This study examined whether intolerance of uncertainty and decision-making styles were associated with theoretical START triage knowledge among paramedic students. Secondary exploratory analyses assessed psychosocial differences according to self-rated decision-making under stress, perceived coping with uncertainty, professional motivation, and challenges in prehospital emergency care.

In this cross-sectional study, 121 students from a First and Emergency Aid Program completed a self-administered paper-based questionnaire including a sociodemographic form, the Decision-Making Styles Scale, the Intolerance of Uncertainty Scale-12, and the START Triage Knowledge Test. Data were collected in classroom settings under researcher supervision between May and June 2025 and analyzed using descriptive statistics, group comparisons, and correlation analyses.

The mean theoretical START triage knowledge score was 69.99 ± 14.76. START knowledge was not significantly associated with intolerance of uncertainty or decision-making style subscale scores. Exploratory analyses identified associations between psychosocial scores and self-rated decision-making under stress, coping with uncertainty, professional motivation, and perceived challenges.

Theoretical START triage knowledge was not associated with intolerance of uncertainty or decision-making styles. Secondary findings were limited to self-reported psychosocial associations. The study assessed declarative knowledge and did not evaluate START application in simulated or field settings. Future studies should use simulation-based, scenario-based, or observational outcomes.

Triage and data transfer are critical to the medical management of mass-casualty incidents (MCIs). However, the chaotic nature of such events makes it difficult to classify casualties according to structured triage protocols. Furthermore, even when triage is implemented effectively, communication disruptions between the incident scene and dispatch centers can hinder response operations. The aim of this study was to present a drone-integrated system that enables non-contact vital sign measurement, remote triage, and real-time data transmission during MCIs.

The system development process involved three steps: (1) developing the Vital-Sign Measurement Module; (2) developing the Triage Decision Support Module; and (3) developing the User Interfaces and Data Transmission Module to enable information transmission between dispatch centers and response teams. Within the Vital-Sign Measurement Module, heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2), and body temperature (BT) measurement algorithms were developed using the following techniques, respectively: video-based photoplethysmography (vPPG), analysis of thermal temperature fluctuations around the nose, a regression-based neural network approach, and heat maps and thermal thresholding. A pilot study was conducted under controlled indoor conditions to evaluate the accuracy of these algorithms.

The system can measure vital signs by processing drone-captured images, can provide triage decision support, and can transmit victims’ locations, vital signs, and triage categories to response teams and dispatch centers via dedicated user interfaces. A pilot evaluation of the Vital-Sign Measurement Module showed that the relative accuracy rate of the non-contact vital-sign measurement algorithms ranged from 86% to 99%.

The system provides an innovative approach to improving medical response management in MCIs by enabling remote triage and monitoring. Its non-contact vital sign measurement, triage decision support, and near real-time data transmission capabilities provide an infrastructure that can contribute to faster response and improved operational coordination. However, further field trials and development are required to improve the robustness of the vital-sign measurement algorithms to motion, to improve their adaptability to changing environmental conditions, and to maintain high accuracy despite individual differences.

Response agencies use mathematical modeling to quantify the consequences of mass-casualty incidents. Medical consequence models estimate the number of people to be treated for their injuries and rely on triage protocols based on injury severity to estimate the number of people who are expected to die. Available models ignore the time required to be rescued, which presents an incomplete picture of how many people would live long enough to be rescued and treated. We propose a new damage zone-based population sorting algorithm to improve estimates of people who would require treatment after a nuclear detonation in a U.S. urban setting.

We expanded the Administration for Strategic Preparedness and Response (ASPR)nuclear detonation model to include specific blast injuries such as casualties with fractures or hemorrhage. We evaluated 3 population sorting methods: no sorting (i.e., count everyone as treatable), sorting based on Department of War (DOW)/North Atlantic Treaty Organization (NATO) expectant rules, and damage zone-based population sorting. Damage zone-based population sorting introduces a new population category termed unrescuable, who are expected to die before being rescued based on the damage zone, injury severity, and the expected timing of response operations. We assessed the impact of population sorting on the number of injured and the number of injuries to be treated.

