf [(so often prior to EMS arrival. Those remaining are either dead, need an intervention to save their life, are still on scene because )] TJ ET BT 26.250 367.708 Td /F1 9.8 Tf [(they cannot ambulate, or are rending bystander medical assistance; as was witnessed during the Boston Marathon bombing. )] TJ ET BT 26.250 355.803 Td /F1 9.8 Tf [(Those victims left on scene, as organized first responders arrive, are evaluated, and often moved to a gathering location where )] TJ ET BT 26.250 343.899 Td /F1 9.8 Tf [(more medical supplies or shelter is available \(i.e. treatment tent in the Boston Marathon, I-10 causeway, Louis Armstrong )] TJ ET BT 26.250 331.994 Td /F1 9.8 Tf [(international airport\). It is here that transportation and other logistical considerations become additional factors that may impact )] TJ ET BT 26.250 320.089 Td /F1 9.8 Tf [(triage decisions, all of which are an integral part of pre-hospital decisions. Interestingly, aside from SALT, no popular triage )] TJ ET BT 26.250 308.184 Td /F1 9.8 Tf [(algorithm discusses patient movement, transport, and logistics.)] TJ ET BT 26.250 288.780 Td /F1 9.8 Tf [(Ideally, triage decisions, made without emotional input or bias, should be able to identify those victims likely to survive if taken to )] TJ ET BT 26.250 276.875 Td /F1 9.8 Tf [(definitive care. However, the ranking of victims into severity and priority treatment categories makes triage dynamic and, )] TJ ET BT 26.250 264.970 Td /F1 9.8 Tf [(depending on numerous external variables, can be an emotive activity that might skew priority categories, possibly introducing )] TJ ET BT 26.250 253.065 Td /F1 9.8 Tf [(bias, leading to either under triage or over triage, which, as mentioned earlier, can cause an increase in mortality. Recently, )] TJ ET BT 26.250 241.161 Td /F1 9.8 Tf [(Cross and Cicero compared six different triage systems and found that none worked well for every event with most resulting in )] TJ ET BT 26.250 229.256 Td /F1 9.8 Tf [(over triage.)] TJ ET 0.267 0.267 0.267 rg BT 75.019 230.763 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 84.657 229.256 Td /F1 9.8 Tf [( Travers and colleagues suggest that triage systems providing the most reliable and effective patient outcomes )] TJ ET BT 26.250 217.351 Td /F1 9.8 Tf [(have multiple triage categories, with the optimum number of five levels felt to be safer, with greater discrimination, reliability and )] TJ ET BT 26.250 205.446 Td /F1 9.8 Tf [(improved specificity.)] TJ ET 0.267 0.267 0.267 rg BT 117.266 206.954 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 126.904 205.446 Td /F1 9.8 Tf [( This was independently supported by others such as Burkle whose triage levels include: immediate, )] TJ ET BT 26.250 193.542 Td /F1 9.8 Tf [(delayed, minimal, expectant, and deceased as recommended for bioevent triage, and with ICU teams where physician seniority )] TJ ET BT 26.250 181.637 Td /F1 9.8 Tf [(was considered a favorable independent factor in ICU admission criteria.)] TJ ET 0.267 0.267 0.267 rg BT 339.459 183.144 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 344.278 185.525 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 346.687 183.144 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 26.250 162.232 Td /F1 9.8 Tf [(Admittedly, triage is a fluid and dynamic process; it has multiple variables influencing the decision maker and should be )] TJ ET BT 26.250 150.327 Td /F1 9.8 Tf [(adaptable to a myriad of situations. Most triage criteria endorsed by the American College of Surgeons, Emergency Nursing )] TJ ET BT 26.250 138.423 Td /F1 9.8 Tf [(Association, and the American College of Emergency Physicians use a combination of physiological, anatomical, mechanism of )] TJ ET BT 26.250 126.518 Td /F1 9.8 Tf [(injury, and special considerations categories to determine severity categorization.)] TJ ET 0.267 0.267 0.267 rg BT 376.850 128.025 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 386.488 130.406 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 388.897 128.025 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 398.534 126.518 Td /F1 9.8 Tf [( It is created as a step-by-step algorithm )] TJ ET BT 26.250 114.613 Td /F1 9.8 Tf [(for the provider to follow to allow for the best patient transportation designation. However, triage is a very complex task that is )] TJ ET BT 26.250 102.708 Td /F1 9.8 Tf [(dynamic, heuristic, and driven primarily by provider judgment rather than specific triage criteria.)] TJ ET 0.267 0.267 0.267 rg BT 441.834 104.216 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 451.471 102.708 Td /F1 9.8 Tf [( Newgard and colleagues )] TJ ET BT 26.250 90.804 Td /F1 9.8 Tf [(further demonstrated the independent predictive value of the EMS providers judgment, a gut feeling-like primary triage criteria )] TJ ET BT 26.250 78.899 Td /F1 9.8 Tf [(for identifying seriously injured victims, showing that the cognitive reasoning processes encapsulated in this criteria can help in )] TJ ET BT 26.250 66.994 Td /F1 9.8 Tf [(identifying seriously injured patients potentially missed by other triage criteria.)] TJ ET 0.267 0.267 0.267 rg BT 363.288 68.501 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 26.250 47.589 Td /F1 9.8 Tf [(The purpose of this survey was to query practicing field experts and identify factors that for them affect their triage category )] TJ ET Q q 15.000 33.304 577.500 743.696 re W n 0.965 0.965 0.965 rg 26.250 747.845 555.000 29.155 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 747.845 m 581.250 747.845 l 581.250 748.595 l 26.250 748.595 l f q 35.250 759.095 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 2: Percent of respondents by triage experience category, who ranked supplies in the top four choices.)] TJ ET Q BT 26.250 730.821 Td /F1 9.8 Tf [(The )] TJ ET BT 45.760 730.821 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 75.019 730.821 Td /F1 9.8 Tf [( group had a significantly lower Z proportion ranking the supplies/resource availability factor in the top four than in )] TJ ET BT 26.250 718.917 Td /F1 9.8 Tf [(the )] TJ ET BT 42.513 718.917 Td /F5 9.8 Tf [(ExpNoExpectant)] TJ ET BT 115.131 718.917 Td /F1 9.8 Tf [( group \(c2=7.2, df=1, p=.008\), who in turn had a significantly lower proportion, ranking the )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(supplies/resource availability factor in the top four, than the )] TJ ET BT 287.452 707.012 Td /F5 9.8 Tf [(ExpExpectant)] TJ ET BT 347.610 707.012 Td /F1 9.8 Tf [( group \(c2=7.1, df=1, p=.008\). This statistical )] TJ ET BT 26.250 695.107 Td /F1 9.8 Tf [(significance is important when reviewing resource utilization \(supplies/resource availability\) considerations among the three )] TJ ET BT 26.250 683.202 Td /F1 9.8 Tf [(groups. The )] TJ ET BT 80.987 683.202 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 110.246 683.202 Td /F1 9.8 Tf [( group employed resource utilization based factors as important in disaster triage decision-making 62% of )] TJ ET BT 26.250 671.298 Td /F1 9.8 Tf [(the time compared with )] TJ ET BT 129.746 671.298 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 171.466 671.298 Td /F1 9.8 Tf [( and )] TJ ET BT 193.150 671.298 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 222.410 671.298 Td /F1 9.8 Tf [( groups, who employed it 39% and 25% of the time, respectively.)] TJ ET BT 26.250 634.695 Td /F4 12.0 Tf [(LIMITATIONS)] TJ ET BT 26.250 614.741 Td /F1 9.8 Tf [(Surveys are not strong science, with a sampling bias in this case due to the use of specific and limited access listservs, )] TJ ET BT 26.250 602.836 Td /F1 9.8 Tf [(personal email lists, and web site visit. The results were analyzed as professionally pooled and therefore might be skewed )] TJ ET BT 26.250 590.931 Td /F1 9.8 Tf [(toward the larger numbers of physicians, EMTs, and paramedics among the EMS providers surveyed. The electronic survey )] TJ ET BT 26.250 579.027 Td /F1 9.8 Tf [(limited the pool of respondents to those willing and able to use and access the survey using a computer. The true potential )] TJ ET BT 26.250 567.122 Td /F1 9.8 Tf [(response rate is unknown as the actual number of people who received an invitation via email list or listserv is unknown. The )] TJ ET BT 26.250 555.217 Td /F1 9.8 Tf [(use of a convenience sample, such as we used, did not allow for us to have any control over who chose to respond. It is not an )] TJ ET BT 26.250 543.312 Td /F1 9.8 Tf [(ideal method of gathering data, but in this case, it allowed for the survey to be distributed to a much larger geographic )] TJ ET BT 26.250 531.408 Td /F1 9.8 Tf [(population to give a better sense of the triage provider population at large and was not cost prohibitive, as we only had to pay )] TJ ET BT 26.250 519.503 Td /F1 9.8 Tf [(for the SurveyMonkey annual fee of $400 U.S.. In addition, the top three ranked attributes \(airway, circulation, and )] TJ ET BT 26.250 507.598 Td /F1 9.8 Tf [(neurological status\) are seen in START triage, possibly skewing their priority ranking due to the Hawthorne affect, where )] TJ ET BT 26.250 495.693 Td /F1 9.8 Tf [(participants change behavior because they are aware of being observed. Moreover, the survey did not inquire whether triage )] TJ ET BT 26.250 483.789 Td /F1 9.8 Tf [(decisions were made individually, or with assistance such as a team and this triage aspect will be included in subsequent )] TJ ET BT 26.250 471.884 Td /F1 9.8 Tf [(studies.)] TJ ET BT 26.250 435.281 Td /F4 12.0 Tf [(DISCUSSION)] TJ ET BT 26.250 415.327 Td /F1 9.8 Tf [(Only in a perfect world would the ideal MCI triage system exist that accurately identified each casualty by severity and type of )] TJ ET BT 26.250 403.422 Td /F1 9.8 Tf [(injury/illness, ensures that victims received the proper treatment and transport prioritization, and are delivered to appropriate )] TJ ET BT 26.250 391.518 Td /F1 9.8 Tf [(medical care quickly and efficiently. Admittedly, in every mass casualty event patients who are able to leave the scene often do )] TJ ET BT 26.250 379.613 Td /F1 9.8 Tf [(so often prior to EMS arrival. Those remaining are either dead, need an intervention to save their life, are still on scene because )] TJ ET BT 26.250 367.708 Td /F1 9.8 Tf [(they cannot ambulate, or are rending bystander medical assistance; as was witnessed during the Boston Marathon bombing. )] TJ ET BT 26.250 355.803 Td /F1 9.8 Tf [(Those victims left on scene, as organized first responders arrive, are evaluated, and often moved to a gathering location where )] TJ ET BT 26.250 343.899 Td /F1 9.8 Tf [(more medical supplies or shelter is available \(i.e. treatment tent in the Boston Marathon, I-10 causeway, Louis Armstrong )] TJ ET BT 26.250 331.994 Td /F1 9.8 Tf [(international airport\). It is here that transportation and other logistical considerations become additional factors that may impact )] TJ ET BT 26.250 320.089 Td /F1 9.8 Tf [(triage decisions, all of which are an integral part of pre-hospital decisions. Interestingly, aside