Introduction
Triage refers to sorting people’s needs for medical attention, and it is done in healthcare emergency rooms during disaster events and wars. Limited medical resources have to be allocated strategically to maximize the number of survivors. In it sense, triage originated during the First World War where wounded soldiers were grouped into perceived care need. For instance, there were some who could make it without medical attention, others likely to die without interventions, and the survivors after receiving treatments.
In relation to disaster, the world health organization (WHO) defines natural events as disruption of normal conditions and suffering that exceed the community’s capacity to respond. Normally, more than a hundred people lose their lives during catastrophes globally, while leaving many injured and disabled (“Corporation for National and community service,” n.d). In the wake of adverse situations, it can be difficult to provide medical care. The purpose of this paper is to focus on ways of medical triage in Japan and the United States.
Medical Triage during Disasters
Before looking into details how the concept of medical triages revolves around disaster and emergencies in various places, it is crucial to have an overview of its origin. Triage is commonly used today to reference sorting patients, but the term originated from France, referring to the classification of agricultural products. Triage strategies arose in military medicine during the war, and a French army surgeon was credited for developing the first battlefield system in 1812. The approach involved medically attending to severely wounded soldiers first, while the battle continues. Later, a differing triage principle emerged, requiring treatments for individuals who had minor and severe injuries.
During the First World War, the US adopted a triage mechanism to maximize the number of armies returning to duty. Military persons to return to the combat quickly were attended first to maintain the number of armed forces. During the most recent conflicts, especially in the middle east, transporting wounded militias by air or on the ground to medical facilities changed modern battleground triage. As such, military medicine expanded the understanding of combat triage, and so has the global disaster episodes. For instance, recent natural events have exposed a significant deficiency in civilian emergency alertness.
By definition, a disaster is known to overwhelm response abilities, and during mass casualty incidents (MCI), sometimes interventions might not be much strained. However, some patients require triage in these situations on a daily basis. In the US, an excellent example of common triage involves multiple vehicle collisions. Regardless of whether an event is an MCI or a medical disaster, rapid triages approaches are required. To optimize the outcomes, there is a shift in focus on doing what is best for a person to avail the best to a large population. Systems of triage are utilized by determining people who should receive treatment, those who will not, and ethical issues that revolve around the process of distributing scarce medical resources.
Medical triage strategies are vital in minimizing the spread of risks associated with disasters or other emergencies. Every territory in the US is at risk of one or more natural events. Calamities happen without warnings and incur great damage to properties hence devastating financial loss. Also, they pose health risks such as causing physical injuries, disease outbreaks, short and long-term psychological harm. Destruction of community infrastructures such as water supply, roads, electricity, and communication networks affect communities’ wellbeing.
Disruption occurring during and after emerge ices requires immediate actions from the public health and local emergency response teams to mitigate adverse health effects. Responding effectively to public health threats posed by disasters, whether induced by human beings or nature, requires sufficient data (“Centers for Disease Control and Prevention,” 2019b). Common natural calamities include earthquakes, flooding, hurricane, and tornadoes. On the other hand, human-induced disasters are accidental chemical pillage, terrorist attacks, wars, and feminine.
The modern primary triage is grouped into four categories: immediate, delayed, minimal, and expectant. A colored red tag code notes a quick triage to imply that people require urgent medical care and have limited survival chances if not well attended. A major hemorrhagic wound or internal bleeding in the medical setting is an excellent example warranting top priority for care. Delayed triage is noted by a yellow tag and informs that a person needs healthcare services within two to four hours (Alton, 2012).
Nevertheless, injuries can be life-threatening if ignored, but it could wait until all red tags are treated. An example of this includes treating open fractures without major bleeding. A green label indicates minimal triage, and in this condition, a patient is stabilized under ambulatory care but requires medical services (Alton, 2012). The last color code of medical triage is a black tag for expectant- where disaster victims are either deceased or expected to die any moment. Relatable conditions include open fracture, brain damage, or multiple chest wounds.
Medical Triage in Japan
The traditional approach of availing emergency care in Japan is organized per the level of emergency and the perceived patient acuity. The concept behind this method aimed to centralize the transfer of sick people to tertiary emergency units for care optimization. However, recent demographic change and the occurrence of disasters seem to challenge health care systems in the country. After the 2011 event of great earthquakes, Japan noted that most disaster shelters did not meet necessary standards for providing fundamental needs and care to the vulnerable populations. The country did not adequately test hospital disaster plans and was inadequate while the emergency communication equipment was a failure. As such, this implies that there were drawbacks in disaster triage systems that escalated public health issues and damage of properties.
Same in the US, Japan is a high-income nation with effective disaster response mechanisms. The country had suffered a mass-destruction disaster when the great earthquakes struck, especially in the northern coastal areas. Lessons learned regarding difficulties faced by Japan in responding to the disaster have been useful to the US response planners. The need for emergency medical triage systems has changed lately in Japan as it becomes an aging community with reduced birth rates.
