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Population-based Triage Management in
Response to Surge-capacity Requirements
during a Large-scale Bioevent Disaster
Frederick M. Burkle Jr., MD, MPH
Abstract
Both the naturally occurring and deliberate release of a biological agent in a population can bring cata-
strophic consequences. Although these bioevents have similarities with other disasters, there also are ma-
jor differences, especially in the approach to triage management of surge capacity resources. Conventional
mass-casualty events use uniform methods for triage on the basis of severity of presentation and do not
consider exposure, duration, or infectiousness, thereby impeding control of transmission and delaying rec-
ognition of victims requiring immediate care. Bioevent triage management must be population based, with
the goal of preventing secondary transmission, beginning at the point of contact, to control the epidemic
outbreak. Whatever triage system is used, it must first recognize the requirements of those Susceptible but
not exposed, those Exposed but not yet infectious, those Infectious, those Removed by death or recovery,
and those protected by Vaccination or prophylactic medication (SEIRV methodology). Everyone in the
population falls into one of these five categories. This article addresses a population approach to
SEIRV-based triage in which decision making falls under a two-phase system with specific measures of
effectiveness to increase likelihood of medical success, epidemic control, and conservation of scarce
resources.
ACADEMIC EMERGENCY MEDICINE 2006; 13:1118–1129 ª2006 by the Society for Academic Emergency
Medicine
Keywords: disaster, triage, bioevents, population-based medicine, epidemics, pandemics, surge
capacity
Bioevents are defined as large-scale disasters sec-
ondary to biological agents that either are natu-
rally occurring (e.g., severe acute respiratory
syndrome [SARS], influenza A, potential H5N1 outbreak),
or deliberate (e.g., smallpox, inhalational plague, an-
thrax) in nature. The communicable disease is likely to
be silent, odorless, invisible, and undetectable for several
days or weeks. Severity is gauged by the ability of the
communicable disease to infect and transmit itself in a
susceptible population. Bioevents are managed by out-
break investigation and control, involving a collection
of interventional tasks designed to identify and terminate
human-to-human transmission of the infectious agent,
control the epidemic, and ultimately save the maximum
number of lives.
1
Emergency personnel may find themselves in a ‘‘situa-
tion in which the demand for resources clearly exceeds
supply,’’ in which individual triage decisions must ‘‘reach
beyond the hospital emergency department,’’ to protect
the surrounding community and beyond.
2
Decision
makers at every level may voice frustration over the dif-
ficulty of handling the massive population demands. A
major challenge facing health care providers lies in their
capacity and capability to make an operational shift from
individual-based care to population-based care and to
understand the consequences of such a decision, includ-
ing the necessity for an emergency operations center that
From the Center for Disaster and Refugee Studies, Departments
of Emergency Medicine and International Health, Schools of
Medicine and Public Health, Johns Hopkins University Medical
Institutions (FMB), Baltimore, MD; and Asia Pacific Center for
Biosecurity, Disaster and Conflict Research, John A. Burns
School of Medicine, University of Hawaii (FMB), Honolulu, HI.
Received June 4, 2006; revision received June 13, 2006; accepted
June 27, 2006.
Supported in part by National Health and Medical Research
Council grant 409973: Avian Influenza—National Perception of
Risks to Paramedics and Service Population-based Models of
Surveillance and Triage, University of Queensland and Monash
University, Australia.
Presented at the Academic Emergency Medicine Consensus
Conference, ‘‘Establishing the Science of Surge,’’ San Francisco,
CA, May 17, 2006.
Address for correspondence and reprints: Frederick M. Burkle
Jr., MD, MPH, University of Hawaii, 452 Iana Street, Kailua, HI
96734. Fax: 808-262-2538; e-mail: fburkle@jhsph.edu.
ISSN 1069-6563 ª2006 by the Society for Academic Emergency Medicine
PII ISSN 1069-6563583 doi: 10.1197/j.aem.2006.06.0401118
functions as a central triage-management system. This
article develops the organizational continuity framework
and a two-phased triage-management system that sup-
ports the public-health decision-making tasks required
for coordinated outbreak investigation and control.
PUBLIC HEALTH EMERGENCIES
The discovery of an infectious disease of public health
consequence is based on the utilization of ongoing dis-
ease surveillance. Day-to-day passive surveillance refers
to data supplied to a health department on the basis of
a set of rules and regulations and a list of reportable dis-
eases.