from SALT, no popular triage )] TJ ET BT 26.250 308.184 Td /F1 9.8 Tf [(algorithm discusses patient movement, transport, and logistics.)] TJ ET BT 26.250 288.780 Td /F1 9.8 Tf [(Ideally, triage decisions, made without emotional input or bias, should be able to identify those victims likely to survive if taken to )] TJ ET BT 26.250 276.875 Td /F1 9.8 Tf [(definitive care. However, the ranking of victims into severity and priority treatment categories makes triage dynamic and, )] TJ ET BT 26.250 264.970 Td /F1 9.8 Tf [(depending on numerous external variables, can be an emotive activity that might skew priority categories, possibly introducing )] TJ ET BT 26.250 253.065 Td /F1 9.8 Tf [(bias, leading to either under triage or over triage, which, as mentioned earlier, can cause an increase in mortality. Recently, )] TJ ET BT 26.250 241.161 Td /F1 9.8 Tf [(Cross and Cicero compared six different triage systems and found that none worked well for every event with most resulting in )] TJ ET BT 26.250 229.256 Td /F1 9.8 Tf [(over triage.)] TJ ET 0.267 0.267 0.267 rg BT 75.019 230.763 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 84.657 229.256 Td /F1 9.8 Tf [( Travers and colleagues suggest that triage systems providing the most reliable and effective patient outcomes )] TJ ET BT 26.250 217.351 Td /F1 9.8 Tf [(have multiple triage categories, with the optimum number of five levels felt to be safer, with greater discrimination, reliability and )] TJ ET BT 26.250 205.446 Td /F1 9.8 Tf [(improved specificity.)] TJ ET 0.267 0.267 0.267 rg BT 117.266 206.954 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 126.904 205.446 Td /F1 9.8 Tf [( This was independently supported by others such as Burkle whose triage levels include: immediate, )] TJ ET BT 26.250 193.542 Td /F1 9.8 Tf [(delayed, minimal, expectant, and deceased as recommended for bioevent triage, and with ICU teams where physician seniority )] TJ ET BT 26.250 181.637 Td /F1 9.8 Tf [(was considered a favorable independent factor in ICU admission criteria.)] TJ ET 0.267 0.267 0.267 rg BT 339.459 183.144 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 344.278 185.525 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 346.687 183.144 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 26.250 162.232 Td /F1 9.8 Tf [(Admittedly, triage is a fluid and dynamic process; it has multiple variables influencing the decision maker and should be )] TJ ET BT 26.250 150.327 Td /F1 9.8 Tf [(adaptable to a myriad of situations. Most triage criteria endorsed by the American College of Surgeons, Emergency Nursing )] TJ ET BT 26.250 138.423 Td /F1 9.8 Tf [(Association, and the American College of Emergency Physicians use a combination of physiological, anatomical, mechanism of )] TJ ET BT 26.250 126.518 Td /F1 9.8 Tf [(injury, and special considerations categories to determine severity categorization.)] TJ ET 0.267 0.267 0.267 rg BT 376.850 128.025 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 386.488 130.406 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 388.897 128.025 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 398.534 126.518 Td /F1 9.8 Tf [( It is created as a step-by-step algorithm )] TJ ET BT 26.250 114.613 Td /F1 9.8 Tf [(for the provider to follow to allow for the best patient transportation designation. However, triage is a very complex task that is )] TJ ET BT 26.250 102.708 Td /F1 9.8 Tf [(dynamic, heuristic, and driven primarily by provider judgment rather than specific triage criteria.)] TJ ET 0.267 0.267 0.267 rg BT 441.834 104.216 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 451.471 102.708 Td /F1 9.8 Tf [( Newgard and colleagues )] TJ ET BT 26.250 90.804 Td /F1 9.8 Tf [(further demonstrated the independent predictive value of the EMS providers judgment, a gut feeling-like primary triage criteria )] TJ ET BT 26.250 78.899 Td /F1 9.8 Tf [(for identifying seriously injured victims, showing that the cognitive reasoning processes encapsulated in this criteria can help in )] TJ ET BT 26.250 66.994 Td /F1 9.8 Tf [(identifying seriously injured patients potentially missed by other triage criteria.)] TJ ET 0.267 0.267 0.267 rg BT 363.288 68.501 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 26.250 47.589 Td /F1 9.8 Tf [(The purpose of this survey was to query practicing field experts and identify factors that for them affect their triage category )] TJ ET Q q 15.000 33.304 577.500 743.696 re W n 0.965 0.965 0.965 rg 26.250 747.845 555.000 29.155 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 747.845 m 581.250 747.845 l 581.250 748.595 l 26.250 748.595 l f q 35.250 759.095 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 767.476 Td /F4 9.8 Tf [(Fig. 2: Percent of respondents by triage experience category, who ranked supplies in the top four choices.)] TJ ET Q BT 26.250 730.821 Td /F1 9.8 Tf [(The )] TJ ET BT 45.760 730.821 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 75.019 730.821 Td /F1 9.8 Tf [( group had a significantly lower Z proportion ranking the supplies/resource availability factor in the top four than in )] TJ ET BT 26.250 718.917 Td /F1 9.8 Tf [(the )] TJ ET BT 42.513 718.917 Td /F5 9.8 Tf [(ExpNoExpectant)] TJ ET BT 115.131 718.917 Td /F1 9.8 Tf [( group \(c2=7.2, df=1, p=.008\), who in turn had a significantly lower proportion, ranking the )] TJ ET BT 26.250 707.012 Td /F1 9.8 Tf [(supplies/resource availability factor in the top four, than the )] TJ ET BT 287.452 707.012 Td /F5 9.8 Tf [(ExpExpectant)] TJ ET BT 347.610 707.012 Td /F1 9.8 Tf [( group \(c2=7.1, df=1, p=.008\). This statistical )] TJ ET BT 26.250 695.107 Td /F1 9.8 Tf [(significance is important when reviewing resource utilization \(supplies/resource availability\) considerations among the three )] TJ ET BT 26.250 683.202 Td /F1 9.8 Tf [(groups. The )] TJ ET BT 80.987 683.202 Td /F5 9.8 Tf [(ExpBT)] TJ ET BT 110.246 683.202 Td /F1 9.8 Tf [( group employed resource utilization based factors as important in disaster triage decision-making 62% of )] TJ ET BT 26.250 671.298 Td /F1 9.8 Tf [(the time compared with )] TJ ET BT 129.746 671.298 Td /F5 9.8 Tf [(ExpNoBT)] TJ ET BT 171.466 671.298 Td /F1 9.8 Tf [( and )] TJ ET BT 193.150 671.298 Td /F5 9.8 Tf [(NoExp)] TJ ET BT 222.410 671.298 Td /F1 9.8 Tf [( groups, who employed it 39% and 25% of the time, respectively.)] TJ ET BT 26.250 634.695 Td /F4 12.0 Tf [(LIMITATIONS)] TJ ET BT 26.250 614.741 Td /F1 9.8 Tf [(Surveys are not strong science, with a sampling bias in this case due to the use of specific and limited access listservs, )] TJ ET BT 26.250 602.836 Td /F1 9.8 Tf [(personal email lists, and web site visit. The results were analyzed as professionally pooled and therefore might be skewed )] TJ ET BT 26.250 590.931 Td /F1 9.8 Tf [(toward the larger numbers of physicians, EMTs, and paramedics among the EMS providers surveyed. The electronic survey )] TJ ET BT 26.250 579.027 Td /F1 9.8 Tf [(limited the pool of respondents to those willing and able to use and access the survey using a computer. The true potential )] TJ ET BT 26.250 567.122 Td /F1 9.8 Tf [(response rate is unknown as the actual number of people who received an invitation via email list or listserv is unknown. The )] TJ ET BT 26.250 555.217 Td /F1 9.8 Tf [(use of a convenience sample, such as we used, did not allow for us to have any control over who chose to respond. It is not an )] TJ ET BT 26.250 543.312 Td /F1 9.8 Tf [(ideal method of gathering data, but in this case, it allowed for the survey to be distributed to a much larger geographic )] TJ ET BT 26.250 531.408 Td /F1 9.8 Tf [(population to give a better sense of the triage provider population at large and was not cost prohibitive, as we only had to pay )] TJ ET BT 26.250 519.503 Td /F1 9.8 Tf [(for the SurveyMonkey annual fee of $400 U.S.. In addition, the top three ranked attributes \(airway, circulation, and )] TJ ET BT 26.250 507.598 Td /F1 9.8 Tf [(neurological status\) are seen in START triage, possibly skewing their priority ranking due to the Hawthorne affect, where )] TJ ET BT 26.250 495.693 Td /F1 9.8 Tf [(participants change behavior because they are aware of being observed. Moreover, the survey did not inquire whether triage )] TJ ET BT 26.250 483.789 Td /F1 9.8 Tf [(decisions were made individually, or with assistance such as a team and this triage aspect will be included in subsequent )] TJ ET BT 26.250 471.884 Td /F1 9.8 Tf [(studies.)] TJ ET BT 26.250 435.281 Td /F4 12.0 Tf [(DISCUSSION)] TJ ET BT 26.250 415.327 Td /F1 9.8 Tf [(Only in a perfect world would the ideal MCI triage system exist that accurately identified each casualty by severity and type of )] TJ ET BT 26.250 403.422 Td /F1 9.8 Tf [(injury/illness, ensures that victims received the proper treatment and transport prioritization, and are delivered to appropriate )] TJ ET BT 26.250 391.518 Td /F1 9.8 Tf [(medical care quickly and efficiently. Admittedly, in every mass casualty event patients who are able to leave the scene often do )] TJ ET BT 26.250 379.613 Td /F1 9.8 Tf [(so often prior to EMS arrival. Those remaining are either dead, need an intervention to save their life, are still on scene because )] TJ ET BT 26.250 367.708 Td /F1 9.8 Tf [(they cannot ambulate, or are rending bystander medical assistance; as was witnessed during the Boston Marathon bombing. )] TJ ET BT 26.250 355.803 Td /F1 9.8 Tf [(Those victims left on scene, as organized first responders arrive, are evaluated, and often moved to a gathering location where )] TJ ET BT 26.250 343.899 Td /F1 9.8 Tf [(more medical supplies or shelter is available \(i.e. treatment tent in the Boston Marathon, I-10 causeway, Louis Armstrong )] TJ ET BT 26.250 331.994 Td /F1 9.8 Tf [(international airport\). It is here that transportation and other logistical considerations become additional factors that may impact )] TJ ET BT 26.250 320.089 Td /F1 9.8 Tf [(triage decisions, all of which are an integral part of pre-hospital decisions. Interestingly, aside from SALT, no popular triage )] TJ ET BT 26.250 308.184 Td /F1 9.8 Tf [(algorithm discusses patient movement, transport, and logistics.)] TJ ET BT 26.250 288.780 Td /F1 9.8 Tf [(Ideally, triage decisions, made without emotional input or bias, should be able to identify those victims likely to survive if taken to )] TJ ET BT 26.250 276.875 Td /F1 9.8 Tf [(definitive care. However, the ranking of victims into severity and priority treatment categories makes triage dynamic and, )] TJ ET BT 26.250 264.970 Td /F1 9.8 Tf [(depending on numerous external variables, can be an emotive activity that might skew priority categories, possibly introducing )] TJ ET BT 26.250 253.065 Td /F1 9.8 Tf [(bias, leading to either under triage or over triage, which, as mentioned earlier, can cause an increase in mortality. Recently, )] TJ ET BT 26.250 241.161 Td /F1 9.8 Tf [(Cross and Cicero compared six different triage systems and found that none worked well for every event with most resulting in )] TJ ET BT 