Damage zone-based sorting significantly decreases the estimates of expectants and increases estimates of the population requiring medical treatment for the most serious trauma injuries compared to population sorting based on DOW/NATO expectant rules.

The new damage zone-based population sorting method represents an important modeling refinement that incorporates realism into modeling results estimating the number of trauma-injured people requiring treatment and numbers of specific trauma injuries that would need to be treated in the aftermath of a nuclear detonation. We saw that the choice of population sorting method can influence the allocation of medical countermeasures required to respond in mass-casualty incidents, impacting medical countermeasure requirements, development, and investments.

Neonatal intensive care unit (NICU) evacuation poses distinct operational and ethical challenges because neonates often depend on continuous life-sustaining technologies and specialized care. Although several neonatal or pediatric disaster triage systems have been proposed, actual NICU evacuation cannot be ethically or practically tested under controlled disaster conditions. A reproducible framework comparing evacuation-order strategies is therefore needed.

This study aimed to develop and apply a reproducible simulation framework for NICU evacuation-order evaluation and, within that framework, to compare structured triage with evacuation without triage and quantitative with categorical neonatal triage approaches.

A retrospective simulation study was conducted using routinely recorded clinical triage assessments from a tertiary NICU, comprising 1,079 patient evaluations in 162 neonates across 49 triage days. During clinical practice, clinical severity and triage status had been recorded using the Neonatal Therapeutic Intervention Scoring System (NTISS), Neonatal Extrication Triage (NEXT), and Simple Triage and Rapid Treatment for Neonates, Revised (START-Neo-R); NEXT was a quantitative six-domain resource-dependency score ranging from zero to 12, whereas START-Neo-R was a five-level categorical neonatal triage system. Three evacuation strategies were evaluated: descending-order evacuation using NEXT, descending-order evacuation using START-Neo-R, and evacuation without triage. Evacuation-order performance was quantified using the Total Evacuation Score (TES), defined as the time integral of cumulative NTISS scores among patients remaining in the NICU across sequential evacuation steps. The TES distributions were compared descriptively across strategies rather than inferentially.

Within the 49 observed triage days, both structured triage strategies generated TES distributions shifted lower than those from evacuation without triage. In the direct comparison between NEXT and START-Neo-R, the worst-case TES under NEXT was lower than more than one-half of the START-Neo-R TES distribution on 34 of the 49 observed triage days (69.4%).

In this simulation study using real-world NICU data, TES provided a reproducible framework for comparing neonatal evacuation-order strategies under explicit assumptions. Within this TES-based framework, structured triage generated TES distributions shifted lower than those from evacuation without triage, and NEXT showed a more favorable distribution-based pattern than START-Neo-R on most observed days. These findings suggest that TES-based evaluation may help identify triage strategies that support more transparent and testable NICU evacuation planning.

This study aimed to describe the epidemiological, clinical, and operational characteristics of violence-related emergency medical services (EMS) encounters recorded on the Anatolian side of Istanbul from 2019 to 2023, to conduct secondary descriptive comparisons by sex, and to identify factors associated with confirmed prehospital death status.

We conducted a retrospective observational registry-based analysis of records coded as “Violence & Assault.” Clinical, operational, and demographic variables were analyzed. Comparisons by sex and confirmed death status were conducted using nonparametric and categorical-data tests. In a secondary exploratory analysis, Firth-penalized multivariable logistic regression was used to estimate adjusted associations with confirmed prehospital death status.

The sample comprised 29,335 violence-related EMS encounters; most involved young adult males and occurred in urban districts. Most recorded clinical findings were normal or preserved, although a small subgroup showed physiological instability. Several sex-based differences were statistically significant, but their effect sizes were generally small. Confirmed prehospital death was recorded in 132 encounters (0.45%). In the exploratory Firth model, severe respiratory status (aOR 56.02, 95% CI 8.62-364.05), altered consciousness (aOR 10.71, 95% CI 1.67-68.67), and cyanotic skin (aOR 4.24, 95% CI 2.67-6.73) were associated with the highest adjusted odds ratios for confirmed prehospital death.