Qualitative and quantitative changes have also taken place due to lessons from experience with disaster responses. Mortality from traffic injuries or work-related hazards has reduced, but there is a tremendous increase in the mild emergency cases from ambulatory services or medical systems (“National Center for Environmental Health,” 2019). Traffic injuries are polarized from minor to severe conditions due to the strengthened government’s focus on safety devices.
The current emergency medical unit in Japan has three layers, which include clinics, large hospitals with emergency units, and critical care facilities. To achieve quality services that are available by the care units, patients are intensified in health institutions through an appropriate pre-hospital triage system. In the event of traffic injuries, judging the severity of the situation is possible in pre-clinical settings. However, it is hard to tell the illness severity of older people because of multiple complications, reduced served physical capacity, and uncured chronic ailment.
To solve the care provision challenges during emergencies, Japan embarks on tight and mutual networks care providers. Primary, secondary and tertiary institutions for emergency medical services are established, strengthened with locals to improve the response capabilities. Typically, there are several systems of medical networking, such as pediatrics in local communities in Japan. Functions of hospitals have become segmented and departments stratified into primary, secondary, and tertiary.
The effectiveness of medical triage in Japan depends on the level and the types of disasters encountered. For instance, patients with radiation exposures are encountered during nuclear or radiation accidents. Studies reveal that there are n uniform regulations or policies on how to triage exposed patients. Japan has a simple triage and rapid treatment (START) program and uses sieve and sort methods during natural events. When a nuclear event occurs, for instance, from terrorist attacks, a number of populations are expected to be harmed due to trauma as well as contamination or exposure.
In individuals exposed to a high dose of nuclear chemicals, rapid doe assessments should be carried, and victims might require transplantations or therapies to treat acute radiation syndrome. On the contrary, individuals exposed to nuclear radiation and who have no experience of trauma are regarded not to have injuries before the prodromal signs, according to the START program. In that way, such persons could be at risk of delayed treatments. Although it is not possible, there are risks of death; decontamination evaluations are not performed, hence reducing contamination.
Medical Triage in the US
In the US, emergency rooms get filled with patients seeking medical attention, especially if there has been an outbreak of disasters, and they vary on presenting conditions. For example, there are those in need of less severe situations while others are critically ill and need urgent care. Healthcare departments start to meet people’s needs, and this is facilitated by staffing level, but when the number of patients is high, there is a call for action- use of triage system.
Using the triage approach ensures that patients requiring lifesaving interventions are seen before those who present less critical conditions. Triage in the US healthcare system is considered a form of rationing and can be a short-term need. For instance, during road accidents involving multiple casualties in need of ambulatory services, triage is applied to determine who should be transported to intensive care centers. Also, triage can be long-term for healthcare organizations understaffed for individuals arriving at the emergency departments.
A medical triage system used in the US is the simple triage, and rapid transport (START) developed in the 1980s in California as a civilian system adopted for disaster response. START algorithm is used for patients who are above eight years, and its status must be enacted in not more than 60 seconds. While doing so, some considerations are taken into place, including checking patients’ heart status such as pulses, respiratory rates, presence of bleeding, or ability to heed commands.
For children below eight years old, a medical triage system used is called Jump-START. During the mass casualty triage process, a most recent response mechanism is the sort assess lifesaving interventions treatments (SALT), which was developed by the center for diseases prevention and control (CDC). SALT was developed by the CDC committed by combining the key elements of existing systems. Several organizations such as the American college of emergency physicians have endorsed the SALY program for disaster medical response in the US.
Under unprecedented situations and a lack of federal guidance, healthcare organizations in the US form triage committees to help navigate life-threatening or death decisions. For example, amid the most recent pandemic situation, American healthcare workers have been forced to make difficult decisions about people’s fate. The most pressing concern in the COVID-19 pandemic was the lack of supportive resources such as ventilators (“Centers for Disease Control and Prevention,” 2020a).
More of these necessities were required and anticipated to increase in demand as the virus spread. Other crucial tools needed during emergencies include the dialysis machines, as most patients with the viruses got into kidney failures. Additionally, doctors were low in supply of painkillers, sedatives for ventilators patients, and protective gears. To deal with such challenging situations, there was the need to establish triage committees that would provide instructions on how patients should be grouped. However, the prospect of the triage approach did not proceed without issues such as how the elderly patient population would be segmented for treatments. Typically, it was noted that patients at age 70 and above were susceptible to suffer COVID-19; hence there were worries that the elderly group would be disadvantaged to receive care.