26.250 229.256 Td /F1 9.8 Tf [(over triage.)] TJ ET 0.267 0.267 0.267 rg BT 75.019 230.763 Td /F4 8.7 Tf [(11)] TJ ET 0.271 0.267 0.267 rg BT 84.657 229.256 Td /F1 9.8 Tf [( Travers and colleagues suggest that triage systems providing the most reliable and effective patient outcomes )] TJ ET BT 26.250 217.351 Td /F1 9.8 Tf [(have multiple triage categories, with the optimum number of five levels felt to be safer, with greater discrimination, reliability and )] TJ ET BT 26.250 205.446 Td /F1 9.8 Tf [(improved specificity.)] TJ ET 0.267 0.267 0.267 rg BT 117.266 206.954 Td /F4 8.7 Tf [(12)] TJ ET 0.271 0.267 0.267 rg BT 126.904 205.446 Td /F1 9.8 Tf [( This was independently supported by others such as Burkle whose triage levels include: immediate, )] TJ ET BT 26.250 193.542 Td /F1 9.8 Tf [(delayed, minimal, expectant, and deceased as recommended for bioevent triage, and with ICU teams where physician seniority )] TJ ET BT 26.250 181.637 Td /F1 9.8 Tf [(was considered a favorable independent factor in ICU admission criteria.)] TJ ET 0.267 0.267 0.267 rg BT 339.459 183.144 Td /F4 8.7 Tf [(5)] TJ ET 0.271 0.267 0.267 rg BT 344.278 185.525 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 346.687 183.144 Td /F4 8.7 Tf [(13)] TJ ET 0.271 0.267 0.267 rg BT 26.250 162.232 Td /F1 9.8 Tf [(Admittedly, triage is a fluid and dynamic process; it has multiple variables influencing the decision maker and should be )] TJ ET BT 26.250 150.327 Td /F1 9.8 Tf [(adaptable to a myriad of situations. Most triage criteria endorsed by the American College of Surgeons, Emergency Nursing )] TJ ET BT 26.250 138.423 Td /F1 9.8 Tf [(Association, and the American College of Emergency Physicians use a combination of physiological, anatomical, mechanism of )] TJ ET BT 26.250 126.518 Td /F1 9.8 Tf [(injury, and special considerations categories to determine severity categorization.)] TJ ET 0.267 0.267 0.267 rg BT 376.850 128.025 Td /F4 8.7 Tf [(14)] TJ ET 0.271 0.267 0.267 rg BT 386.488 130.406 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 388.897 128.025 Td /F4 8.7 Tf [(15)] TJ ET 0.271 0.267 0.267 rg BT 398.534 126.518 Td /F1 9.8 Tf [( It is created as a step-by-step algorithm )] TJ ET BT 26.250 114.613 Td /F1 9.8 Tf [(for the provider to follow to allow for the best patient transportation designation. However, triage is a very complex task that is )] TJ ET BT 26.250 102.708 Td /F1 9.8 Tf [(dynamic, heuristic, and driven primarily by provider judgment rather than specific triage criteria.)] TJ ET 0.267 0.267 0.267 rg BT 441.834 104.216 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 451.471 102.708 Td /F1 9.8 Tf [( Newgard and colleagues )] TJ ET BT 26.250 90.804 Td /F1 9.8 Tf [(further demonstrated the independent predictive value of the EMS providers judgment, a gut feeling-like primary triage criteria )] TJ ET BT 26.250 78.899 Td /F1 9.8 Tf [(for identifying seriously injured victims, showing that the cognitive reasoning processes encapsulated in this criteria can help in )] TJ ET BT 26.250 66.994 Td /F1 9.8 Tf [(identifying seriously injured patients potentially missed by other triage criteria.)] TJ ET 0.267 0.267 0.267 rg BT 363.288 68.501 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 26.250 47.589 Td /F1 9.8 Tf [(The purpose of this survey was to query practicing field experts and identify factors that for them affect their triage category )] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(6)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 193 0 obj << /Type /Annot /Subtype /Link /A 194 0 R /Border [0 0 0] /H /I /Rect [ 75.0195 229.9614 84.6568 238.7798 ] >> endobj 194 0 obj << /Type /Action >> endobj 195 0 obj << /Type /Annot /Subtype /Link /A 196 0 R /Border [0 0 0] /H /I /Rect [ 117.2662 206.1519 126.9036 214.9703 ] >> endobj 196 0 obj << /Type /Action >> endobj 197 0 obj << /Type /Annot /Subtype /Link /A 198 0 R /Border [0 0 0] /H /I /Rect [ 339.4590 182.3424 344.2777 191.1608 ] >> endobj 198 0 obj << /Type /Action >> endobj 199 0 obj << /Type /Annot /Subtype /Link /A 200 0 R /Border [0 0 0] /H /I /Rect [ 346.6870 182.3424 356.3243 191.1608 ] >> endobj 200 0 obj << /Type /Action >> endobj 201 0 obj << /Type /Annot /Subtype /Link /A 202 0 R /Border [0 0 0] /H /I /Rect [ 376.8503 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The assumption made is that medical providers with practical experience in triage situations will prioritize )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(different attributes for the sorting of patients compared to those providers with no disaster experience. These findings in turn, )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(could provide more attribute weighting of the factors used create a more accurate triage algorithm. For example, in this study, )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(the top ranked categories regardless of experience level were cardiovascular and neurological with those respondents with )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(disaster experience placing a higher value on the ability of the patient to speak than on the cardiovascular criteria. This )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(suggests that brain perfusion to the experienced triage provider is considered a good indicator of injury severity.)] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(After the physiological attributes, in our rankings, Gut instinct ranked forth, regardless of disaster experience level with 8% )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(reporting, that they used it as their primary form of triage guidance. Instinct or gut instinct is related to experience, which is a )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(part of expert knowledge, and is very effective in cases of complex decisions such as triage.)] TJ ET 0.267 0.267 0.267 rg BT 422.383 666.245 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 432.020 664.738 Td /F1 9.8 Tf [( In the nursing literature, much )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(has been written about experience and instinct in patient care, with an acceptance that experience creates intuition which )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(guides recognition of subtle deterioration and subsequent appropriate nursing action.)] TJ ET 0.267 0.267 0.267 rg BT 392.070 642.436 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 401.707 640.929 Td /F1 9.8 Tf [( In the prehospital literature the support )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(of gust instinct has been mixed. A review of the earlier prehospital triage literature is varied, with some studies suggesting that )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(provider judgment is effective in increasing the sensitivity of triage.)] TJ ET 0.267 0.267 0.267 rg BT 312.364 618.626 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 322.001 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 324.410 618.626 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 334.048 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 336.457 618.626 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 346.094 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 348.504 618.626 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 358.141 617.119 Td /F1 9.8 Tf [( Other papers suggest it has no affect at all, which )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(could be due to a lack of overall provider experience.)] TJ ET 0.267 0.267 0.267 rg BT 254.400 606.722 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 264.037 609.103 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 266.447 606.722 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 276.084 605.214 Td /F1 9.8 Tf [( There have been two large retrospective trauma studies examining )] TJ ET BT 26.250 593.310 Td /F1 9.8 Tf [(prehospital triage and destination assignment to determine what historically prehospital providers have used for decision-)] TJ ET BT 26.250 581.405 Td /F1 9.8 Tf [(making. These analyzed a three year period where >250,000 injured person were transported; 36% of the time, EMS provider )] TJ ET BT 26.250 569.500 Td /F1 9.8 Tf [(judgment was the most commonly used triage criterion.)] TJ ET 0.267 0.267 0.267 rg BT 264.667 571.007 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 274.304 573.388 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 276.713 571.007 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 286.351 569.500 Td /F1 9.8 Tf [( This is further supported in a variety of published case reports )] TJ ET BT 26.250 557.595 Td /F1 9.8 Tf [(which have noticed that gut instinct played an enormous role in correctly assigning triage criteria to patients.)] TJ ET 0.267 0.267 0.267 rg BT 494.991 559.103 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 504.628 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 507.038 559.103 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 516.675 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 519.084 559.103 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 528.722 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 531.131 559.103 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 540.768 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 543.178 559.103 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 26.250 538.191 Td /F1 9.8 Tf [(Supplies ranked 5th amongst the 403 factors analyzed, in toto, was found to rank in the top three in 68% of responses when )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(subset analysis was performed on those claiming prior disaster experience. Other than being used in the SACCO scoring )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(system, this factor is not part of the most popular triage algorithm decision trees, but is part of the MUCC criteria and SALT )] TJ ET BT 26.250 502.476 Td /F1 9.8 Tf [(system.)] TJ ET 0.267 0.267 0.267 rg BT 59.839 503.984 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 69.476 502.476 Td /F1 9.8 Tf [( When the write-in sections were reviewed, respondents with Expectant Category experience wrote in that the )] TJ ET BT 26.250 490.572 Td /F1 9.8 Tf [(reason for the placing of patients in the expectant category was due to the lack of supplies/transportation. This pivotal point is )] TJ ET BT 26.250 478.667 Td /F1 9.8 Tf [(not unique to the pre-hospital or disaster arena. It has been described often in the critical care literature, where, during times of )] TJ ET BT 26.250 466.762 Td /F1 9.8 Tf [(resource limitations in critical care units, patients who normally would meet admission/treatment criteria are refused a bed in )] TJ ET BT 26.250 454.857 Td /F1 9.8 Tf [(favor of patients with a perceived more favorable set of sociological and medical parameters that might predict a better outcome.