Pitfalls and Challenges

There are a number of problems which can arise even when patients are triaged appropriately using the previously discussed tools.

Similar to a diagnostic test, each triage tool will have its own performance characteristics. With triage tools being comprised of simple physiological assessments (even the Triage Sort) it is impossible for them to achieve 100% sensitivity and specificity. This is unsurprising given that they are expected to perform across the age range, in complex patients, potentially with multiple comorbidities/polypharmacy, in situations arising from a variety of mechanisms of injury. As such, in any incident there will be a number of patients who are ‘under-triaged’ – meaning that they are allocated to a lower priority than they should – or ‘over-triaged’ to a more urgent category than is appropriate.

In most situations in medicine, it would be deemed better to have patients ‘over-triaged’ – thereby receiving care more urgently than they are strictly requiring – than ‘under-triaged’ and receiving delayed attention. However, in the case of a mass casualty incident this brings its own problems. Where resources are limited, having a greater number of patients allocated to receive urgent care may result in overwhelming of resources and a situation that is very difficult to manage, especially as there is no way of identifying the most critical patients within the T1/P1 pool. (8)

It is also important to be mindful that the triage system is in its nature a ‘snapshot’ assessment, considering a patient’s condition at just one point in time. As such, a casualty may be effectively compensating at the point of triage but subsequently deteriorate, and their stable physiology at the moment of assessment may put them at risk of not receiving the care that they require. Conversely a casualty may become much more stable following simple interventions or the passage of time after a stressful event, and if not reassessed appropriately they would continue to be prioritised for care despite it no longer being urgent for them. The value of revisiting the triage assessments for casualties such as these is clear – however the practicalities of performing repeated triage assessments in what is by definition a resource-limited environment, are challenging. (14)