Violence-related EMS encounters were concentrated among young adult males, and most did not meet the confirmed-death definition. Nevertheless, a clinically important subgroup presented with physiological instability. In the exploratory analysis, confirmed prehospital death was most strongly associated with acute physiological compromise; operational intervals should be interpreted cautiously as potential markers of case complexity and EMS workflow rather than as causal determinants.

In mass-casualty incidents, inaccurate pretriage labeling at Advanced Medical Post (AMP) arrival, whether due to undertriage or clinical deterioration before arrival, may affect downstream workflow processes and delay recognition of critically injured patients. Although triage accuracy has been widely studied, the operational impact of inaccurate pretriage labelling at AMP entry on time-critical care processes within AMP systems remains poorly understood.

To evaluate the impact of inaccurate pretriage labeling at AMP entry on downstream time-critical care processes in simulated red-category patients.

Prospective, pilot simulation-based study conducted during 2 full-scale AMP exercises. The AMP reflected the real-world operational structure, personnel, and logistics of an AMP deployed during the World Economic Forum (WEF) 2026. Each simulation included 18 standardized patients; 10 met predefined red-triage criteria and constituted the analytic cohort. The primary objective was to compare time to predefined first critical action between correctly labeled and mislabeled patients.

Mislabeled at AMP entry, defined as red patients entering the AMP undertriaged with a lower-acuity pretriage label (yellow instead of red).

The primary outcome was time from AMP entry to first predefined critical action. Secondary outcomes included reaching predefined case-specific deterioration or death thresholds prior to intervention and time to correction of triage category. Outcomes were analyzed descriptively using within-patient paired comparisons across simulation runs.

Across 2 simulation runs, 6 paired observations were analyzed. In 4 of 5 comparisons in which a predefined critical action was performed, mislabeling was associated with longer time to predefined critical action, with delays ranging from 5 to 24 minutes. In 2 cases, these delays resulted in crossing of case-specific deterioration thresholds. In 1 additional mislabeled patient, the predefined critical action was not performed before the deterioration threshold was reached, and the patient subsequently progressed to the scripted death threshold. No correctly labelled red patient reached deterioration or death. Early correction of triage status mitigated delays, whereas delayed correction was associated with adverse progression.

In this pilot full-scale simulation study, inaccurate pretriage labeling at AMP entry was associated with delays in time-critical interventions. These findings highlight the importance of early and continuous structured reassessment and timely correction of triage categorization within AMP workflows. The results are hypothesis-generating and require confirmation in further simulation or real-world studies.

Mass-casualty incident (MCI) triage algorithms are evaluated against reference standards that operationally define the “critical casualty,” yet the constructs underlying these standards and the completeness of their reporting have not been systematically characterized.

A PRISMA-ScR methodology scoping review was conducted using a pre-registered Open Science Framework (OSF) protocol; MEDLINE, Scopus, Web of Science, and CINAHL were searched on May 5, 2026 for English-language full-text sources that described, derived, validated, or applied a reference standard for distinguishing critical from non-critical casualties in MCI triage. Reference standards were classified using a pre-specified taxonomy, and reporting completeness was assessed with the eight-item Reference Standard Reporting Index for MCI Triage (RSRI-MCI), developed a priori for this review and not externally validated. Two reviewers independently classified and coded all sources.

Sixty sources published from 2001 through 2025 were included. Operationalized reference standards clustered around four foundational methodological sources, while only five sources (8%) analyzed retrospective data from actual MCIs. Five reference-standard families were identified: Life-Saving Intervention (LSI)-Based (38%), Composite/Hybrid (30%), Expert Panel (15%), Outcome/Resource (12%), and Anatomic Severity (5%); LSI-Based and Composite constructs together accounted for approximately two-thirds of the field. Reporting was asymmetric: definition (98%), components (97%), and rationale (88%) were reported almost universally, whereas time window (40%), dead/expectant handling (57%), binary mapping (65%), missing-data handling (58%), and reference-standard limitations (58%) were reported less consistently. Inter-rater agreement was substantial overall (83%) and for family classification (93%; Gwet’s Chance-Corrected Agreement Coefficient [AC1] = 0.919; 95% CI, 0.837–0.980).

