Editing Triage (section)

== Limitations of current practices ==
Notions of mass casualty triage as an efficient rationing process of determining priority based upon injury severity are not supported by research, evaluation and testing of current triage practices, which lack scientific and methodological bases. START and START-like (START) triage that use color-coded categories to prioritize provide poor assessments of injury severity and then leave it to providers to subjectively order and allocate resources within flawed categories.<ref name="Lindsey_2005">{{cite journal | vauthors = Lindsey J | title = New triage method considers available resources | journal = JEMS: A Journal of Emergency Medical Services | volume = 30 | issue = 7 | pages = 92–94 | date = July 2005 | pmid = 16027670 | doi = 10.1016/S0197 | doi-broken-date = 1 November 2024 | url = http://saccotriage.com/pdf/JEMS_7_05_New_Triage_v2.pdf | archive-url = https://web.archive.org/web/20160304054034/http://saccotriage.com/pdf/JEMS_7_05_New_Triage_v2.pdf | archive-date = 2016-03-04 }}</ref> Some of these limitations include:

* lacking the clear goal of maximizing the number of lives saved, as well as the focus, design and objective methodology to accomplish that goal (a protocol of taking the worst Immediate – lowest chances for survival – first can be statistically invalid and dangerous)<ref name="Lindsey_2005" /><ref name="Lerner_2008">{{cite journal | vauthors = Lerner EB, Schwartz RB, Coule PL, Weinstein ES, Cone DC, Hunt RC, Sasser SM, Liu JM, Nudell NG, Wedmore IS, Hammond J, Bulger EM, Salomone JP, Sanddal TL, Markenson D, O'Connor RE | display-authors = 6 | title = Mass casualty triage: an evaluation of the data and development of a proposed national guideline | journal = Disaster Medicine and Public Health Preparedness | volume = 2 | issue = Suppl 1  | pages = S25–S34 | date = September 2008 | pmid = 18769263 | doi = 10.1097/DMP.0b013e318182194e | s2cid = 8262943 | doi-access = free }}</ref>
* using trauma measures that are problematic (e.g., capillary refill)<ref name="Lerner_2008" /> and grouping into broad color-coded categories that are not in accordance with injury severities, medical evidence and needs. Categories do not differentiate among injury severities and survival probabilities, and are invalid based on categorical definitions and evacuation priorities
* ordering (prioritization) and allocating resources subjectively within Immediate and Delayed categories, which are neither reproducible nor scalable, with little chance of being optimal<ref name="Lindsey_2005" />
* not considering/addressing size of incident, resources, and injury severities and prioritization within its categories<ref name="Lindsey_2005" /><ref name="Lerner_2008" /> – e.g., protocol does not change whether 3, 30 or 3,000 casualties require its use, and regardless of available resources to be rationed
* not considering differences in injury severities and survival probabilities between types of trauma (blunt versus penetrating, etc.) and ages
* resulting in inconsistent tagging and prioritizing/ordering of casualties and substantial overtriage

Research indicates there are wide ranges and overlaps of survival probabilities of the Immediate and Delayed categories, and other START limitations. The same physiologic measures can have markedly different survival probabilities for blunt and penetrating injuries. For example, a START Delayed (second priority) can have a survival probability of 63% for blunt trauma and a survival probability of 32% for penetrating trauma with the same physiological measures – both with expected rapid deterioration, while a START Immediate (first priority) can have survival probabilities that extend to above 95% with expected slow deterioration. Age categories exacerbate this. For example, a geriatric patient with a penetrating injury in the Delayed category can have an 8% survival probability, and a pediatric patient in the Immediate category can have a 98% survival probability. Issues with the other START categories have also been noted.<ref name="Lerner_2008" /> In this context, color-coded tagging accuracy metrics are not scientifically meaningful.

Poor assessments, invalid categories, no objective methodology and tools for prioritizing casualties and allocating resources, and a protocol of worst first triage provide some challenges for emergency and disaster preparedness and response. These are clear obstacles for efficient triage and resource rationing, for maximizing savings of lives, for best practices and National Incident Management System (NIMS) compatibilities,<ref name="thirteen">{{cite web | work = US Department of Homeland Security. | title = National Incident Management System. | date = December 2008 | url = http://www.fema.gov/national-incident-management-system }}</ref><ref name="Villani_2007">{{cite web | vauthors = Villani D | work = Department of Public Safety, Okaloosa County, Florida. | title = Letter to FEMA asking if START and STM are NIMS compatible. | date = September 2007 | url = http://saccotriage.com/pdf/Florida_official_letter_toFEMA.pdf | archive-url = https://web.archive.org/web/20160303233313/http://saccotriage.com/pdf/Florida_official_letter_toFEMA.pdf | archive-date=2016-03-03 }}</ref><ref name="Fluman_2007">{{cite web | vauthors = Fluman A | title = FEMA Letter to Dino Villani, former State of Florida EMS Director, summarizing FEMA Evaluation and Testing Program of STM NIMS compatibilities and operational effectiveness and suitability. | date = December 2007 | url = http://saccotriage.com/pdf/FEMAresponseNIMS.pdf | archive-url = https://web.archive.org/web/20160304053929/http://saccotriage.com/pdf/FEMAresponseNIMS.pdf | archive-date=2016-03-04 }}</ref> and for effective response planning and training.

Inefficient triage also provides challenges in containing health care costs and waste. [[Field triage]] is based upon the notion of up to 50% overtriage as being acceptable. There have been no cost-benefit analyses of the costs and mitigation of triage inefficiencies embedded in the healthcare system. Such analyses are often required for healthcare grants funded by taxpayers, and represent normal engineering and management science practice. These inefficiencies relate to the following cost areas:

* tremendous investment in time and money since [[September 11 attacks|9/11]] to develop and improve responders' triage skills<ref name="Lerner_2008" />
* cited benefits from standardization of triage methodology, reproducibility and interoperability,<ref name="Lerner_2008" /> and NIMS compatibilities
* avoided capital costs for taxpayer investment in additional EMS and trauma infrastructure<ref name="Brown_2006">{{cite news | vauthors = Brown D | title = Crisis Seen in Nation's ER Care. | newspaper = The Washington Post | date = June 2006 | url = https://www.washingtonpost.com }}</ref>
* wasteful daily resource utilization and increased operating costs from acceptance of substantial levels of overtriage
* prescribed values of a statistical life<ref name="Appelbaum_2011">{{Cite news | vauthors = Appelbaum B |date=2011-02-16 |title=As U.S. Agencies Put More Value on a Life, Businesses Fret |language=en-US |work=The New York Times |url=https://www.nytimes.com/2011/02/17/business/economy/17regulation.html |access-date=2023-02-17 |issn=0362-4331}}</ref> and estimated savings in human lives that could reasonably be expected using evidence-based triage practices
* ongoing performance improvements<ref name="thirteen" /> that could reasonably be expected from a more objective optimization-based triage system and practices