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 444.460 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 35.887 446.576 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 38.297 444.460 Td /F4 8.7 Tf [(28)] TJ ET 0.271 0.267 0.267 rg BT 47.934 446.576 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 50.343 444.460 Td /F4 8.7 Tf [(29)] TJ ET 0.271 0.267 0.267 rg BT 59.981 446.576 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 62.390 444.460 Td /F4 8.7 Tf [(30)] TJ ET 0.271 0.267 0.267 rg BT 26.250 424.871 Td /F1 9.8 Tf [(This document supports the MUCC, as it provides an additional framework for the development of local and adaptable triage )] TJ ET BT 26.250 412.966 Td /F1 9.8 Tf [(algorithms that include resource availability, sorting, lifesaving interventions, and individual patient assessment endorsing five )] TJ ET BT 26.250 401.061 Td /F1 9.8 Tf [(triage categories. From the MUCC came the resulting CDC endorsed SALT triage \(Figure 3\))] TJ ET 0.965 0.965 0.965 rg 26.250 156.526 555.000 234.655 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 391.180 m 581.250 391.180 l 581.250 390.430 l 26.250 390.430 l f 26.250 156.526 m 581.250 156.526 l 581.250 157.276 l 26.250 157.276 l f q 450.000 0 0 189.750 35.250 191.680 cm /I15 Do Q q 35.250 167.776 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 176.156 Td /F4 9.8 Tf [(Fig. 3: SALT Triage)] TJ ET Q BT 26.250 139.502 Td /F1 9.8 Tf [(as an example of a disaster triage algorithm and is presently taught as part of the National Disaster Life Support \(NDLS\) course )] TJ ET BT 26.250 127.597 Td /F1 9.8 Tf [(series. Triage is a fluid and dynamic process; it has multiple variables influencing the decision maker and should be adaptable )] TJ ET BT 26.250 115.692 Td /F1 9.8 Tf [(to a myriad of situations)] TJ ET BT 26.250 79.090 Td /F4 12.0 Tf [(CONCLUSION)] TJ ET BT 26.250 59.135 Td /F1 9.8 Tf [(Based upon this survey analysis, respondents both with and without direct disaster triage experience identified and ranked )] TJ ET BT 26.250 47.231 Td /F1 9.8 Tf [(triage attributes that support the MUCC guidelines. What appears to best support a balanced disaster mass casualty triage )] TJ ET Q q 15.000 32.945 577.500 744.055 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(placement of patients. The assumption made is that medical providers with practical experience in triage situations will prioritize )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(different attributes for the sorting of patients compared to those providers with no disaster experience. These findings in turn, )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(could provide more attribute weighting of the factors used create a more accurate triage algorithm. For example, in this study, )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(the top ranked categories regardless of experience level were cardiovascular and neurological with those respondents with )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(disaster experience placing a higher value on the ability of the patient to speak than on the cardiovascular criteria. This )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(suggests that brain perfusion to the experienced triage provider is considered a good indicator of injury severity.)] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(After the physiological attributes, in our rankings, Gut instinct ranked forth, regardless of disaster experience level with 8% )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(reporting, that they used it as their primary form of triage guidance. Instinct or gut instinct is related to experience, which is a )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(part of expert knowledge, and is very effective in cases of complex decisions such as triage.)] TJ ET 0.267 0.267 0.267 rg BT 422.383 666.245 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 432.020 664.738 Td /F1 9.8 Tf [( In the nursing literature, much )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(has been written about experience and instinct in patient care, with an acceptance that experience creates intuition which )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(guides recognition of subtle deterioration and subsequent appropriate nursing action.)] TJ ET 0.267 0.267 0.267 rg BT 392.070 642.436 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 401.707 640.929 Td /F1 9.8 Tf [( In the prehospital literature the support )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(of gust instinct has been mixed. A review of the earlier prehospital triage literature is varied, with some studies suggesting that )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(provider judgment is effective in increasing the sensitivity of triage.)] TJ ET 0.267 0.267 0.267 rg BT 312.364 618.626 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 322.001 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 324.410 618.626 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 334.048 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 336.457 618.626 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 346.094 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 348.504 618.626 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 358.141 617.119 Td /F1 9.8 Tf [( Other papers suggest it has no affect at all, which )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(could be due to a lack of overall provider experience.)] TJ ET 0.267 0.267 0.267 rg BT 254.400 606.722 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 264.037 609.103 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 266.447 606.722 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 276.084 605.214 Td /F1 9.8 Tf [( There have been two large retrospective trauma studies examining )] TJ ET BT 26.250 593.310 Td /F1 9.8 Tf [(prehospital triage and destination assignment to determine what historically prehospital providers have used for decision-)] TJ ET BT 26.250 581.405 Td /F1 9.8 Tf [(making. These analyzed a three year period where >250,000 injured person were transported; 36% of the time, EMS provider )] TJ ET BT 26.250 569.500 Td /F1 9.8 Tf [(judgment was the most commonly used triage criterion.)] TJ ET 0.267 0.267 0.267 rg BT 264.667 571.007 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 274.304 573.388 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 276.713 571.007 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 286.351 569.500 Td /F1 9.8 Tf [( This is further supported in a variety of published case reports )] TJ ET BT 26.250 557.595 Td /F1 9.8 Tf [(which have noticed that gut instinct played an enormous role in correctly assigning triage criteria to patients.)] TJ ET 0.267 0.267 0.267 rg BT 494.991 559.103 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 504.628 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 507.038 559.103 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 516.675 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 519.084 559.103 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 528.722 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 531.131 559.103 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 540.768 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 543.178 559.103 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 26.250 538.191 Td /F1 9.8 Tf [(Supplies ranked 5th amongst the 403 factors analyzed, in toto, was found to rank in the top three in 68% of responses when )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(subset analysis was performed on those claiming prior disaster experience. Other than being used in the SACCO scoring )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(system, this factor is not part of the most popular triage algorithm decision trees, but is part of the MUCC criteria and SALT )] TJ ET BT 26.250 502.476 Td /F1 9.8 Tf [(system.)] TJ ET 0.267 0.267 0.267 rg BT 59.839 503.984 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 69.476 502.476 Td /F1 9.8 Tf [( When the write-in sections were reviewed, respondents with Expectant Category experience wrote in that the )] TJ ET BT 26.250 490.572 Td /F1 9.8 Tf [(reason for the placing of patients in the expectant category was due to the lack of supplies/transportation. This pivotal point is )] TJ ET BT 26.250 478.667 Td /F1 9.8 Tf [(not unique to the pre-hospital or disaster arena. It has been described often in the critical care literature, where, during times of )] TJ ET BT 26.250 466.762 Td /F1 9.8 Tf [(resource limitations in critical care units, patients who normally would meet admission/treatment criteria are refused a bed in )] TJ ET BT 26.250 454.857 Td /F1 9.8 Tf [(favor of patients with a perceived more favorable set of sociological and medical parameters that might predict a better outcome.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 444.460 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 35.887 446.576 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 38.297 444.460 Td /F4 8.7 Tf [(28)] TJ ET 0.271 0.267 0.267 rg BT 47.934 446.576 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 50.343 444.460 Td /F4 8.7 Tf [(29)] TJ ET 0.271 0.267 0.267 rg BT 59.981 446.576 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 62.390 444.460 Td /F4 8.7 Tf [(30)] TJ ET 0.271 0.267 0.267 rg BT 26.250 424.871 Td /F1 9.8 Tf [(This document supports the MUCC, as it provides an additional framework for the development of local and adaptable triage )] TJ ET BT 26.250 412.966 Td /F1 9.8 Tf [(algorithms that include resource availability, sorting, lifesaving interventions, and individual patient assessment endorsing five )] TJ ET BT 26.250 401.061 Td /F1 9.8 Tf [(triage categories. From the MUCC came the resulting CDC endorsed SALT triage \(Figure 3\))] TJ ET 0.965 0.965 0.965 rg 26.250 156.526 555.000 234.655 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 391.180 m 581.250 391.180 l 581.250 390.430 l 26.250 390.430 l f 26.250 156.526 m 581.250 156.526 l 581.250 157.276 l 26.250 157.276 l f q 450.000 0 0 189.750 35.250 191.680 cm /I15 Do Q q 35.250 167.776 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 176.156 Td /F4 9.8 Tf [(Fig. 3: SALT Triage)] TJ ET Q BT 26.250 139.502 Td /F1 9.8 Tf [(as an example of a disaster triage algorithm and is presently taught as part of the National Disaster Life Support \(NDLS\) course )] TJ ET BT 26.250 127.597 Td /F1 9.8 Tf [(series. Triage is a fluid and dynamic process; it has multiple variables influencing the decision maker and should be adaptable )] TJ ET BT 26.250 115.692 Td /F1 9.8 Tf [(to a myriad of situations)] TJ ET BT 26.250 79.090 Td /F4 12.0 Tf [(CONCLUSION)] TJ ET BT 26.250 59.135 Td /F1 9.8 Tf [(Based upon this survey analysis, respondents both with and without direct disaster triage experience identified and ranked )] TJ ET BT 26.250 47.231 Td /F1 9.8 Tf [(triage attributes that support the MUCC guidelines. What appears to best support a balanced disaster mass casualty triage )] TJ ET Q q 15.000 32.945 577.500 744.055 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(placement