3
Although many such lists have expanded since
9/11, there is a lack of uniformity across jurisdictions
because state lists often differ widely by the number
and type of diseases included.
4,5
Active syndromic surveillance occurs when each suspi-
cious case is pursued to identify additional cases and in-
cludes the functional capacity for development of a case
definition (a set of diagnostic criteria that must be ful-
filled to identify a particular disease, usually based on
combined clinical and laboratory criteria), data collec-
tion, analysis (including an epidemic curve that graphi-
cally plots the distribution of cases by time and onset),
and health information dissemination. Epidemic curve
analysis represents an early triage-management tool
that is essential in answering questions concerning dis-
ease identification, origin, propagation, incidence, preva-
lence, incubation periods, likely modes of transmission,
clues to weaponization of the bioagent, and where to
concentrate emergency and public health interventions
to limit its spread.
1,3,6–9
ORGANIZATIONAL FRAMEWORK OF A
POPULATION-BASED APPROACH
Bioevents are characterized by massive numbers of
individuals seeking health care. A population-based ap-
proach requires a departure from the individual care
role of clinicians with patients. This does not minimize
the importance of clinical tasks but rather adds the di-
mension of new public health and surge-capacity inter-
ventions that improve access and availability of limited
health resources for the entire population. All individuals
within a population share the following:
10–12
All either have the same condition or are susceptible
to it.
All have shared health care needs.
All require some intervention.
All fall into one of five triage-management categories
(described in the next section).
Large-scale bioevents may require a sustained opera-
tional response lasting 12–24 months.
Severity, as indicated by rising case-fatality rates, rises
dramatically as transmission increases and resources
become limited. What at first appears to be a static,
well-controlled local event quickly can become a re-
gional, national, or international disaster of paralytic
proportions.
1,13
PHASE-BASED POPULATION MANAGEMENT
Triagemanagement will occurwithin two phases (Figure1).
Phase One
Phase one occurs when an outbreak is confirmed by
public health authorities and requires immediate imple-
mentation of broad generic interventions (as opposed
to specific interventions in phase 2, next subsection)
that are based on best public health practices such as dis-
ease-containment strategies. Social distancing (e.g., clo-
sure of schools, restaurants, theaters, and mass events),
guidelines for respiratory hygiene and cough etiquette,
hand washing, masking, separation, shelter-in-place,
quarantine, and isolation all are designed to limit and
eventually arrest the transmission of the disease.
14
The following phase one interventions occur simulta-
neously, with the assumption that this capacity exists
in all jurisdictions and is protected under state public
health law:
Political authorities declare a disaster;
Health authorities execute generic disease-contain-
ment strategies;
An emergency operations center (EOC) is deployed,
which has central jurisdiction; and
The population divides itself into one of five triage
categories, which are self-selected but assisted by
public health announcements, hotlines, and trained
volunteers.
Phase one interventions ensure the best opportunities
for immediate safety of the community. If not addressed
in a timely and accurate manner, existing health care fa-
cilities risk being burdened and possibly overwhelmed
by a population seeking safety from fears of being in-
fected.
In a bioevent, the medical component within the
incident command system (ICS) requires supplementa-
tion with infectious disease and public health experts.
The EOC becomes the central tactical operations center,
providing a decision-making hub
15
and institutional poly-
math for the following:
Broad evidence-based situational awareness of the
outbreak;
Local linkages for regional resources;
Ongoing development and maintenance of strategic
alliances with local, national, and international agencies
and organizations;
Facilitation and integration of resources;
Communication and health information system content
and management;
Just-in-time training of volunteers to meet hot and cold
zone surge capacity duties; and
Triage of resources and decision making.
A centrally placed triage decision-making function
is critical in establishing lines of authority to eliminate
competition for resources among providers and health
facilities.
15,16
To optimize outcomes, the EOC, or its
equivalent at regional, national, and international levels,
must possess a timely and accurate evidence-based
situational-awareness capacity to coordinate daily, if
ACAD EMERG MED November 2006, Vol. 13, No. 11 www.aemj.org 1119
not hourly, triage-management decisions that are
passed immediately to hospitals, ambulatory health care
facilities, and other public and private agencies and
organizations with health care responsibilities.