Mass-casualty incident triage studies routinely report what their reference standard is but inconsistently report how it is operationalized, particularly its time window. Five reporting recommendations are proposed for future MCI triage validation research.

Out-of-hours primary care (OOH-PC) has been introduced in many health systems to reduce non-urgent emergency department (ED) use. While prior studies suggest potential efficiency gains, economic evaluations rarely stratify outcomes by patient risk, limiting policy relevance. This study assesses the cost-effectiveness of diverting low-risk patients from ED to OOH-PC.

Compare direct medical costs, time spent at the facility, and hospitalization probability across risk and care setting subgroups from a societal perspective.

We analysed data from a cluster-randomized trial conducted in Belgium that examined a nurse-led triage system. Under the study trial’s extended Manchester Triage System (eMTS) protocol, patients eligible for primary care were assigned to OOH-PC and are referred to in our study as low-risk, while those assigned to the ED are defined as high-risk. To complement previous work, we stratified costs and effects by risk group. Mixed-effects regression models estimated costs, time at the facility, and hospitalization, with bootstrap confidence intervals. We also calculated the incremental net monetary benefit (INMB).

Treating low-risk patients at the OOH-PC instead of at the ED reduced costs by €24 (€14–€39) per patient, shortened the time spent at the facility by 69 (52–94) minutes. From a societal perspective, the average INMB was €49.5 per low-risk patient. Aggregately, we estimated that the 37 intervention weekends in 2019 led to an average saving of €14,136 in direct medical costs and cumulative time savings of 28 days.

Diverting low-risk patients from the ED to OOH-PC resulted in cost- and time-savings for low-risk patients at the study site. These findings highlight the potential to improve out-of-hours healthcare delivery to maximize benefits for patients and healthcare systems, although confirmation in other healthcare settings is required before wider implementation.

This study explored emergency nurses’ lived experiences and perceived challenges during the triage process.

This qualitative study was conducted with 25 emergency department nurses at Atatürk University Research Hospital. Criterion sampling was used to include nurses with direct triage experience. Data were collected through face-to-face, semi-structured interviews and analyzed using Colaizzi’s descriptive phenomenological method. Significant statements were extracted, meanings were formulated, and these were organized into theme clusters. To enhance credibility, 2 researchers conducted the analysis independently, and a consensus was reached through discussion.

Four main themes, 10 sub-themes, and 35 codes were identified. Nurses reported multiple challenges, including lack of institutional support, high patient load, time pressure, and patient dissatisfaction. Decision-making was influenced by both environmental and individual factors. Triage assessment involved a combination of subjective judgment and objective tools. Common errors included misdirection and insufficient questioning. Nurses also suggested improvements related to staffing, training, and organizational conditions.

Triage was experienced as a complex and demanding process shaped by workload, time pressure, and limited support. Findings highlight the importance of organizational and contextual factors in shaping triage practices.

This convergent parallel mixed-methods cross-sectional national survey informs us of current disaster trainings and perceived preparedness of school nurses and their anticipated roles.

Disasters are increasing while training to handle the emergency care is not prioritized. School nurse education is outdated, consisting of one quality program focusing on triage in disasters.

A convergent parallel mixed-methods survey, with closed- and open-ended questions, was distributed online to elementary, middle school, and high school nurses.

Quantitative results identified cardiopulmonary resuscitation, active shooter, and fire training as the most prevalent training with floods and earthquakes lacking training. Thematic analysis provided views on past disaster experience, previous nursing experience, first aid and triage, desire to be included on safety committees, need for mandatory scheduled disaster training, and benefits of debriefing.