of patients. The assumption made is that medical providers with practical experience in triage situations will prioritize )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(different attributes for the sorting of patients compared to those providers with no disaster experience. These findings in turn, )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(could provide more attribute weighting of the factors used create a more accurate triage algorithm. For example, in this study, )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(the top ranked categories regardless of experience level were cardiovascular and neurological with those respondents with )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(disaster experience placing a higher value on the ability of the patient to speak than on the cardiovascular criteria. This )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(suggests that brain perfusion to the experienced triage provider is considered a good indicator of injury severity.)] TJ ET BT 26.250 688.548 Td /F1 9.8 Tf [(After the physiological attributes, in our rankings, Gut instinct ranked forth, regardless of disaster experience level with 8% )] TJ ET BT 26.250 676.643 Td /F1 9.8 Tf [(reporting, that they used it as their primary form of triage guidance. Instinct or gut instinct is related to experience, which is a )] TJ ET BT 26.250 664.738 Td /F1 9.8 Tf [(part of expert knowledge, and is very effective in cases of complex decisions such as triage.)] TJ ET 0.267 0.267 0.267 rg BT 422.383 666.245 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 432.020 664.738 Td /F1 9.8 Tf [( In the nursing literature, much )] TJ ET BT 26.250 652.833 Td /F1 9.8 Tf [(has been written about experience and instinct in patient care, with an acceptance that experience creates intuition which )] TJ ET BT 26.250 640.929 Td /F1 9.8 Tf [(guides recognition of subtle deterioration and subsequent appropriate nursing action.)] TJ ET 0.267 0.267 0.267 rg BT 392.070 642.436 Td /F4 8.7 Tf [(19)] TJ ET 0.271 0.267 0.267 rg BT 401.707 640.929 Td /F1 9.8 Tf [( In the prehospital literature the support )] TJ ET BT 26.250 629.024 Td /F1 9.8 Tf [(of gust instinct has been mixed. A review of the earlier prehospital triage literature is varied, with some studies suggesting that )] TJ ET BT 26.250 617.119 Td /F1 9.8 Tf [(provider judgment is effective in increasing the sensitivity of triage.)] TJ ET 0.267 0.267 0.267 rg BT 312.364 618.626 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 322.001 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 324.410 618.626 Td /F4 8.7 Tf [(20)] TJ ET 0.271 0.267 0.267 rg BT 334.048 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 336.457 618.626 Td /F4 8.7 Tf [(21)] TJ ET 0.271 0.267 0.267 rg BT 346.094 621.007 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 348.504 618.626 Td /F4 8.7 Tf [(22)] TJ ET 0.271 0.267 0.267 rg BT 358.141 617.119 Td /F1 9.8 Tf [( Other papers suggest it has no affect at all, which )] TJ ET BT 26.250 605.214 Td /F1 9.8 Tf [(could be due to a lack of overall provider experience.)] TJ ET 0.267 0.267 0.267 rg BT 254.400 606.722 Td /F4 8.7 Tf [(23)] TJ ET 0.271 0.267 0.267 rg BT 264.037 609.103 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 266.447 606.722 Td /F4 8.7 Tf [(24)] TJ ET 0.271 0.267 0.267 rg BT 276.084 605.214 Td /F1 9.8 Tf [( There have been two large retrospective trauma studies examining )] TJ ET BT 26.250 593.310 Td /F1 9.8 Tf [(prehospital triage and destination assignment to determine what historically prehospital providers have used for decision-)] TJ ET BT 26.250 581.405 Td /F1 9.8 Tf [(making. These analyzed a three year period where >250,000 injured person were transported; 36% of the time, EMS provider )] TJ ET BT 26.250 569.500 Td /F1 9.8 Tf [(judgment was the most commonly used triage criterion.)] TJ ET 0.267 0.267 0.267 rg BT 264.667 571.007 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 274.304 573.388 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 276.713 571.007 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 286.351 569.500 Td /F1 9.8 Tf [( This is further supported in a variety of published case reports )] TJ ET BT 26.250 557.595 Td /F1 9.8 Tf [(which have noticed that gut instinct played an enormous role in correctly assigning triage criteria to patients.)] TJ ET 0.267 0.267 0.267 rg BT 494.991 559.103 Td /F4 8.7 Tf [(16)] TJ ET 0.271 0.267 0.267 rg BT 504.628 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 507.038 559.103 Td /F4 8.7 Tf [(17)] TJ ET 0.271 0.267 0.267 rg BT 516.675 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 519.084 559.103 Td /F4 8.7 Tf [(18)] TJ ET 0.271 0.267 0.267 rg BT 528.722 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 531.131 559.103 Td /F4 8.7 Tf [(25)] TJ ET 0.271 0.267 0.267 rg BT 540.768 561.484 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 543.178 559.103 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 26.250 538.191 Td /F1 9.8 Tf [(Supplies ranked 5th amongst the 403 factors analyzed, in toto, was found to rank in the top three in 68% of responses when )] TJ ET BT 26.250 526.286 Td /F1 9.8 Tf [(subset analysis was performed on those claiming prior disaster experience. Other than being used in the SACCO scoring )] TJ ET BT 26.250 514.381 Td /F1 9.8 Tf [(system, this factor is not part of the most popular triage algorithm decision trees, but is part of the MUCC criteria and SALT )] TJ ET BT 26.250 502.476 Td /F1 9.8 Tf [(system.)] TJ ET 0.267 0.267 0.267 rg BT 59.839 503.984 Td /F4 8.7 Tf [(27)] TJ ET 0.271 0.267 0.267 rg BT 69.476 502.476 Td /F1 9.8 Tf [( When the write-in sections were reviewed, respondents with Expectant Category experience wrote in that the )] TJ ET BT 26.250 490.572 Td /F1 9.8 Tf [(reason for the placing of patients in the expectant category was due to the lack of supplies/transportation. This pivotal point is )] TJ ET BT 26.250 478.667 Td /F1 9.8 Tf [(not unique to the pre-hospital or disaster arena. It has been described often in the critical care literature, where, during times of )] TJ ET BT 26.250 466.762 Td /F1 9.8 Tf [(resource limitations in critical care units, patients who normally would meet admission/treatment criteria are refused a bed in )] TJ ET BT 26.250 454.857 Td /F1 9.8 Tf [(favor of patients with a perceived more favorable set of sociological and medical parameters that might predict a better outcome.)] TJ ET 0.267 0.267 0.267 rg BT 26.250 444.460 Td /F4 8.7 Tf [(26)] TJ ET 0.271 0.267 0.267 rg BT 35.887 446.576 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 38.297 444.460 Td /F4 8.7 Tf [(28)] TJ ET 0.271 0.267 0.267 rg BT 47.934 446.576 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 50.343 444.460 Td /F4 8.7 Tf [(29)] TJ ET 0.271 0.267 0.267 rg BT 59.981 446.576 Td /F1 8.7 Tf [(,)] TJ ET 0.267 0.267 0.267 rg BT 62.390 444.460 Td /F4 8.7 Tf [(30)] TJ ET 0.271 0.267 0.267 rg BT 26.250 424.871 Td /F1 9.8 Tf [(This document supports the MUCC, as it provides an additional framework for the development of local and adaptable triage )] TJ ET BT 26.250 412.966 Td /F1 9.8 Tf [(algorithms that include resource availability, sorting, lifesaving interventions, and individual patient assessment endorsing five )] TJ ET BT 26.250 401.061 Td /F1 9.8 Tf [(triage categories. From the MUCC came the resulting CDC endorsed SALT triage \(Figure 3\))] TJ ET 0.965 0.965 0.965 rg 26.250 156.526 555.000 234.655 re f 0.267 0.267 0.267 rg 0.267 0.267 0.267 RG 26.250 391.180 m 581.250 391.180 l 581.250 390.430 l 26.250 390.430 l f 26.250 156.526 m 581.250 156.526 l 581.250 157.276 l 26.250 157.276 l f q 450.000 0 0 189.750 35.250 191.680 cm /I15 Do Q q 35.250 167.776 537.000 17.905 re W n 0.271 0.267 0.267 rg BT 35.250 176.156 Td /F4 9.8 Tf [(Fig. 3: SALT Triage)] TJ ET Q BT 26.250 139.502 Td /F1 9.8 Tf [(as an example of a disaster triage algorithm and is presently taught as part of the National Disaster Life Support \(NDLS\) course )] TJ ET BT 26.250 127.597 Td /F1 9.8 Tf [(series. Triage is a fluid and dynamic process; it has multiple variables influencing the decision maker and should be adaptable )] TJ ET BT 26.250 115.692 Td /F1 9.8 Tf [(to a myriad of situations)] TJ ET BT 26.250 79.090 Td /F4 12.0 Tf [(CONCLUSION)] TJ ET BT 26.250 59.135 Td /F1 9.8 Tf [(Based upon this survey analysis, respondents both with and without direct disaster triage experience identified and ranked )] TJ ET BT 26.250 47.231 Td /F1 9.8 Tf [(triage attributes that support the MUCC guidelines. 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Based on the success of this survey, the designed electronic survey tool is considered reliable for a second stage )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(international EMS qualitative analysis study of factors influencing primary triage decisions.)] TJ ET BT 26.250 671.350 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 651.396 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 614.793 Td /F4 12.0 Tf [(Data Statement)] TJ ET BT 26.250 594.839 Td /F1 9.8 Tf [(All relevant data are available within the paper.)] TJ ET BT 26.250 558.236 Td /F4 12.0 Tf [(Abbreviations)] TJ ET BT 26.250 538.282 Td /F1 9.8 Tf [(ARC: American Red Cross)] TJ ET BT 26.250 518.877 Td /F1 9.8 Tf [(CDP-Noble: Center for Domestic Preparedness-Noble Training Center)] TJ ET BT 26.250 499.473 Td /F1 9.8 Tf [(ESI: Emergency Severity Index)] TJ ET BT 26.250 480.068 Td /F1 9.8 Tf [(FEMA: Federal Emergency Management Agency)] TJ ET BT 26.250 460.663 Td /F1 9.8 Tf [(MASS: Move Assess, Sort, Send)] TJ ET BT 26.250 441.258 Td /F1 9.8 Tf [(NDLS: National Disaster Life Support)] TJ ET BT 26.250 421.854 Td /F1 9.8 Tf [(SALT: Sort, Assess, Lifesaving Interventions, Treatment/Transport)] TJ ET BT 26.250 402.449 Td /F1 9.8 Tf [(SAVE: Secondary Assessment of Victim Endpoint)] TJ ET BT 26.250 383.044 Td /F1 9.8 Tf [(START: Simple Triage and Rapid Treatment)] TJ ET BT 26.250 363.639 Td /F1 9.8 Tf [(STM: Sacco Triage Method)] TJ ET BT 26.250 327.037 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 299.583 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 299.583 Td /F1 9.8 Tf [(World Health Organization. Mass casualty management systems: Strategies and guidelines for building health sector )] TJ ET BT 26.250 287.678 Td /F1 9.8 Tf [(capacity. WHO, 2007. Available at: https://www.who.int/hac/techguidance/MCM_guidelines_inside_final.pdf. Accessed 1 April )] TJ ET BT 26.250 275.773 Td /F1 9.8 Tf [(2016.)] TJ ET BT 26.250 256.368 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 256.368 Td /F1 9.8 Tf [(Institute of Medicine \(IOM\). 