1
EOC
outcome-data analyses will further determine the effect
on the population base and redirect resources where
needed.
The EOC next will determine surge-capacity require-
ments for the five population categories of those sus-
ceptible but not exposed (Susceptible category), those
exposed but not yet infectious (Exposed category), those
infectious (Infectious category), those removed by death
or recovery (Removed category), and those protected
by vaccination or prophylactic medication (Vaccinated
category), termed the SEIRV methodology (Figure
1).
1,17,18
The majority of the population will use self-selection in
deciding what category they fall into. However, timely
health information announcements, and assistance from
hotlines and trained volunteers, will guide the population
in knowing into what category they fall and what inter-
ventions they require.
Phase Two
Phase two triage-management decisions are specific,
surge-capacity dependent, and directed toward the five
population categories. The EOC does the following:
determines surge capacity requirements for each
SEIRV category;
determines triage criteria, including minimal qualifica-
tions for survival (MQSs) and exclusion criteria;
enforces compliance measures; and
ensures data collection, analysis, and measures of ef-
fectiveness (MOEs), using this information as the basis
of daily reports.
In contrast to the assumed universal availability of
phase one interventions, capacity to implement phase
two interventions varies considerably from jurisdiction
to jurisdiction. The developing situational-awareness pro-
cess within the EOC will identify gaps, limitations, and
the surge-capacity requirements as fed back to the EOC
by disaster managers, health care facilities, volunteer
agencies and organizations, and others with specific
roles and responsibilities for each triage category.
Figure 1. Susceptible-Exposed-Infectious-Removed-Vaccinated (SEIRV) phase one triage categorization for the entire pop-
ulation and phase two triage management of these subpopulation groups during a bioevent. *Percentages based on influenza
and severe acute respiratory syndrome outbreak data.
1120 Burkle POPULATION-BASED TRIAGE MANAGEMENT
As assistance shifts to population-based care, the tri-
age process also makes major changes. Decision criteria
require that those selected to benefit from the limited
resources must have a likelihood of medical success,
yet the selection must not impede the conservation of
scarce resources for those equally in need.
19
Interna-
tional-law precedence requires an equitable, fair, and
transparent triage process that provides the best oppor-
tunities to survive for as many victims as possible.
1,20,21
All patients will be cared for, every human life must be
valued, and every human being deserves respect, caring,
and compassion.
22
However, triage does not guarantee
survival, only the best opportunity to survive within the
constraints of the available resources.
1
Early point-of-contact triage must be sensitive and
specific enough to account for the diversity of subpopu-
lations and for identification of vulnerable populations
through analysis of demographic information and health
indices, immunization coverage, comorbid diseases, and
population densities, to name but a few. If not, unsus-
pecting individuals will risk being potential sources or
recipients of transmission. The unique requirements and
demands of each population category may mandate
that professionals with specific category expertise be
assigned to the medical component of the ICS or the
centralized EOC.
23
The National Disaster Medical System designates Sim-
ple Triage and Rapid Treatment (START) as the uniform
method for initial field triage in mass-casualty incidents
and disasters.
24
START evaluates respiratory, circula-
tory, and neurological functions and provides four care
categories (non-salvageable or dead, major injury, minor
injury, and walking wounded). Field emergency care is
restricted to airway, breathing, and circulation proce-
dures.
24
A second-phase triage process termed Secondary
Assessment of Victim Endpoint (SAVE) further assesses
injuries on the basis of trauma survival statistics to direct
limited resources, triage tags, and tracking to victims ex-
pected to derive the most benefits from treatment.
25
Both methodologies remain the basis for point-of-contact
initial evaluation for all-hazards planning documents and
in basic and advanced disaster life-support training that
includes bioevents.
24,25
These conventional triage methodologies risk imped-
ing control of transmission by not recognizing those
most in need of care. The START and SAVE triage meth-
odologies are based on severity of presentation and have
limited application in bioevents in which point-of-contact
decisions must be based instead on exposure or infec-
tiousness.
1
Decisions at every level are influenced by
bioagent lethality, dose-dependent onset and duration,
illness-severity profiles, time to death or recovery, and
surge-capacity requirements and resources.
1
The majority
of the SEIRV population seeking an immediate interven-
tion will come from the susceptible category. The Toronto
health system treated 375 inpatient SARS cases but ini-
tially was inundated with those unexposed but suscepti-
ble, potentially overwhelming health care facilities and
risking population mixing and secondary infections.
