Updated Triage Tools
In April 2023, NHS England announced that following a review of major incident triage, two new triage tools have been developed and are ready for use.
Ten Second Triage Tool - TST
Major Incident Triage Tool - MITT
The new guidance has been developed following a period of time where challenging clinical incidents have occurred. This includes events resulting in blast injuries, penetrating injuries and the use of chemical agents that aren’t normally seen day to day. You can probably recall some of these incidents over the last few years, and it’s good to see lessons being learnt and new findings implemented.
Of course, you might be thinking that this doesn’t apply to you, or onboard your vessel - especially if you don’t work in the cruise industry. On most vessels, there’s just not enough people to make any incident major is there?
But, the definition of a major incident is an event or situation with a range of serious consequences that requires special arrangements and a response beyond routine, business-as-usual operations from one or more emergency responder agencies.
In most cases for medical teams, this will be when the number of casualties are more than the available resources can cope with. So in reality, that could be just two casualties if you have limited resources - both in terms of people and equipment.
In any major incident, it is generally the people involved in the incident who become the first responders. As you might imagine, it takes time for agencies (Police, Fire, Ambulance and others) to assess the situation, plan and execute a response. This time may be as little as a few minutes, but for the casualties at the scene, that few minutes is the difference between life and death.
In the vital few minutes after any kind of incident, it will come down to those in the middle of it who need to act.
In the inquiry following the Manchester Arena bombing, the actions of the Transport Police (the arena is also a tramway hub), the public and event staff were commended. The bomb was detonated at 22.31, the first solo Paramedic was on scene at 22.53, some 22 minutes later. It took a further 6 minutes for a second Paramedic to arrive. The triage of casualties started at 23.05, over half an hour after the detonation, meaning vital time was lost in assessing injuries and making life saving interventions.
TST and MITT were created following this inquiry and took into account learning points from the incident, those injured and the families of those affected.
Speed of response to establish certain life saving measures is vital and in the UK, there is an ongoing campaign to train members of the public in ‘stop the bleed’ techniques. Both the TST and MITT triage plans focus on sorting severe and minor injuries and doing the most for the most.
The links below allow you to print out PDFs of both triage tools, including the METHANE reporting tool which goes hand in hand with triage.
1. Ten Second Triage (TST)
TST is designed to be used by non-medical responders.
TST is quick, simple and effective at prioritising large numbers of casualties rapidly, with a focus on immediately providing lifesaving interventions (LSI). These LSIs include bleeding control and opening the airway, which are known to be the key requirements to maximise patient survival in the early stages of injury.
The simplicity of the tool minimises cognitive burden and frees up bandwidth to assist responders to treat casualties in what will be very challenging circumstances.
There are no physiological parameters; breathing and pulse rate are not measured which means that the tool can be used by responders with little or no clinical training. In addition, the tool does not triage casualties to ‘dead’, but labels them as not breathing.This allows for appropriate interventions, such as recovery position or CPR, depending on the circumstances, until formal triage by a registered healthcare professional can take place.
The Ten Second Triage tool shows the recommended priority triage routes depending on incident characteristics. Each has a YES or NO answer, which guides you to the next question, or determines the casualty priority (P1, P2 and P3) or if they are Not Breathing.
Clinical instructions are in bold.
Walking – Yes = P3. This is regardless of any injuries they may have.
Severe bleeding – Yes = P1. you can apply Pressure, a Tourniquet, or Pack the wound.
Talking – Yes – Penetrating injury (front or back) Yes = P1 or No = P2
Breathing – open airway if able. Place in recovery position Yes = P1. No = Not Breathing – CPR if resources allow.
The tool then sets out the METHANE model – which brings structure and clarity to the initial stages of managing any multi-agency or major incident.
M – Major incident
E – Exact location
T – Type of incident
H – Hazardous
A – Access
N – Number of casualties
E – Emergency services
The tool also provides option boxes to number how many patients are in each category of priority – P1, P2 and P3 as well as Not Breathing from 1 to 19.
You can see how the Ten Second Triage should be implemented here: Ten Second Triage (TST) – training video
2. Major Incident Triage Tool MITT
The biggest change for the MITT, is that it has become a single tool for both adult and paediatric patients, while still allowing for rapid, reliable and reproducible triage.
When compared to other triage tools, the MITT demonstrates an increased sensitivity and reduced rate of under-triage in those patients requiring lifesaving interventions. MITT will replace the current triage sieve tool, the triage sort tool and the paediatric triage tape.
The major incident triage tool (MITT) shows the recommended priority triage routes depending on incident characteristics. Each has a ‘yes’, which guides you to the next question, or ‘no’ answer which determines priority (P1, P2 and P3) or dead.
Clinical instruction is in bold.
Catastrophic bleeding – Yes =P1 – Pressure dressing, tourniquet, haemostatic packing
Walking – Yes = P3
Breathing – No – Open airway if required = Dead.
Or in children (under 12 years) who are not breathing. If resources allow, consider 5 rescue breaths if : submersion/immersion/smoke inhalation.
Responds to Voice – No – Place in recovery position = P1
Aged over 2 years – No = P1
Breathing rate 12 – 23 – No = P1
Heart rate – No = P2
The tool then sets out the METHANE model – which brings structure and clarity to the initial stages of managing any multi-agency or major incident.
M – Major incident
E – Exact location
T – Type of incident
H – Hazardous
A – Access
N – Number of casualties
E – Emergency services
The tool then provides option boxes to number how many patients are in each category of priority – P1, P2 and P3 as well as Dead from 1 to 19.
You can find the full details of MITT and TST here.
If you have any questions about the new triage tools, or would like some help in putting together major incident and triage drills for your crew, please feel free to get in touch.
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