2009. Guidance for establishing crisis standards of care for use in disaster situations: a letter )] TJ ET BT 26.250 244.464 Td /F1 9.8 Tf [(report. Washington, DC: The National Academies Press. Available at: )] TJ ET BT 26.250 232.559 Td /F1 9.8 Tf [(https://www.nationalacademies.org/hmd/Reports/2009/DisasterCareStandards.aspx. Accessed 1 April 2016.)] TJ ET BT 26.250 213.154 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 213.154 Td /F1 9.8 Tf [(FICEMS Report: National Implementation of the Model Uniform Core Criteria for Mass Casualty Incident Triage. A Report of )] TJ ET BT 26.250 201.249 Td /F1 9.8 Tf [(the FICEMS \(Federal Interagency Committee on Emergency Medical Services\). July 13, 2013. Available at: )] TJ ET BT 26.250 189.345 Td /F1 9.8 Tf [(ems.gov/pdf/2013/ficems_meet/07-FICEMS_MUCC_Implementation_Plan.pdf. Accessed on 22 January 2014.)] TJ ET BT 26.250 169.940 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 169.940 Td /F1 9.8 Tf [(McDonald L, Butterworth T, Yates DW. Triage: a literature review 1985-1993. Accid Emerg Nurs. 1995;3:201-207)] TJ ET BT 26.250 150.535 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 150.535 Td /F1 9.8 Tf [(Garrouste-Orgeas M, Montuclard L, Timsit JF, et al. Triaging patients to the ICU: a pilot study of factors influencing admission )] TJ ET BT 26.250 138.630 Td /F1 9.8 Tf [(decisions and patient outcomes. Intensive Care Med. 2003;29: 774-781)] TJ ET BT 26.250 119.226 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 119.226 Td /F1 9.8 Tf [(Burkle FM Jr. The triage dilemma: opening Pandora's box... ever so slowly. Crit Care. 2010;14\(1\):401.)] TJ ET BT 26.250 99.821 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 99.821 Td /F1 9.8 Tf [(Ramesh AC, Kumar S. Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, )] TJ ET BT 26.250 87.916 Td /F1 9.8 Tf [(or nuclear agents. J Pharm Bioallied Sci. 2010 Jul;2\(3\):239-47)] TJ ET BT 26.250 68.511 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 68.511 Td /F1 9.8 Tf [(Ashkenazi I, Turgano-Fuentes F, Einav S, et al. Pitfalls to avoid in the medical management of mass casualty incidents )] TJ ET BT 26.250 56.607 Td /F1 9.8 Tf [(following terrorist bombings: the hospital perspective. Eur J Trauma Emerg Surg. 2014 Aug;40\(4\):445-50.)] TJ ET Q q 15.000 46.726 577.500 730.274 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(system and considered the most important factors among the surveyed respondents are neurological/cardiovascular condition, )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(resource availability, and the personal attribute of gut instinct. In addition, decision making in primary triage of a MCI scenario )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(is multifactorial and encompasses life saving interventions, patient mobility, situational instincts and logistics all considered as )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(critical components of a triage scheme that needs more study and analysis. Consensus places experience during MCIs as very )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(important. Based on the success of this survey, the designed electronic survey tool is considered reliable for a second stage )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(international EMS qualitative analysis study of factors influencing primary triage decisions.)] TJ ET BT 26.250 671.350 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 651.396 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 614.793 Td /F4 12.0 Tf [(Data Statement)] TJ ET BT 26.250 594.839 Td /F1 9.8 Tf [(All relevant data are available within the paper.)] TJ ET BT 26.250 558.236 Td /F4 12.0 Tf [(Abbreviations)] TJ ET BT 26.250 538.282 Td /F1 9.8 Tf [(ARC: American Red Cross)] TJ ET BT 26.250 518.877 Td /F1 9.8 Tf [(CDP-Noble: Center for Domestic Preparedness-Noble Training Center)] TJ ET BT 26.250 499.473 Td /F1 9.8 Tf [(ESI: Emergency Severity Index)] TJ ET BT 26.250 480.068 Td /F1 9.8 Tf [(FEMA: Federal Emergency Management Agency)] TJ ET BT 26.250 460.663 Td /F1 9.8 Tf [(MASS: Move Assess, Sort, Send)] TJ ET BT 26.250 441.258 Td /F1 9.8 Tf [(NDLS: National Disaster Life Support)] TJ ET BT 26.250 421.854 Td /F1 9.8 Tf [(SALT: Sort, Assess, Lifesaving Interventions, Treatment/Transport)] TJ ET BT 26.250 402.449 Td /F1 9.8 Tf [(SAVE: Secondary Assessment of Victim Endpoint)] TJ ET BT 26.250 383.044 Td /F1 9.8 Tf [(START: Simple Triage and Rapid Treatment)] TJ ET BT 26.250 363.639 Td /F1 9.8 Tf [(STM: Sacco Triage Method)] TJ ET BT 26.250 327.037 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 299.583 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 299.583 Td /F1 9.8 Tf [(World Health Organization. Mass casualty management systems: Strategies and guidelines for building health sector )] TJ ET BT 26.250 287.678 Td /F1 9.8 Tf [(capacity. WHO, 2007. Available at: https://www.who.int/hac/techguidance/MCM_guidelines_inside_final.pdf. Accessed 1 April )] TJ ET BT 26.250 275.773 Td /F1 9.8 Tf [(2016.)] TJ ET BT 26.250 256.368 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 256.368 Td /F1 9.8 Tf [(Institute of Medicine \(IOM\). 2009. Guidance for establishing crisis standards of care for use in disaster situations: a letter )] TJ ET BT 26.250 244.464 Td /F1 9.8 Tf [(report. Washington, DC: The National Academies Press. Available at: )] TJ ET BT 26.250 232.559 Td /F1 9.8 Tf [(https://www.nationalacademies.org/hmd/Reports/2009/DisasterCareStandards.aspx. Accessed 1 April 2016.)] TJ ET BT 26.250 213.154 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 213.154 Td /F1 9.8 Tf [(FICEMS Report: National Implementation of the Model Uniform Core Criteria for Mass Casualty Incident Triage. A Report of )] TJ ET BT 26.250 201.249 Td /F1 9.8 Tf [(the FICEMS \(Federal Interagency Committee on Emergency Medical Services\). July 13, 2013. Available at: )] TJ ET BT 26.250 189.345 Td /F1 9.8 Tf [(ems.gov/pdf/2013/ficems_meet/07-FICEMS_MUCC_Implementation_Plan.pdf. Accessed on 22 January 2014.)] TJ ET BT 26.250 169.940 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 169.940 Td /F1 9.8 Tf [(McDonald L, Butterworth T, Yates DW. Triage: a literature review 1985-1993. Accid Emerg Nurs. 1995;3:201-207)] TJ ET BT 26.250 150.535 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 150.535 Td /F1 9.8 Tf [(Garrouste-Orgeas M, Montuclard L, Timsit JF, et al. Triaging patients to the ICU: a pilot study of factors influencing admission )] TJ ET BT 26.250 138.630 Td /F1 9.8 Tf [(decisions and patient outcomes. Intensive Care Med. 2003;29: 774-781)] TJ ET BT 26.250 119.226 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 119.226 Td /F1 9.8 Tf [(Burkle FM Jr. The triage dilemma: opening Pandora's box... ever so slowly. Crit Care. 2010;14\(1\):401.)] TJ ET BT 26.250 99.821 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 99.821 Td /F1 9.8 Tf [(Ramesh AC, Kumar S. Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, )] TJ ET BT 26.250 87.916 Td /F1 9.8 Tf [(or nuclear agents. J Pharm Bioallied Sci. 2010 Jul;2\(3\):239-47)] TJ ET BT 26.250 68.511 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 68.511 Td /F1 9.8 Tf [(Ashkenazi I, Turgano-Fuentes F, Einav S, et al. Pitfalls to avoid in the medical management of mass casualty incidents )] TJ ET BT 26.250 56.607 Td /F1 9.8 Tf [(following terrorist bombings: the hospital perspective. Eur J Trauma Emerg Surg. 2014 Aug;40\(4\):445-50.)] TJ ET Q q 15.000 46.726 577.500 730.274 re W n 0.271 0.267 0.267 rg BT 26.250 767.476 Td /F1 9.8 Tf [(system and considered the most important factors among the surveyed respondents are neurological/cardiovascular condition, )] TJ ET BT 26.250 755.571 Td /F1 9.8 Tf [(resource availability, and the personal attribute of gut instinct. In addition, decision making in primary triage of a MCI scenario )] TJ ET BT 26.250 743.667 Td /F1 9.8 Tf [(is multifactorial and encompasses life saving interventions, patient mobility, situational instincts and logistics all considered as )] TJ ET BT 26.250 731.762 Td /F1 9.8 Tf [(critical components of a triage scheme that needs more study and analysis. Consensus places experience during MCIs as very )] TJ ET BT 26.250 719.857 Td /F1 9.8 Tf [(important. Based on the success of this survey, the designed electronic survey tool is considered reliable for a second stage )] TJ ET BT 26.250 707.952 Td /F1 9.8 Tf [(international EMS qualitative analysis study of factors influencing primary triage decisions.)] TJ ET BT 26.250 671.350 Td /F4 12.0 Tf [(Competing Interests)] TJ ET BT 26.250 651.396 Td /F1 9.8 Tf [(The authors have declared that no competing interests exist.)] TJ ET BT 26.250 614.793 Td /F4 12.0 Tf [(Data Statement)] TJ ET BT 26.250 594.839 Td /F1 9.8 Tf [(All relevant data are available within the paper.)] TJ ET BT 26.250 558.236 Td /F4 12.0 Tf [(Abbreviations)] TJ ET BT 26.250 538.282 Td /F1 9.8 Tf [(ARC: American Red Cross)] TJ ET BT 26.250 518.877 Td /F1 9.8 Tf [(CDP-Noble: Center for Domestic Preparedness-Noble Training Center)] TJ ET BT 26.250 499.473 Td /F1 9.8 Tf [(ESI: Emergency Severity Index)] TJ ET BT 26.250 480.068 Td /F1 9.8 Tf [(FEMA: Federal Emergency Management Agency)] TJ ET BT 26.250 460.663 Td /F1 9.8 Tf [(MASS: Move Assess, Sort, Send)] TJ ET BT 26.250 441.258 Td /F1 9.8 Tf [(NDLS: National Disaster Life Support)] TJ ET BT 26.250 421.854 Td /F1 9.8 Tf [(SALT: Sort, Assess, Lifesaving Interventions, Treatment/Transport)] TJ ET BT 26.250 402.449 Td /F1 9.8 Tf [(SAVE: Secondary Assessment of Victim Endpoint)] TJ ET BT 26.250 383.044 Td /F1 9.8 Tf [(START: Simple Triage and Rapid Treatment)] TJ ET BT 26.250 363.639 Td /F1 9.8 Tf [(STM: Sacco Triage Method)] TJ ET BT 26.250 327.037 Td /F4 12.0 Tf [(References)] TJ ET BT 26.250 299.583 Td /F1 9.8 Tf [(1.)] TJ ET BT 38.132 299.583 Td /F1 9.8 Tf [(World Health Organization. Mass casualty management systems: Strategies and guidelines for building health sector )] TJ ET BT 26.250 287.678 Td /F1 9.8 Tf [(capacity. WHO, 2007. Available at: https://www.who.int/hac/techguidance/MCM_guidelines_inside_final.pdf. Accessed 1 April )] TJ ET BT 26.250 275.773 Td /F1 9.8 Tf [(2016.)] TJ ET BT 26.250 256.368 Td /F1 9.8 Tf [(2.)] TJ ET BT 38.132 256.368 Td /F1 9.8 Tf [(Institute of Medicine \(IOM\). 