26–28
Restrictive resource limitations and a worsening case
definition may require further EOC triage decisions
based on inclusion and exclusion criteria, as well as
MQSs.
1,12,29,30
Inclusion criteria are the expected standards that
health care providers are trained to meet, on the basis
of a resource-complete environment. Examples are
universally accepted standards for resuscitation and
management found in courses and programs such as
advanced cardiac, trauma, and pediatric life support.
Exclusion criteria conversely refer to situations in
which expected resources are limited or lacking and
care must proceed without all standards of care and
equipment being met.
MQSs represent a ceiling on the amount of resource
expenditures that will be allocated to any one case defi-
nition, ensuring that a maximum benefit of available
resources is realized to ensure a population-based best
opportunity for survival. Examples are the EOC deter-
mining that resource limitations would dictate ceasing
interventions for high-maintenance cardiac or respira-
tory arrests and implementing criteria for ceasing venti-
lator use on patients who deteriorate with unlikelihood
of survival. Each MQS diagnosis is subject to change
on arrival of surge-capacity resources.
The EOC must balance available resources against the
best opportunity to survive. With sound best practices,
triage-management decisions may yield no more than an
additional 10%–15% of the population being saved.
1,16,30
The impact of this triage-management practice may not
be fully known until the end of the epidemic.
Phase Two Example: Infectious-category Triage. Few
infectious-category phase two triage protocols exist.
Hick and O’Laughlin provide a sample concept of opera-
tions for the development of triage criteria for restriction
of mechanical ventilation in epidemic situations.
31
Chris-
tian et al.
16
provide an expanded critical-care pandemic
triage protocol for assessment of admission to critical-
care units during an influenza pandemic. This triage
protocol uses the Sequential Organ Failure Assessment
score, which has utility for ‘‘inclusion’’ as a triage compo-
nent
16,32
and specifically addresses the importance of a
centrally placed or EOC-level triage committee to imple-
ment critical inclusion, exclusion, and MQS criteria as
well as EOC ‘‘absolute command and control over critical
care resources to ensure accountability.’’
16
Both articles
emphasize ethical principles and potential pitfalls of their
approaches. Emergency medical personnel must be op-
erationally familiar with all available phase two triage-
management protocols in each triage category because
they have a direct effect on decisions at the emergency
department level.
Phase Two Example: EOC Triage Management of
Essential Personnel. Triage-management planning oc-
curs under the assumption that less than 50% of health
care providers will report to work in a major bioevent.
To ensure participation, the EOC must provide just-in-
time training, personal and family support, immunization
or prophylactic antibiotics and antivirals, and bioagent-
specific protective equipment to these workers.
33
The
EOC may consider systemwide exclusion criteria that
would limit EMS transport to only noninfectious cases.
EMS providers in Hong Kong experienced a higher
attack rate for SARS, a risk dependent on the usage of
ACAD EMERG MED November 2006, Vol. 13, No. 11 www.aemj.org 1121
personal protective equipment, type of transfer, and
decision to intubate.
34
Such population-based triage de-
cisions underscore the importance of a central opera-
tions management authority. However, if used, EMS
personnel have the potential of providing additional
real-time syndromic surveillance information.
35
Phase Two Example: Susceptible-category Triage.
Psychological stress is ubiquitous among the population
but, for the most part, does not represent psychiatric ill-
ness.
36–38
The triage system must be alert to identify per-
sons with fear, poor resilience, and a lack of coping skills
who may require further monitoring and evaluation that
does not increase risk of exposure. Fear is mitigated
cognitively by effective information that is honest and
transparent. Even then, hypervigilant fear states may
compel some to flee their shelter-in-place and seek ED
assistance.
36
Hypervigilant fear can be debilitating and,
if left undetected and untreated, may lead to risk of per-
manent damage to the locus ceruleus stress-response
system and chronic symptoms.
39–43
A rapid severity-
score checklist is performed easily by trained volunteers,
administered by phone or face to face (Figure 2).
42
High
scores alert volunteers to obtain health care provider
backup for further evaluation, monitoring of fear-related
negative behaviors and actions, or medications. Treating
hypervigilant fear with anxiolytic medications or critical-
incident debriefing is contraindicated.