School nurse disaster management is essential to protect our children. School administrators need to appreciate this multi-faceted resource and provide up-to-date comprehensive mandatory training.

Mass casualty incidents (MCIs) continue to pose significant operational challenges for health care facilities, particularly when compounded by electronic health record (EHR) downtime or cyberattacks. Despite advancements in technology, providers may consider using simple, paper-based patient triage and tracking methods during an MCI. This study describes the implementation of a paper-based triage and patient tracking tool, integrated into a broader MCI Toolkit, to support operational continuity.

Developed by NYU Langone Hospital—Brooklyn Emergency Department in collaboration with Emergency Management, the tool was deployed in 6 full-scale exercises (2021–2025) and 2 real-world MCIs across trauma and non-trauma ED settings. The tool follows a 3-step process: rapid triage using Simple Triage and Rapid Treatment (START), documentation of acuity and location, and post-triage identity reconciliation. The MCI Toolkit includes operational resources such as contact lists, patient placement maps, and job action sheets. After each event, feedback was gathered from clinical staff and senior leadership.

In the feedback sessions, the tool was noted to be intuitive and required minimal training. It enabled rapid triage, patient placement, and real-time situational awareness for Incident Command. During a downtime simulation, it supported a seamless transition from electronic to manual processes. Across incidents, it improved patient throughput, ensured appropriate team assignment, and supported role flexibility when leadership was unavailable.

Our experience using the paper-based Triage Tracker showed it reliably maintained patient tracking without electronic systems. Its ease of use and integrated resources supported coordination, patient flow, and operational continuity during MCIs and EHR disruptions.

Efficient triage in general practice is critical to optimize appointment allocation and minimize patient delays. Delays in receiving clinical information, such as photographs or symptom questionnaires, lead to unnecessary consultations and inefficiencies. This study evaluated the feasibility and impact of a structured pre-triage protocol requesting photos and questionnaires for common conditions (skin, eye, tonsillitis, and urinary tract infections).

A pre-post intervention quality improvement project was conducted in a UK general practice. Triage administrators were instructed to proactively request photographs for skin and eye complaints and symptom questionnaires for tonsillitis and UTIs at initial patient contact. Outcomes included process metrics (number of pre-triage requests, proportion of cases managed directly by the triage GP) and subjective measures of ease, speed, satisfaction, and confidence.

The protocol increased photo requests for skin (mean increase 4.0/session, Cohen’s d = 7.77) and eye (2.2/session, d = 4.09) conditions, while questionnaire requests remained unchanged. The proportion of skin cases managed directly by the triage GP increased significantly (from 0.2 to 2.2 cases/session, d = 1.65), and eye case management also improved. Questionnaire-based pathways showed minimal change in efficiency or direct management. Subjective feedback indicated a slight reduction in triage speed, but ease and satisfaction were maintained, while diagnostic confidence increased, particularly for photo-supported conditions.

A structured pre-triage protocol is feasible, acceptable, and potentially effective in enhancing triage efficiency, particularly for visually assessable conditions like skin and eye presentations. By enabling earlier access to essential information, such protocols may reduce unnecessary consultations, improve workflow, and support clinician confidence.

To perform a cost-utility analysis of the p16/Ki67 dual stain compared to liquid cytology (LC) in the screening of women aged 25–60 years with high-risk papillomavirus (HR-HPV) non 16/18, from the perspective of the Sistema Único de Saúde (SUS) of Brazil.

A Markov-coupled decision tree cost-utility analysis model was developed for the follow-up of a hypothetical cohort of 1,000 women in the age group, in health states that simulated the natural progression of cervical cancer. The time horizon was lifetime with a discount rate of 5 percent for costs and benefits. To survey the resources used for the procedures involved, the recommendations of the Brazilian Guidelines for Cervical Cancer Screening were considered. Most of the cost data were obtained from SUS administrative and public databases. Deterministic and probabilistic sensitivity analyses were carried out.