The primary healthcare systems in the US use a triage algorithm known as emergency severity index (ESI), which has different levels focusing on how patients are prioritized. The ESI program has gone through a series of revisions based on evidence research in emergency departments. Unlike in other countries that use the same triage, in the US, ESI pays more attention to the urgency and severity of symptoms instead of evaluating long patients should wait before being medically attended. Another notable change is that the ESI system is a nurse requirement to forecast subacute patients’ needs or those perceived as stable.
Patients who finally see healthcare professionals are appropriately placed in the right care for their respective conditions. According to studies, nurses and administrators have experienced significant benefits from the ESI approach, including improved communication between triage and charge nurses. To hospital administrators, this is an opportunity for administrators to look for available resources in healthcare organizations that are needed to various levels of acuity. Generally, in the US, ESI triage system have improved approaches of assessing patients and enhanced resource allocations by caregivers or administrators,
Comparing Medical Triage in Japan and the US
While in the US, the most embraced medical triage is ESI, Japan has used START and the Canadian Triage and acuity scale. In 2012, the Canadian system was applied in the emergency departments and named the Japanese Triage and Acuity Scale (Hsieh, 2014). However, although the program validation in Canada is approved, in Japan, they are limited. In the US, the emergency severity index (ESI) is an authenticated triage approach without chief complaints. After the spread of US-based emergency medicine in Japan, doctors in different healthcare organizations are required to treat people with varying illnesses.
As such, adequate triage has become essential for people walking in emergency rooms. Typically, there are numerous triage approaches to be used by nurse professionals in the emergency rooms. Still, the Japanese society for emergency medicine (JSEM) is considering adopting a triage acuity scale of their own (JTAS) (Koyama et al., 2017)). Also, in Funakoshi et al (2016), studies the authors inform that treatment of individuals with severe health problems started and have increased after the premiering of triage nurses.
Emergency Severity Index (ESI) used in the US seems better, unlike the JTAS triage approach with validation issues in Japan. ESI is a five-level triage system that was developed by healthcare teams comprising physicians and nurses (Funakoshi et al., 2016). Most emergency departments in the US and other regions such as Europe have integrated this system for response to situations. ESI has been revised, and studies have shown high reliability as well as validity. Inter reliability of ESI help to ensure patients will receive the same score irrespective of nurse triage or which healthcare facilities one attends. On the other hand, strong validity means that triage levels are precise, presenting the tour acuity rating. Individuals who are assigned the highest acuity rating means that they need urgent and immediate care that is lifesaving.
The medical triage systems used in Japan and the US have similar purposes and achievements. For instance, the programs provide crucial data elements needed to describe an acuity of emergency departments; they allow benchmarking and provision of information for healthcare administrators. Medical triage in Japan and the US is used by policymakers in the government, state, or local public health to describe the trend of events. The center for diseases control and prevention (CDC) relies heavily on the use of triage data (“Centers for Disease Control and Prevention,” 2016c).
Also, in Japan and the US, the use of the START triage approach is the same, especially to address mass casualty incidents MCI. Normally, START program patient triage fast and straightforward by assessing respiration, perfusion, and mental wellness to know which patients are in critical conditions. The processes involved triage individuals based on color codes, including red, green, white, or yellow. Studies recommend that START is the quickest and best method to identify problems in times of health crises.
On the contrary, triaging incoming patients in a sophisticated process, often misunderstood by individuals with limited knowledge about the approaches. Triage nurses are continually sorting and prioritizing injured patients who required medical interventions. In that way, nurses base their decision making on available evidence to make sure people receive the care they need on time. Emergency departments (ED) have been using triage scales that are subjective to validity or reliability. Today the 5-level ESI and Canadian triage and acuity scale (CTAS) are the most used in the US and other parts of the world. The challenge is a lack of sufficient knowledge or education related to the usage of triage scales by nurses. In that case, nurses are required to have comprehensive training concerning the use of acuity scales.
To conclude, challenges that Japan and the United States have faced amid the outbreak of disasters shine a light on the need for proactive efforts to save or improve lives. Natural events such as the great Earthquakes in Japan paved the way for valuable insights on the value and how medial triage systems should be incorporated. US disaster response team of healthcare have planned extended care to large populations and vulnerable groups affected by circumstances. Triage systems such as ESI and JTAS prove effective to inform how peoples need must be attended.
References
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Funakoshi, H., Shiga, T., Homma, Y., Nakashima, Y., Takahashi, J., Kamura, H., & Ikusaka, M. (2016). Validation of the modified Japanese Triage and Acuity Scale-based triage system emphasizing the physiologic variables or mechanism of injuries. International Journal of Emergency Medicine, 9(1). Web.
Hsieh, A. (2014). 5 triage lessons learned from the Boston Marathon Bombing. EMS1. Web.
Koyama, T., Kashima, T., Yamamoto, M., Ouchi, K., Kotoku, T., & Mizuno, Y. (2017). A study of the effect of introduction of JTAS in the emergency room. Acute Medicine & Surgery, 4(3), 262-270. Web.
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