44,45
Consultation
may warrant the short-term use of a b-blocker (propran-
olol)
46,47
or of an alpha-1 antagonist (prazosin) to reduce
noradrenalin overactivation–related recurrent dreams,
difficulty with sleep, and debilitating hypervigilance.
48–50
Population-based triage categories and potential phase
one and phase two management decisions are summa-
rized in Tables 1–5.
1,17,18,28,36–38,44–56
POPULATION-BASED TRIAGE TAGGING
A triage-monitoring system must incorporate tagging
concerns for all five SEIRV categories. This may best be
performed by using rapidly produced wrist bands or
smart cards rather than by using paper tagging. Chris-
tian et al.
16
suggest a color scheme of blue (expectant),
red (highest priority for ICU and ventilator), yellow
Figure 2. The Bracha-Burkle Fear and Resilience Checklist. This provides a two-minute volunteer-administered tool to iden-
tify those who may require additional medical and psychological evaluation.
1122 Burkle POPULATION-BASED TRIAGE MANAGEMENT
(very sick and may or may not benefit from critical care),
and green (should be considered for transfer out of the
ICU) for the prioritization of patients within the critical-
care environment. Essential personnel, many coming
from the Vaccinated triage category, must have clearly
distinguishable tagging that documents their protective
status, either through robust personal-protective equip-
ment or by immunity or prophylaxis.
1
MEASURES OF EFFECTIVENESS
Measures of effectiveness are quantitative and qualitative
key indices that correspond to outcomes used to gauge
the success of the triage-management process.
57,58
The
central EOC would collect and analyze MOEs to docu-
ment and optimize scarce-resource allocation, assess
risk for exposure, and assist public health agencies in
Table 1
Potential Phase-one and Phase-two Management Decisions for Susceptible Category
Management Decision by Phase Modifiers
Phase one
Rapidly mobilize a broad public-affairs program
Emphasis on vital information, risks, and direction to remain
safe
Public announcements by trusted and credible authorities
Multimedia: TV, radio, Internet
28
Health information system (HIS) designed to pare down
susceptible population to manageable size
Frequent updates and clarifications that are language and
culture specific; anticipate and prepare frequently asked
questions (FAQs)
36
Based on premise that timely, accurate, consistent, and
frequent information will result in adaptive, effective, and
resilient behaviors
28,36
Despite good risk communication, a percentage of the
population will make fear-based decisions, resulting in
unhelpful behaviors, even panic, leading them to seek care
or safety at health care facilities
27,28,36
Phase two
Protocol-driven recorded and live information and rapid
assessment of severity of fear-based behaviors
36
Community-based programs: reassert EOC-based messages,
reemphasize shelter-in-place and managing of perceived
and actual dangers
Assess for additional safety issues that prevent adequate
shelter-in-place: for example, chronic disease and
medication requirements, comorbid disease risks
Rapid assessment checklists for fear and resiliency may serve
to recognize those experiencing hypervigilant fear
requiring referral evaluation and monitoring
46
Primarily consist of phone-based hotlines and face-to-face
encounters in infection-free triage and information centers,
vaccination, and mass-medication centers
37,38
By using protocol-driven recorded and live assessments and
advice, the phone-based Canadian system was able to sepa-
rate callers into probable infected versus uninfected cate-
gories and served to minimize duplication of efforts and
mixing of triage category populations at the hospital level
38,39
Anxiolytics and psychological debriefing therapies are
contraindicated and may make behaviors worse
44,45
Hypervigilant fear population may benefit from supervised
short-term beta-blocker and alpha-1 antagonist medication
and close follow-up, with repeat evaluation and
monitoring
46–50
Goals for this category include the following: prevent population exposure, avoid population mixing and concentration of population density, shelter-in-
place environments. The Susceptible group includes those in the population who are not exposed but are susceptible; it is the largest population group:
5–20 times that of the group of actually exposed or infectious victims.
1
EOC = emergency operations center.