Screening with p16/Ki67 outperformed LC, resulting in an incremental gain of 2.5 quality-adjusted life years (QALYs) and an incremental cost-effectiveness ratio of R$31.40/QALY (range R$12.98–62.90/QALY), well below the reference value of R$40,000/QALY.

The p16/Ki67 test proved to be cost-effective in screening women with non 16/18 HR-HPV. The results can help Brazilian managers plan and make decisions about incorporating technologies for triage considering the use of HPV tests in cervical cancer screening.

Mass casualty incidents (MCIs) in high-risk environments pose major challenges for coordinated emergency response. Training is often infrequent, resource-intensive, and lacks interagency consistency. This study explores the use of Virtual Reality (VR) simulation to train responders in the RAMP triage model across emergency services.

An observational qualitative design was used. Sixteen participants from various emergency services engaged in a VR-based MCI scenario involving 26 patients and hazardous conditions. The scenario required rapid RAMP triage based on essential cues (radial pulse and the ability to follow commands). Structured interviews followed, and data were analyzed thematically.

Three themes emerged: (1) Deficiencies in current training, including inconsistent MCI protocols, lack of guideline familiarity, and limited interagency practice; (2) VR as an effective, low-resource training method enabling repeatable and safe practice—RAMP triage was found intuitive and efficient, even for non-medical personnel; and (3) prerequisites for VR implementation, such as realistic design, technical infrastructure, and stakeholder involvement to support shared understanding.

VR-based MCI training is a feasible and effective supplement to traditional drills. It enables scalable and flexible skill-building, though it should complement and not replace live exercises.

This study explored the prevalence and attributes of triage errors made by emergency responders during virtual reality simulations of mass casualty incidents.

The study analyzed errors made by 99 emergency responders during their triage and treatment of a mass casualty incident in virtual reality. Responders received training on the Sort, Assess, Life-saving Intervention, Treatment, Transport (SALT) protocol, then responded to a virtual bombed subway station. Responder accuracy, efficiency, and application of treatments were tracked. Error analysis was performed through the lens of human factors. Accordingly, errors were categorized by their nature: either perception, proficiency, or procedure.

Responders correctly triaged 70% of virtual patients, and 78% demonstrated relative efficiency. Interaction times between responders and patients averaged 20 seconds. The time to assess and treat all patients for life-threatening bleeding injuries across the entire scene averaged six minutes. Most errors were related to proficiency (e.g., competence or experience). However, procedural errors (shortcomings of SALT) and perceptual errors (degraded sensory input from programmed environmental chaos, i.e., virtual smoke/debris and louder sound) were also observed. Most errors were related to patients with either respiratory issues or multiple injuries.

Virtual reality (VR) offered a controlled environment for studying errors made by emergency responders in a mass casualty incident, which will lead to improved training and protocols to better prepare them for these events.

Evaluate and improve the accuracy of disaster triage decisions for pediatric patients among clinicians of various training levels using the Sort, Assess, Life-Saving Intervention, Treatment/Transport (SALT) triage system.

We used an online pediatric disaster triage module to evaluate and improve accuracy of triage decisions. During a pre- and post-test activity, participants triaged 20 fictional patients. Between activities, participants completed a didactic covering concepts of disaster triage, SALT triage, and pediatric limitations of triage systems. We assessed accuracy and improvement with non-parametric tests.

There were 48 participants: 27 pediatric emergency medicine attendings (56%), 9 pediatric emergency medicine fellows (19%), 12 pediatric residents (25%). The median (interquartile range [IQR]) pre-test percent accuracy across all participants was 75 (IQR 65-85). Attendings scored higher than residents 80 (IQR 73-88) compared to 60 (IQR 55-65, P < 0.01) but not significantly higher than fellows 75 (IQR 70-85, P = 0.6). For the 44 participants who completed both the pre- and post-test, median score significantly improved from 75 (65-85) to 80 (75-90), P < 0.01.

The accuracy of triage decisions varies at different training levels. An online module can deliver just-in-time triage training and improve accuracy of triage decisions for pediatric patients, especially among pediatric residents.