2009. Guidance for establishing crisis standards of care for use in disaster situations: a letter )] TJ ET BT 26.250 244.464 Td /F1 9.8 Tf [(report. Washington, DC: The National Academies Press. Available at: )] TJ ET BT 26.250 232.559 Td /F1 9.8 Tf [(https://www.nationalacademies.org/hmd/Reports/2009/DisasterCareStandards.aspx. Accessed 1 April 2016.)] TJ ET BT 26.250 213.154 Td /F1 9.8 Tf [(3.)] TJ ET BT 38.132 213.154 Td /F1 9.8 Tf [(FICEMS Report: National Implementation of the Model Uniform Core Criteria for Mass Casualty Incident Triage. A Report of )] TJ ET BT 26.250 201.249 Td /F1 9.8 Tf [(the FICEMS \(Federal Interagency Committee on Emergency Medical Services\). July 13, 2013. Available at: )] TJ ET BT 26.250 189.345 Td /F1 9.8 Tf [(ems.gov/pdf/2013/ficems_meet/07-FICEMS_MUCC_Implementation_Plan.pdf. Accessed on 22 January 2014.)] TJ ET BT 26.250 169.940 Td /F1 9.8 Tf [(4.)] TJ ET BT 38.132 169.940 Td /F1 9.8 Tf [(McDonald L, Butterworth T, Yates DW. Triage: a literature review 1985-1993. Accid Emerg Nurs. 1995;3:201-207)] TJ ET BT 26.250 150.535 Td /F1 9.8 Tf [(5.)] TJ ET BT 38.132 150.535 Td /F1 9.8 Tf [(Garrouste-Orgeas M, Montuclard L, Timsit JF, et al. Triaging patients to the ICU: a pilot study of factors influencing admission )] TJ ET BT 26.250 138.630 Td /F1 9.8 Tf [(decisions and patient outcomes. Intensive Care Med. 2003;29: 774-781)] TJ ET BT 26.250 119.226 Td /F1 9.8 Tf [(6.)] TJ ET BT 38.132 119.226 Td /F1 9.8 Tf [(Burkle FM Jr. The triage dilemma: opening Pandora's box... ever so slowly. Crit Care. 2010;14\(1\):401.)] TJ ET BT 26.250 99.821 Td /F1 9.8 Tf [(7.)] TJ ET BT 38.132 99.821 Td /F1 9.8 Tf [(Ramesh AC, Kumar S. Triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, )] TJ ET BT 26.250 87.916 Td /F1 9.8 Tf [(or nuclear agents. J Pharm Bioallied Sci. 2010 Jul;2\(3\):239-47)] TJ ET BT 26.250 68.511 Td /F1 9.8 Tf [(8.)] TJ ET BT 38.132 68.511 Td /F1 9.8 Tf [(Ashkenazi I, Turgano-Fuentes F, Einav S, et al. Pitfalls to avoid in the medical management of mass casualty incidents )] TJ ET BT 26.250 56.607 Td /F1 9.8 Tf [(following terrorist bombings: the hospital perspective. Eur J Trauma Emerg Surg. 2014 Aug;40\(4\):445-50.)] TJ ET Q q 0.000 0.000 0.000 rg BT 291.710 19.825 Td /F1 11.0 Tf [(8)] TJ ET BT 25.000 19.825 Td /F1 11.0 Tf [(PLOS Currents Disasters)] TJ ET Q endstream endobj 372 0 obj << /Type /Page /Parent 3 0 R /Contents 373 0 R >> endobj 373 0 obj << /Length 21034 >> stream 0.271 0.267 0.267 rg q 15.000 61.286 577.500 715.714 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 759.976 Td /F1 9.8 Tf [(Ashkenazi I, Kessel B, Khashan T, et al. Precision of in-hospital triage in mass-casualty incidents after terror attacks. )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(Prehosp Disaster Med. 2006 Jan-Feb;21\(1\):20-3.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(Rosenfeld JV, Fitzgerald M, Kossmann T, et al.Is the Australian hospital system adequately prepared for terrorism? Med J )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(Aust. 2005 Dec 5-19;183\(11-12\):567-70.)] TJ ET BT 26.250 697.357 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 697.357 Td /F1 9.8 Tf [(Cross KP, Cicero MX. Head-to-Head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann of )] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(Emerg Med. 2013;61:668-676.e7.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Travers DA, Waller AE, Bowling JM, et al. Five-level triage system more effective than three-level in tertiary emergency )] TJ ET BT 26.250 654.143 Td /F1 9.8 Tf [(department. J Emerg Nurs 2002; 28:395400.)] TJ ET BT 26.250 634.738 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 634.738 Td /F1 9.8 Tf [(Burkle FM. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage )] TJ ET BT 26.250 622.833 Td /F1 9.8 Tf [(decisions. Emerg Med Clin North Am. 2002;20:409-36.)] TJ ET BT 26.250 603.429 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 603.429 Td /F1 9.8 Tf [(Sasser SM, Hunt RC, Faul M, et al. Guidelines for Field Triage of Injured Patients Recommendations of the National Expert )] TJ ET BT 26.250 591.524 Td /F1 9.8 Tf [(Panel on Field Triage, 2011. MMWR. 2011;61\(1\):20)] TJ ET BT 26.250 572.119 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 572.119 Td /F1 9.8 Tf [(Fernandes CM, Tanabe P, Bonalumi N, et al. Emergency department triage: why we need a research agenda. Ann Emerg )] TJ ET BT 26.250 560.214 Td /F1 9.8 Tf [(Med. 2005 Aug;46\(2\):204-5.)] TJ ET BT 26.250 540.810 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 540.810 Td /F1 9.8 Tf [(Newgard CD, Nelson MJ, Kampp M, et al. Out-of-Hospital Decision Making and Factors Influencing the Regional )] TJ ET BT 26.250 528.905 Td /F1 9.8 Tf [(Distribution of Injured Patients in a Trauma System. Journal of Trauma Injury, Infection, and Critical Care. 2011;70\(6\):8.)] TJ ET BT 26.250 509.500 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 509.500 Td /F1 9.8 Tf [(Newgard CD, Kampp M, Nelson M, et al. Deciphering the use and predictive value of emergency medical ser- vices )] TJ ET BT 26.250 497.595 Td /F1 9.8 Tf [(provider judgment in out-of-hospital trauma triage: a multisite, mixed methods assessment. J Trauma Acute Care Surg. )] TJ ET BT 26.250 485.691 Td /F1 9.8 Tf [(2012;72\(5\):123948.)] TJ ET BT 26.250 466.286 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 466.286 Td /F1 9.8 Tf [(Hick JL, Ho JD, Heegaard WG, et al. Emergency medical services response to a major freeway bridge collapse. Disaster )] TJ ET BT 26.250 454.381 Td /F1 9.8 Tf [(Med Public Health Prep. 2008: suppl 1:S17-24)] TJ ET BT 26.250 434.976 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 434.976 Td /F1 9.8 Tf [(Hill W. Cognitive human factors in ICU: An original qualitative study of resilience and techniques ICU clinicians report they )] TJ ET BT 26.250 423.072 Td /F1 9.8 Tf [(use to develop their anticipation, intuition and foresight at change of shift report. Canadian Journal of Respiratory Therapy. )] TJ ET BT 26.250 411.167 Td /F1 9.8 Tf [(2010; 46\(4\): 16-24.)] TJ ET BT 26.250 391.762 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 391.762 Td /F1 9.8 Tf [(Mulholland SA, Gabbe BJ, Cameron P, et al. Is paramedic judgment useful in prehospital trauma triage? Injury. 2005;36:7.)] TJ ET BT 26.250 372.357 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 372.357 Td /F1 9.8 Tf [(Mulholland SA, Cameron PA, Gabbe BJ, et al. Prehospital Prediction of the Severity of Blunt Anatomic Injury. J )] TJ ET BT 26.250 360.453 Td /F1 9.8 Tf [(Trauma.2008;64:6.)] TJ ET BT 26.250 341.048 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 341.048 Td /F1 9.8 Tf [(Lavoie A, Emond M, Moore L, et al. Evaluation of the prehospital Index, presence of high-velocity impact and judgment of )] TJ ET BT 26.250 329.143 Td /F1 9.8 Tf [(emergency medical technicians as criteria for trauma triage. Canadian Journal of Emergency Medicine. 2010;12\(2\):7.)] TJ ET BT 26.250 309.738 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 309.738 Td /F1 9.8 Tf [(Ornato J, Edward J Mlinek J, et al. Ineffectiveness of the Trauma Score and the CRAMS Scale for Accurately Triaging )] TJ ET BT 26.250 297.834 Td /F1 9.8 Tf [(Patients to Trauma Centers. Annals of Emergency Medicine. 1985;14\(11\):5.)] TJ ET BT 26.250 278.429 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 278.429 Td /F1 9.8 Tf [(Rainer TH, Houlihan KPG, Robertson CE, et al. An evaluation of paramedic activities in prehospital trauma care. Injury. )] TJ ET BT 26.250 266.524 Td /F1 9.8 Tf [(1997;28\(9-10\):4.)] TJ ET BT 26.250 247.119 Td /F1 9.8 Tf [(25.)] TJ ET BT 43.553 247.119 Td /F1 9.8 Tf [(Barnett AS, Wang NE, Sahni R, et al. Variation in prehospital use and uptake of the national Field Triage Decision Scheme. )] TJ ET BT 26.250 235.215 Td /F1 9.8 Tf [(Prehosp Emerg Care. 2013;17\(2\):13548.)] TJ ET BT 26.250 215.810 Td /F1 9.8 Tf [(26.)] TJ ET BT 43.553 215.810 Td /F1 9.8 Tf [(Calder LA, Forster AJ, Stiell IG, et al. Mapping out the emergency department disposition decision for high-acuity patients. )] TJ ET BT 26.250 203.905 Td /F1 9.8 Tf [(Ann Emerg Med. 2012;60:567-576)] TJ ET BT 26.250 184.500 Td /F1 9.8 Tf [(27.)] TJ ET BT 43.553 184.500 Td /F1 9.8 Tf [(Sacco WJ, Navin DM, Fiedler KE, et al. Precise formulation and evidence-based application of resource-constrained triage. )] TJ ET BT 26.250 172.596 Td /F1 9.8 Tf [(Acad Emerg Med. 2005;12:287-302.)] TJ ET BT 26.250 153.191 Td /F1 9.8 Tf [(28.)] TJ ET BT 43.553 153.191 Td /F1 9.8 Tf [(Joynt GM, Gomersall CD, Tan P, et al. Prospective evaluation of patients refused admission to an intensive care unit: triage, )] TJ ET BT 26.250 141.286 Td /F1 9.8 Tf [(futility and outcome. Intensive Care Med. 2001 Sep;27\(9\):1459-65.)] TJ ET BT 26.250 121.881 Td /F1 9.8 Tf [(29.)] TJ ET BT 43.553 121.881 Td /F1 9.8 Tf [(Caldeira VM, Silva Jnior JM, Oliveira AM, et al. Criteria for patient admission to an intensive care unit and related mortality )] TJ ET BT 26.250 109.977 Td /F1 9.8 Tf [(rates. Rev Assoc Med Bras. 2010 Sep-Oct;56\(5\):528-34.)] TJ ET BT 26.250 90.572 Td /F1 9.8 Tf [(30.)] TJ ET BT 43.553 90.572 Td /F1 9.8 Tf [(Toffart AC, Pizarro CA, Schwebel C, et al. Selection criteria for intensive care unit referral of lung cancer patients: a pilot )] TJ ET BT 26.250 78.667 Td /F1 9.8 Tf [(study. Eur Respir J. 2015 Feb;45\(2\):491-500.)] TJ ET Q q 15.000 61.286 577.500 715.714 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 759.976 Td /F1 9.8 Tf [(Ashkenazi I, Kessel B, Khashan T, et al. Precision of in-hospital triage in mass-casualty incidents after terror attacks. )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(Prehosp Disaster Med. 2006 Jan-Feb;21\(1\):20-3.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(Rosenfeld JV, Fitzgerald M, Kossmann T, et al.Is the Australian hospital system adequately prepared for terrorism? Med J )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(Aust. 2005 Dec 5-19;183\(11-12\):567-70.)] TJ ET BT 26.250 697.357 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 697.357 Td /F1 9.8 Tf [(Cross KP, Cicero MX. Head-to-Head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann of )] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(Emerg Med. 2013;61:668-676.e7.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Travers DA, Waller AE, Bowling JM, et al. Five-level triage system more effective than three-level in tertiary emergency )] TJ ET BT 26.250 654.143 Td /F1 9.8 Tf [(department. J Emerg Nurs 2002; 28:395400.)] TJ ET BT 26.250 634.738 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 634.738 Td /F1 9.8 Tf [(Burkle FM. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage )] TJ ET BT 26.250 622.833 Td /F1 9.8 Tf [(decisions. Emerg Med Clin North Am. 2002;20:409-36.)] TJ ET BT 26.250 603.429 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 603.429 Td /F1 9.8 Tf [(Sasser SM, Hunt RC, Faul M, et al. Guidelines for Field Triage of Injured Patients Recommendations of the National Expert )] TJ ET BT 26.250 591.524 Td /F1 9.8 Tf [(Panel on Field Triage, 2011. MMWR. 2011;61\(1\):20)] TJ ET BT 26.250 572.119 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 572.119 Td /F1 9.8 Tf [(Fernandes CM, Tanabe P, Bonalumi N, et al. Emergency department triage: why we need a research agenda. Ann Emerg )] TJ ET BT 26.250 560.214 Td /F1 9.8 Tf [(Med. 2005 Aug;46\(2\):204-5.)] TJ ET BT 26.250 540.810 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 540.810 Td /F1 9.8 Tf [(Newgard CD, Nelson MJ, Kampp M, et al. Out-of-Hospital Decision Making and Factors Influencing the Regional )] TJ ET BT 26.250 528.905 Td /F1 9.8 Tf [(Distribution of Injured Patients in a Trauma System. Journal of Trauma Injury, Infection, and Critical Care. 2011;70\(6\):8.)] TJ ET BT 26.250 509.500 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 509.500 Td /F1 9.8 Tf [(Newgard CD, Kampp M, Nelson M, et al. Deciphering the use and predictive value of emergency medical ser- vices )] TJ ET BT 26.250 497.595 Td /F1 9.8 Tf [(provider judgment in out-of-hospital trauma triage: a multisite, mixed methods assessment. J Trauma Acute Care Surg. )] TJ ET BT 26.250 485.691 Td /F1 9.8 Tf [(2012;72\(5\):123948.)] TJ ET BT 26.250 466.286 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 466.286 Td /F1 9.8 Tf [(Hick JL, Ho JD, Heegaard WG, et al. Emergency medical services response to a major freeway bridge collapse. Disaster )] TJ ET BT 26.250 454.381 Td /F1 9.8 Tf [(Med Public Health Prep. 2008: suppl 1:S17-24)] TJ ET BT 26.250 434.976 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 434.976 Td /F1 9.8 Tf [(Hill W. Cognitive human factors in ICU: An original qualitative study of resilience and techniques ICU clinicians report they )] TJ ET BT 26.250 423.072 Td /F1 9.8 Tf [(use to develop their anticipation, intuition and foresight at change of shift report. Canadian Journal of Respiratory Therapy. )] TJ ET BT 26.250 411.167 Td /F1 9.8 Tf [(2010; 46\(4\): 16-24.)] TJ ET BT 26.250 391.762 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 391.762 Td /F1 9.8 Tf [(Mulholland SA, Gabbe BJ, Cameron P, et al. Is paramedic judgment useful in prehospital trauma triage? Injury. 