Table 2
Potential Phase-one and Phase-two Management Decisions for Exposed Category
Management Decision by Phase Modifiers
Phase one
Education and support services for victims and
families
Disease-containment strategies
Determination of appropriate antivirals or
antibiotics
Determination of strict follow-up regimens if signs
and symptoms develop
Determination of appropriate outpatient facilities
May be difficult, if not impossible, to verify positive exposure
Early in epidemic, there will be lack of diagnostic capacity, impeding
capacity to identify mildly symptomatic or asymptomatic carriers
Disease-control strategies based on public-health law
Phase two
Time-sensitive vaccination (e.g., smallpox)
Mass antibiotic distribution
Criteria to increase antiviral dosage
EOC may identify as exposed the most vulnerable of subpopulations:
children, elders, immunocompromised
Standards for mass antibiotic-dispensing call for state and local
planners to dispense medications to their communities in less than
48 hours
51
Goals for this category include early identification and management of those exposed. The Exposed group includes those who claim exposure but are
asymptomatic, assumed to be incubating, but are not infectious.
1
EOC = emergency operations center.
ACAD EMERG MED November 2006, Vol. 13, No. 11 www.aemj.org 1123
rapidly identifying and reporting emerging areas of ac-
tivity, such as clusters of illness.
9,59–61
Four key MOEs
are depicted in Table 6.
DISCUSSION
Bioevent disasters require strong public health leader-
ship and an operational workforce to control an out-
break. No single agency, organization, or authority
possesses the expertise and diversity of resources to
optimize response. Population-based triage management
draws upon a public health perspective rather than
that of an individual victim and further ensures, in the
process, organizational continuity. Every agency and
organization involved must ensure that its workforce
possesses the public-health and population-based skills
that are required to meet its responsibilities for outbreak
control.
All bioevents result in a common susceptibility condi-
tion, making it easier to identify those individuals who
Table 4
Potential Phase-one and Phase-two Management Decisions for Removed Category
Management Decision by Phase Modifiers
Phase one
Education and support strategies for recovered victims and
families
EOC must plan for outpatient care and rehabilitation
Outpatient care will be prolonged and resource intensive
1,52
Public health authorities may restrict funerals to prevent
exposure from mass gatherings
Phase two
Those recovered may require further assistance to deal with
issues of stigma, survivor guilt, and other psychological
issues
36
Similar issues of stigma, lack of closure, and potential for
anger among families of those who died
36
Close follow-up of this population will be required for many
months after closure of the EOC and other emergency-based
community programs
Uncommonly high posttraumatic stress disorder and
depression reported in health care providers recovering from
severe acute respiratory syndrome
Community must consider close and prolonged follow-up;
outpatient services may be required for those recovering
from an invasive infectious disease
1,56
Goals for this category include preventing secondary physical, behavioral, and social complications and morbidity. The Removed group includes those
who are no longer sources of infection, either because of death or recovery.
1
EOC = emergency operations center.
Table 3
Potential Phase-one and Phase-two Management Decisions for Infectious Category
Management Decision by Phase Modifiers
Phase one
Estimate primary and secondary infections
Estimate self-care, assisted self-care, inpatient, and ICU care
Estimate requirements for inpatient versus outpatient care
Prepandemic prepared policies and clinical pathways for the
following:
BVictim assessment and triage
BPrimary- and secondary-care protocols
BMedical-ventilator criteria
BCare in community and home
Workforce protection and just-in-time training
Mathematical modeling can assist in clarifying the relationships
of a number of complex variables affecting the pattern of
infection within the population, the roles of primary and
secondary infections within specific communities, the
effectiveness of disease-containment strategies and vaccination
programs, transmission rates, illness estimates, the duration
of the epidemic, the duration of surge-capacity logistic
requirements, and the effectiveness of the application of
available resources
17,18,52
Phase two
Shelter-in-place isolation
Close supervision
Inpatient negative-pressure isolation
Palliative-care and surge-capacity just-in-time training of
hospital chaplains
1,53,54
Remains-management decisions may restrict visitation,
funeral, and conventional burials
Triage must be sensitive and specific enough to identify severe
but treatable patients and those most at risk to the population
1
A rapidly worsening case definition revealing a particularly
aggressive clinical course may require preemptive therapies
such as paralysis, intubation, and mechanical ventilation early
in the course of a particularly malignant respiratory process
Prompt isolation of patients and risk-stratified infection control
measures can prevent nosocomial spread among health care
workers
54
Allocating an exclusive portable x-ray to ED prevents mixing
and potential exposure at radiology department level; easily
decontaminated
55
Goals for this category include identifying those with likelihood of medical success when managed with scarce resources and preventing transmissionof
disease. The Infectious group includes those symptomatic and contagious.
