Skip to main content
    • Aa
    • Aa
  • Get access
    Check if you have access via personal or institutional login
  • Cited by 17
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Choon, O. H. Dali, Z. Beng, P. T. and Magdalene, C. P. Y. 2016. Operational Research for Emergency Planning in Healthcare: Volume 1.

    Repoussis, Panagiotis P. Paraskevopoulos, Dimitris C. Vazacopoulos, Alkiviadis and Hupert, Nathaniel 2016. Optimizing emergency preparedness and resource utilization in mass-casualty incidents. European Journal of Operational Research, Vol. 255, Issue. 2, p. 531.

    Morton, Melinda J. DeAugustinis, Matthew L. Velasquez, Christina A. Singh, Sonal Kelen, Gabor D. and Zehtabchi, Shariar 2015. Developments in Surge Research Priorities: A Systematic Review of the Literature Following theAcademic Emergency MedicineConsensus Conference, 2007-2015. Academic Emergency Medicine, Vol. 22, Issue. 11, p. 1235.

    Streckbein, S. Kohlmann, T. Luxen, J. Birkholz, T. and Prückner, S. 2015. Sichtungskonzepte bei Massenanfällen von Verletzten und Erkrankten. Der Unfallchirurg,

    Choon, Oh Hong Dali, Zhang Beng, Phua Tien and Magdalene, Chow Peck Yoke 2014. Uncovering effective process improvement strategies in an emergency department using discrete event simulation. Health Systems, Vol. 3, Issue. 2, p. 93.

    Shen, Wei-feng Jiang, Li-bing Jiang, Guan-yu Zhang, Mao Ma, Yue-feng and He, Xiao-jun 2014. Development of the science of mass casualty incident management: reflection on the medical response to the Wenchuan earthquake and Hangzhou bus fire. Journal of Zhejiang University SCIENCE B, Vol. 15, Issue. 12, p. 1072.

    Risavi, Brian L. Terrell, Mark A. Lee, William and Holsten, Donald L. 2013. Prehospital Mass-Casualty Triage Training—Written Versus Moulage Scenarios: How Much Do EMS Providers Retain?. Prehospital and Disaster Medicine, Vol. 28, Issue. 03, p. 251.

    Hawe, Glenn I. Wilson, Duncan T. Coates, Graham and Crouch, Roger S. 2012. The 6th International Conference on Soft Computing and Intelligent Systems, and The 13th International Symposium on Advanced Intelligence Systems. p. 1221.

    Rauner, Marion S. Schaffhauser-Linzatti, Michaela M. and Niessner, Helmut 2012. Resource planning for ambulance services in mass casualty incidents: a DES-based policy model. Health Care Management Science, Vol. 15, Issue. 3, p. 254.

    Xiong, Wei Bair, Aaron Sandrock, Christian Wang, Sophia Siddiqui, Javeed and Hupert, Nathaniel 2012. Implementing Telemedicine in Medical Emergency Response: Concept of Operation for a Regional Telemedicine Hub. Journal of Medical Systems, Vol. 36, Issue. 3, p. 1651.

    Aacharya, Ramesh P Gastmans, Chris and Denier, Yvonne 2011. Emergency department triage: an ethical analysis. BMC Emergency Medicine, Vol. 11, Issue. 1,

    Nie, Hu Tang, Shi-Yuan Lau, Wayne Bond Zhang, Jian-Cheng Jiang, Yao-Wen Lopez, Bernard L. Ma, Xin L. Cao, Yu and Christopher, Theodore A. 2011. Triage during the week of the Sichuan earthquake: A review of utilized patient triage, care, and disposition procedures. Injury, Vol. 42, Issue. 5, p. 515.

    Hirshberg, Asher Frykberg, Eric R. Mattox, Kenneth L. and Stein, Michael 2010. Triage and Trauma Workload in Mass Casualty: A Computer Model. The Journal of Trauma: Injury, Infection, and Critical Care, Vol. 69, Issue. 5, p. 1074.

    Kahn, Christopher A. Schultz, Carl H. Miller, Ken T. and Anderson, Craig L. 2009. Does START Triage Work? An Outcomes Assessment After a Disaster. Annals of Emergency Medicine, Vol. 54, Issue. 3, p. 424.

    Wang, Hui Xiong, Wei Hupert, Nathaniel Sandrock, Christian Siddiqui, Javeed and Bair, Aaron 2009. Proceedings of the 2009 Winter Simulation Conference (WSC). p. 2809.

    Armstrong, John H. Hammond, Jeffrey Hirshberg, Asher and Frykberg, Erik R. 2008. Is Overtriage Associated With Increased Mortality? The Evidence Says “Yes”. Disaster Medicine and Public Health Preparedness, Vol. 2, Issue. 01, p. 4.

    Hupert, Nathaniel Hollingsworth, Eric and Xiong, Wei 2008. Response to Armstrong et al. Disaster Medicine and Public Health Preparedness, Vol. 2, Issue. 01, p. 5.

  • Disaster Medicine and Public Health Preparedness, Volume 1, Issue S1
  • September 2007, pp. S14-S24

Is Overtriage Associated With Increased Mortality? Insights From a Simulation Model of Mass Casualty Trauma Care


Purpose: To examine the relationship between overtriage and critical mortality after a mass casualty incident (MCI) using a simulation model of trauma system response.

Methods: We created a discrete event simulation model of trauma system management of MCIs involving individual patient triage and treatment. Model variables include triage performance, treatment capability, treatment time, and time-dependent mortality of critically injured patients. We model triage as a variable selection process applied to a hypothetical population of critically and noncritically injured patients. Treatment capability is represented by staffed emergency department trauma bays with associated staffed operating rooms that are recycled after each use. We estimated critical and noncritical patient treatment times and time-dependent mortality rates from the trauma literature.