2005;36:7.)] TJ ET BT 26.250 372.357 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 372.357 Td /F1 9.8 Tf [(Mulholland SA, Cameron PA, Gabbe BJ, et al. Prehospital Prediction of the Severity of Blunt Anatomic Injury. J )] TJ ET BT 26.250 360.453 Td /F1 9.8 Tf [(Trauma.2008;64:6.)] TJ ET BT 26.250 341.048 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 341.048 Td /F1 9.8 Tf [(Lavoie A, Emond M, Moore L, et al. Evaluation of the prehospital Index, presence of high-velocity impact and judgment of )] TJ ET BT 26.250 329.143 Td /F1 9.8 Tf [(emergency medical technicians as criteria for trauma triage. Canadian Journal of Emergency Medicine. 2010;12\(2\):7.)] TJ ET BT 26.250 309.738 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 309.738 Td /F1 9.8 Tf [(Ornato J, Edward J Mlinek J, et al. Ineffectiveness of the Trauma Score and the CRAMS Scale for Accurately Triaging )] TJ ET BT 26.250 297.834 Td /F1 9.8 Tf [(Patients to Trauma Centers. Annals of Emergency Medicine. 1985;14\(11\):5.)] TJ ET BT 26.250 278.429 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 278.429 Td /F1 9.8 Tf [(Rainer TH, Houlihan KPG, Robertson CE, et al. An evaluation of paramedic activities in prehospital trauma care. Injury. )] TJ ET BT 26.250 266.524 Td /F1 9.8 Tf [(1997;28\(9-10\):4.)] TJ ET BT 26.250 247.119 Td /F1 9.8 Tf [(25.)] TJ ET BT 43.553 247.119 Td /F1 9.8 Tf [(Barnett AS, Wang NE, Sahni R, et al. Variation in prehospital use and uptake of the national Field Triage Decision Scheme. )] TJ ET BT 26.250 235.215 Td /F1 9.8 Tf [(Prehosp Emerg Care. 2013;17\(2\):13548.)] TJ ET BT 26.250 215.810 Td /F1 9.8 Tf [(26.)] TJ ET BT 43.553 215.810 Td /F1 9.8 Tf [(Calder LA, Forster AJ, Stiell IG, et al. Mapping out the emergency department disposition decision for high-acuity patients. )] TJ ET BT 26.250 203.905 Td /F1 9.8 Tf [(Ann Emerg Med. 2012;60:567-576)] TJ ET BT 26.250 184.500 Td /F1 9.8 Tf [(27.)] TJ ET BT 43.553 184.500 Td /F1 9.8 Tf [(Sacco WJ, Navin DM, Fiedler KE, et al. Precise formulation and evidence-based application of resource-constrained triage. )] TJ ET BT 26.250 172.596 Td /F1 9.8 Tf [(Acad Emerg Med. 2005;12:287-302.)] TJ ET BT 26.250 153.191 Td /F1 9.8 Tf [(28.)] TJ ET BT 43.553 153.191 Td /F1 9.8 Tf [(Joynt GM, Gomersall CD, Tan P, et al. Prospective evaluation of patients refused admission to an intensive care unit: triage, )] TJ ET BT 26.250 141.286 Td /F1 9.8 Tf [(futility and outcome. Intensive Care Med. 2001 Sep;27\(9\):1459-65.)] TJ ET BT 26.250 121.881 Td /F1 9.8 Tf [(29.)] TJ ET BT 43.553 121.881 Td /F1 9.8 Tf [(Caldeira VM, Silva Jnior JM, Oliveira AM, et al. Criteria for patient admission to an intensive care unit and related mortality )] TJ ET BT 26.250 109.977 Td /F1 9.8 Tf [(rates. Rev Assoc Med Bras. 2010 Sep-Oct;56\(5\):528-34.)] TJ ET BT 26.250 90.572 Td /F1 9.8 Tf [(30.)] TJ ET BT 43.553 90.572 Td /F1 9.8 Tf [(Toffart AC, Pizarro CA, Schwebel C, et al. Selection criteria for intensive care unit referral of lung cancer patients: a pilot )] TJ ET BT 26.250 78.667 Td /F1 9.8 Tf [(study. Eur Respir J. 2015 Feb;45\(2\):491-500.)] TJ ET Q q 15.000 61.286 577.500 715.714 re W n 0.271 0.267 0.267 rg BT 26.250 759.976 Td /F1 9.8 Tf [(9.)] TJ ET BT 38.132 759.976 Td /F1 9.8 Tf [(Ashkenazi I, Kessel B, Khashan T, et al. Precision of in-hospital triage in mass-casualty incidents after terror attacks. )] TJ ET BT 26.250 748.071 Td /F1 9.8 Tf [(Prehosp Disaster Med. 2006 Jan-Feb;21\(1\):20-3.)] TJ ET BT 26.250 728.667 Td /F1 9.8 Tf [(10.)] TJ ET BT 43.553 728.667 Td /F1 9.8 Tf [(Rosenfeld JV, Fitzgerald M, Kossmann T, et al.Is the Australian hospital system adequately prepared for terrorism? Med J )] TJ ET BT 26.250 716.762 Td /F1 9.8 Tf [(Aust. 2005 Dec 5-19;183\(11-12\):567-70.)] TJ ET BT 26.250 697.357 Td /F1 9.8 Tf [(11.)] TJ ET BT 43.553 697.357 Td /F1 9.8 Tf [(Cross KP, Cicero MX. Head-to-Head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann of )] TJ ET BT 26.250 685.452 Td /F1 9.8 Tf [(Emerg Med. 2013;61:668-676.e7.)] TJ ET BT 26.250 666.048 Td /F1 9.8 Tf [(12.)] TJ ET BT 43.553 666.048 Td /F1 9.8 Tf [(Travers DA, Waller AE, Bowling JM, et al. Five-level triage system more effective than three-level in tertiary emergency )] TJ ET BT 26.250 654.143 Td /F1 9.8 Tf [(department. J Emerg Nurs 2002; 28:395400.)] TJ ET BT 26.250 634.738 Td /F1 9.8 Tf [(13.)] TJ ET BT 43.553 634.738 Td /F1 9.8 Tf [(Burkle FM. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage )] TJ ET BT 26.250 622.833 Td /F1 9.8 Tf [(decisions. Emerg Med Clin North Am. 2002;20:409-36.)] TJ ET BT 26.250 603.429 Td /F1 9.8 Tf [(14.)] TJ ET BT 43.553 603.429 Td /F1 9.8 Tf [(Sasser SM, Hunt RC, Faul M, et al. Guidelines for Field Triage of Injured Patients Recommendations of the National Expert )] TJ ET BT 26.250 591.524 Td /F1 9.8 Tf [(Panel on Field Triage, 2011. MMWR. 2011;61\(1\):20)] TJ ET BT 26.250 572.119 Td /F1 9.8 Tf [(15.)] TJ ET BT 43.553 572.119 Td /F1 9.8 Tf [(Fernandes CM, Tanabe P, Bonalumi N, et al. Emergency department triage: why we need a research agenda. Ann Emerg )] TJ ET BT 26.250 560.214 Td /F1 9.8 Tf [(Med. 2005 Aug;46\(2\):204-5.)] TJ ET BT 26.250 540.810 Td /F1 9.8 Tf [(16.)] TJ ET BT 43.553 540.810 Td /F1 9.8 Tf [(Newgard CD, Nelson MJ, Kampp M, et al. Out-of-Hospital Decision Making and Factors Influencing the Regional )] TJ ET BT 26.250 528.905 Td /F1 9.8 Tf [(Distribution of Injured Patients in a Trauma System. Journal of Trauma Injury, Infection, and Critical Care. 2011;70\(6\):8.)] TJ ET BT 26.250 509.500 Td /F1 9.8 Tf [(17.)] TJ ET BT 43.553 509.500 Td /F1 9.8 Tf [(Newgard CD, Kampp M, Nelson M, et al. Deciphering the use and predictive value of emergency medical ser- vices )] TJ ET BT 26.250 497.595 Td /F1 9.8 Tf [(provider judgment in out-of-hospital trauma triage: a multisite, mixed methods assessment. J Trauma Acute Care Surg. )] TJ ET BT 26.250 485.691 Td /F1 9.8 Tf [(2012;72\(5\):123948.)] TJ ET BT 26.250 466.286 Td /F1 9.8 Tf [(18.)] TJ ET BT 43.553 466.286 Td /F1 9.8 Tf [(Hick JL, Ho JD, Heegaard WG, et al. Emergency medical services response to a major freeway bridge collapse. Disaster )] TJ ET BT 26.250 454.381 Td /F1 9.8 Tf [(Med Public Health Prep. 2008: suppl 1:S17-24)] TJ ET BT 26.250 434.976 Td /F1 9.8 Tf [(19.)] TJ ET BT 43.553 434.976 Td /F1 9.8 Tf [(Hill W. Cognitive human factors in ICU: An original qualitative study of resilience and techniques ICU clinicians report they )] TJ ET BT 26.250 423.072 Td /F1 9.8 Tf [(use to develop their anticipation, intuition and foresight at change of shift report. Canadian Journal of Respiratory Therapy. )] TJ ET BT 26.250 411.167 Td /F1 9.8 Tf [(2010; 46\(4\): 16-24.)] TJ ET BT 26.250 391.762 Td /F1 9.8 Tf [(20.)] TJ ET BT 43.553 391.762 Td /F1 9.8 Tf [(Mulholland SA, Gabbe BJ, Cameron P, et al. Is paramedic judgment useful in prehospital trauma triage? Injury. 2005;36:7.)] TJ ET BT 26.250 372.357 Td /F1 9.8 Tf [(21.)] TJ ET BT 43.553 372.357 Td /F1 9.8 Tf [(Mulholland SA, Cameron PA, Gabbe BJ, et al. Prehospital Prediction of the Severity of Blunt Anatomic Injury. J )] TJ ET BT 26.250 360.453 Td /F1 9.8 Tf [(Trauma.2008;64:6.)] TJ ET BT 26.250 341.048 Td /F1 9.8 Tf [(22.)] TJ ET BT 43.553 341.048 Td /F1 9.8 Tf [(Lavoie A, Emond M, Moore L, et al. Evaluation of the prehospital Index, presence of high-velocity impact and judgment of )] TJ ET BT 26.250 329.143 Td /F1 9.8 Tf [(emergency medical technicians as criteria for trauma triage. Canadian Journal of Emergency Medicine. 2010;12\(2\):7.)] TJ ET BT 26.250 309.738 Td /F1 9.8 Tf [(23.)] TJ ET BT 43.553 309.738 Td /F1 9.8 Tf [(Ornato J, Edward J Mlinek J, et al. Ineffectiveness of the Trauma Score and the CRAMS Scale for Accurately Triaging )] TJ ET BT 26.250 297.834 Td /F1 9.8 Tf [(Patients to Trauma Centers. Annals of Emergency Medicine. 1985;14\(11\):5.)] TJ ET BT 26.250 278.429 Td /F1 9.8 Tf [(24.)] TJ ET BT 43.553 278.429 Td /F1 9.8 Tf [(Rainer TH, Houlihan KPG, Robertson CE, et al. An evaluation of paramedic activities in prehospital trauma care. Injury. )] TJ ET BT 26.250 266.524 Td /F1 9.8 Tf [(1997;28\(9-10\):4.)] TJ ET BT 26.250 247.119 Td /F1 9.8 Tf [(25.)] TJ ET BT 43.553 247.119 Td /F1 9.8 Tf [(Barnett AS, Wang NE, Sahni R, et al. Variation in prehospital use and uptake of the national Field Triage Decision Scheme. )] TJ ET BT 26.250 235.215 Td /F1 9.8 Tf [(Prehosp Emerg Care. 2013;17\(2\):13548.)] TJ ET BT 26.250 215.810 Td /F1 9.8 Tf [(26.)] TJ ET BT 43.553 215.810 Td /F1 9.8 Tf [(Calder LA, Forster AJ, Stiell IG, et al. Mapping out the emergency department disposition decision for high-acuity patients. )] TJ ET BT 26.250 203.905 Td /F1 9.8 Tf [(Ann Emerg Med. 2012;60:567-576)] TJ ET BT 26.250 184.500 Td /F1 9.8 Tf [(27.)] TJ ET BT 43.553 184.500 Td /F1 9.8 Tf [(Sacco WJ, Navin DM, Fiedler KE, et al. Precise formulation and evidence-based application of resource-constrained triage. )] TJ ET BT 26.250 172.596 Td /F1 9.8 Tf [(Acad Emerg Med. 2005;12:287-302.)] TJ ET BT 26.250 153.191 Td /F1 9.8 Tf [(28.)] TJ ET BT 43.553 153.191 Td /F1 9.8 Tf [(Joynt GM, Gomersall CD, Tan P, et al. Prospective evaluation of patients refused admission to an intensive care unit: triage, )] TJ ET BT 26.250 141.286 Td /F1 9.8 Tf [(futility and outcome. Intensive Care Med. 2001 Sep;27\(9\):1459-65.)] TJ ET BT 26.250 121.881 Td /F1 9.8 Tf [(29.)] TJ ET BT 43.553 121.881 Td /F1 9.8 Tf [(Caldeira VM, Silva Jnior JM, Oliveira AM, et al. Criteria for patient admission to an intensive care unit and related mortality )] TJ ET BT 26.250 109.977 Td /F1 9.8 Tf [(rates. Rev Assoc Med Bras. 2010 Sep-Oct;56\(5\):528-34.)] TJ ET BT 26.250 90.572 Td /F1 9.8 Tf [(30.)] TJ ET BT 43.553 90.572 Td /F1 9.8 Tf [(Toffart AC, Pizarro CA, Schwebel C, et al. Selection criteria for intensive care unit referral of lung cancer patients: a pilot )] TJ ET BT 26.250 78.667 Td /F1 9.8 Tf [(study. 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