1
EOC = emergency operations center.
1124 Burkle POPULATION-BASED TRIAGE MANAGEMENT
fit into each category and to choose measurable out-
comes that reflect evidence-based best practices. When
a well-defined clinical entity becomes a common condi-
tion within a population, triage analysis is possible even
when only limited human-response data are forthcom-
ing.
10,11
However, initially there is an inherent impetus
to overtriage into the Exposed category and to use re-
strictive control strategies driven by the following:
Novelty of the disease;
Absence of rapid diagnostic tests;
Lack of a vaccine;
Unusual viral-shedding pattern (e.g., low viral shed-
ding in the initial phase as an obstacle to the reliability
of diagnostic tests);
Subclinical or atypical presentations;
Lack of effective treatment;
Inherent severity reflected in high case-fatality rate; and
Uncertainty regarding modes of transmission, includ-
ing the phenomenon of superspreading events (the po-
tential to transmit the bioagent to a large number of
contacts).
62–64
EDs and hospitals should be dealing exclusively with
those Exposed or Infectious. This is possible only if phase
one and two interventions immediately begin to pare
down the Susceptible category populations to manage-
able numbers (Figure 3). Effective information should
mitigate the sense of danger and fear and lead the popu-
lation to accept their home as a safe, shelter-in-place
Table 5
Potential Phase-one and Phase-two Management Decisions for Vaccinated Category
Management Decision by Phase Modifiers
Phase one
EOC responsibility to equip vaccination and
mass-prophylaxis centers
Recognition of essential workforce requiring protective
measures (vaccination, prophylaxis, or disease- or
procedure-specific protective measures)
Information, vaccination, and mass-prophylaxis programs all
require large numbers of skilled personnel
Responsible EOC leadership must ensure that personnel
have maximum protection, either through robust personal-
protective equipment or by immunity or prophylaxis
Phase two
Determine smallpox-vaccination regime on the basis of CDC
guidelines
Ensure personnel for high-maintenance vaccination and
prophylactic medication centers
Verification and registration of those with confirmed
vaccination, immunization, or prophylactic antibiotic levels
Confirm antibiotic or antiviral susceptibility
Personnel may require 48 hours of prophylactic medication
to ensure adequate blood levels before entering personnel or
volunteer pool
Goals for this category include preventing transmission of disease; confirmed protection provides potential source of critical personnel for surge-
capacity workforce. The Vaccinated group includes those with complete protection by vaccination, immunization, or prophylactic antibiotics.
1
EOC = emergency operations center.
Table 6
Measures of Effectiveness
Triage-management Measures of Effectiveness (MOEs)
57,58
MOE Information Should Be the Foundation of Daily Reports from
the EOC to All Health Facilities
Timely and accurate health information system (HIS) Effectiveness is measured as a steady decline in those suscepti-
ble who are seeking inappropriate care
Indirectly measures success of public-affairs and risk-
communication programs
Correlates with decline in transmission
HIS becomes a major triage tool
Decline in mortality and morbidity These indicators must be further disaggregated for age, gender,
and vulnerable populations
Major vulnerable populations include children and elders,
especially those with chronic respiratory diseases, diabetes, and
other comorbid diseases
Case-definition development will clarify vulnerability
Appropriate surge-capacity distribution equitably
across entire population requiring care
National logistic capacity (e.g., Strategic National Stockpile)
does not necessarily translate into equitable distribution at the
local level
Proxy measure for EOC efficiency and effectiveness
Control of the transmission or reproductive rate (R
0
) of the
communicable disease or the ratio of primary to
secondary infections
R
0
> 1: indicates presence or continuance of an epidemic
R
0
= 1: indicates that the disease will or has become endemic
R
0
< 1: indicates that the disease eventually will disappear and the
epidemic will be controlled
59,61
EOC = emergency operations center.
ACAD EMERG MED November 2006, Vol. 13, No. 11 www.aemj.org 1125
environment and to identify those who require additional
professional assessment, evaluation, and monitoring for
fear-related behaviors. Volunteer organizations such as
the Red Cross and Salvation Army play a vital role in pre-
venting transmission by focusing on interventions such
as disseminating information, staffing hotlines, deliver-
ing medications, food, masks, thermometers, and written
health information to those quarantined and those iden-
tified as vulnerable and having special needs.