Results: In this simulation model, overtriage, the proportion of noncritical patients among all of those labeled as critical, has a positive, negative, or variable association with critical mortality depending on its etiology (ie, related to changes in triage sensitivity or to changes in the prevalence and total number of critical patients). In all of the modeled scenarios, the ratio of critical patients to treatment capability has a greater impact on critical mortality than overtriage level or time-dependent mortality assumption.

Conclusions: Increasing overtriage may have positive, negative, or mixed effects on critical mortality in this trauma system simulation model. These results, which contrast with prior analyses describing a positive linear relationship between overtriage and mortality, highlight the need for alternative metrics to describe trauma system response after MCIs. We explore using the relative number of critical patients to available and staffed treatment units, or the critical surge to capability ratio, which exhibits a consistent and nonlinear association with critical mortality in this model. (Disaster Med Public Health Preparedness. 2007;1(Suppl 1):S14–S24)

Corresponding author
Correspondence and reprint requests to Nathaniel Hupert, MD, MPH, Assistant Professor of Public Health and Medicine, Weill Medical College of Cornell University, 411 E 69th St, New York, NY 10021(e-mail:
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

1.RD. Hardern Critical appraisal of papers describing triage systems. Acad Emerg Med. 1999;6:11661171.

2.BA Hoey , CW. Schwab Level I center triage and mass casualties. Clin Orthop Relat Res. 2004;422:2329.

3.Y Kluger , A Mayo , D Soffer , D Aladgem , P. Halperin Functions and principles in the management of bombing mass casualty incidents: lessons learned at the Tel-Aviv Souraski Medical Center. Eur J Emerg Med. 2004;11:329334.

4.J de Boer , M. Debacker A more rational approach to medical disaster management applied retrospectively to the Enschede fireworks disaster, 13 May 2000. Eur J Emerg Med. 2003;10:117123.

5.EB Lerner , RM. Moscati The golden hour: scientific fact or medical “urban legend”? Acad Emerg Med. 2001;8:758760.

6.ER. Frykberg Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53:201212.

8.A. Hirshberg Multiple casualty incidents: lessons from the front line. Ann Surg. 2004;239:322324.

10.U Rodoplu , JL Arnold , T Yucel , R Tokyay , G Ersoy , S. Cetiner Impact of the terrorist bombings of the Hong Kong Shanghai Bank Corporation headquarters and the British Consulate on two hospitals in Istanbul, Turkey, in November 2003. J Trauma. 2005;59:195201.

11.CJ Aylwin , TC Konig , NW Brennan , et alReduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet. 2006;368 9554 22192225.

12.DC Cone , DS. MacMillan Mass-casualty triage systems: a hint of science. Acad Emerg Med. 2005;12:739741.

13.A Hirshberg , M Stein , R. Walden Surgical resource utilization in urban terrorist bombing: a computer simulation. J Trauma. 1999;47:545550.

14.WJ Sacco , DM Navin , KE Fiedler 2nd RK Waddell , WB Long , RF Buckman Jr Precise formulation and evidence-based application of resource-constrained triage. Acad Emerg Med. 2005;12:759770.

15.MD Stevenson , PA Oakley , SM Beard , A Brennan , AL. Cook Triaging patients with serious head injury: results of a simulation evaluating strategies to bypass hospitals without neurosurgical facilities. Injury. 2001;32:267274.

16.JS Sampalis , R Denis , A Lavoie , et alTrauma care regionalization: a process-outcome evaluation. J Trauma. 1999;46:565581.

17.L. Cook The World Trade Center attack. The paramedic response: an insider's view. Crit Care. 2001;5:301303.

18.JG Cushman , HL Pachter , HL. Beaton Two New York City hospitals' surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma. 2003;54:147155.

19.AA Deshpande , S Mehta , NA. Kshirsagar Hospital management of Mumbai train blast victims. Lancet. 2007;369 9562 639640.

20.E. Auf der Heide The importance of evidence-based disaster planning. Ann Emerg Med. 2006;47:3449.

21.BJ McNeil , E Weber , D Harrison , S. Hellman Use of signal detection theory in examining the results of a contrast examination: a case study using the lymphangiogram. Radiology. 1977;123:613617.

22.A Garner , A Lee , K Harrison , CH. Schultz Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001;38:541548.

23.A Hirshberg , BG Scott , T Granchi , MJ Wall Jr, KL Mattox , M. Stein How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis. J Trauma. 2005;58:686695.

24.M Avitzour , M Libergal , J Assaf , et alA multicasualty event: out-of-hospital and in-hospital organizational aspects. Acad Emerg Med. 2004;11:11021104.

25.ER. Frykberg Principles of mass casualty management following terrorist disasters. Ann Surg. 2004;239:319321.

26.S Einav , Z Feigenberg , C Weissman , et alEvacuation priorities in mass casualty terror-related events: implications for contingency planning. Ann Surg. 2004;239:304310.

27.GM. Segell Terrorism: London public transport–July 7, 2005. Defence Security Anal. 2006;22:4559.

28.NJ Liang , YT Shih , FY Shih , et alDisaster epidemiology and medical response in the Chi-Chi earthquake in Taiwan. Ann Emerg Med. 2001;38:549555.

29.LG Connelly , AE. Bair Discrete event simulation of emergency department activity: a platform for system-level operations research. Acad Emerg Med. 2004;11:1177–85.

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Disaster Medicine and Public Health Preparedness
  • ISSN: 1935-7893
  • EISSN: 1938-744X
  • URL: /core/journals/disaster-medicine-and-public-health-preparedness
Please enter your name
Please enter a valid email address
Who would you like to send this to? *