65,66
Community-based programs will primarily consist of
phone-based hotlines and face-to-face encounters in
infection-free (cold zone) triage and information centers
or at vaccination and prophylactic medication distribu-
tion centers within a community. The first level of
communication will be to repeat the exact message dis-
tributed via television, radio, or Internet by department
of health public-affairs personnel. It is critical that infor-
mation be timely, accurate, consistent, and frequent.
38
This reinforcement and clarification of critical informa-
tion should lead to individual recognition of potentially
dangerous behaviors, improved individual confidence
to manage a safe environment in one’s home, and indi-
vidual trust in media-based health information updates.
The Canadian SARS experience suggests that a phone-
bank approach is appropriate for first-line triage contact
during an epidemic. The government-run 1-800-Tele-
health phone bank, which normally received 2,000 calls
per day, surged to 20,000 calls per day during the out-
break, requiring additional staffing by nurses, physicians,
and public health personnel.
39
By using protocol-driven
recorded and live assessments and advice, the system
was able to separate callers into probable-infected versus
uninfected categories and served to minimize duplica-
tion of efforts and mixing of triage-category populations
at the ED and hospital level. Data analysis collated by
the phone bank system contributed to the development
of new protocols and improved advice and referral
schemes.
27,29,38,39
Lessons suggest that hospital guide-
lines and news-media information are the major informa-
tion services that are used. The ability of the phone staff
to triage well was related positively to standardized edu-
cation provided, assessment of prior knowledge of the
disease outbreak, and the early identification and correc-
tion of critical gaps in the knowledge base.
38
CONCLUSIONS
Triage planning, ‘‘the process of establishing criteria for
health prioritization,’’ permits society to recognize di-
verse moral, ethical, and legal perspectives, limited re-
sources, and competing health care demands
67
and
assists in ‘‘identifying when resources are scarce that
may be ethically withdrawn in favor of one more likely
to benefit.’’
68
Disaster planners and emergency personnel
must reevaluate existing disaster plans to ensure that a
population-based approach to triage management is in
place.
67,69
The process must begin with the first point of
contact, support a broader local community–to–interna-
tional disaster scheme, and properly address infectious-
disease exposure or infectiousness rather than severity
of presentation. The goal of every phase of triage man-
agement is the optimizing of population-based outcomes
and the prevention of secondary transmission. EMS is a
crucial part of the larger public-health workforce. This
is best understood and managed through a laterally co-
ordinated central EOC authority that is supplemented
Figure 3. Reducing the Susceptible category population to manageable numbers. The Susceptible population represents the
largest population subgroup requiring immediate intervention. If not attended to in a timely and accurate manner, this pop-
ulation may disrupt resource-limited services at health care facilities. Risk-management information, if effective, will di-
minish this population to a manageable size. Victims suffering hypervigilant fear represent a key subgroup that will
benefit from proper assessment and potential short- and long-term interventions. FAQ = frequently asked questions.
1126 Burkle POPULATION-BASED TRIAGE MANAGEMENT
by relevant public-health and disease-related experts to
the medical component of the ICS.
23
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Dynamic Emergency Medicine
After field testing during the last few months, the editors of Academic Emergency Medicine are pleased to
announce a new section of our journal, Dynamic Emergency Medicine. This section will present video articles
that are relevant to the research, practice, and teaching of emergency medicine. We anticipate these will
include instructional videos related to laboratory or clinical procedures or techniques; videos of cases where
bedside imaging helped in management or diagnosis; interviews of emergency medicine leaders on con-
cepts; history, or practice, or any other material best presented in video form. Videos of lectures or other
didactic presentations will not be considered.
Each submission must be accompanied by a brief written description of the video contents. High-quality
still images will be published in the paper journal and will link to the video in the electronic journal. Videos
should not exceed four minutes in length and will undergo peer review.
Information on preferred formats is listed below; in all cases, the highest possible quality is required.
Preferred format: MPEG -1 or -2 (.mpg extension)
Also acceptable: Apple Quick Time (.mov), and Microsoft Audio/Video interfaced format (.avi)
Please contact the AEM office by email with questions regarding the submission process.
ACAD EMERG MED November 2006, Vol. 13, No. 11 www.aemj.org 1129
