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Prehospital Mass-Casualty Triage Training—Written Versus Moulage Scenarios: How Much Do EMS Providers Retain?

  • Brian L. Risavi (a1), Mark A. Terrell (a2), William Lee (a1) and Donald L. Holsten (a3)



The aim of this study was to assess the effectiveness of written and moulage scenarios using video instruction for mass-casualty triage by evaluating skill retention at six months post intervention.


Prehospital personnel were instructed in the START method of mass-casualty triage using a video. Moulage and written testing were completed by each participant immediately after instruction and at six months post instruction.


There was a significant decrease in performance between initial and six-month testing, indicating skill decay and loss of retention of triage skills after an extended nonuse period. There were no statistically significant differences between written and moulage testing results at either initial testing or at six months. Prior skill level did not influence test performance on the type of testing conducted or long-term retention of triage skills.


These data confirm the skill deterioration associated with an infrequently used triage method. Further research to more precisely define triage criteria, as well as the ability to apply the criteria in a clinical setting and to rapidly identify patients at risk for morbidity/mortality is needed.

RisaviBL, TerrellMA, LeeW, HolstenDLJr. Prehospital Mass-Casualty Triage Training—Written Versus Moulage Scenarios: How Much Do EMS Providers Retain?. Prehosp Disaster Med. 2013;28(3):1-6.


Corresponding author

Correspondence: Brian L. Risavi, DO UPMC Hamot Department of Emergency Medicine 201 State Street Erie, Pennsylvania 16550 USA E-mail


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1.Goh, SH. Bomb blast mass-casualty incidents: initial triage and management of injuries. Singapore Med J. 2009;50(1):101-106.
2.Williams, KA, Sullivan, F, Suner, S, et al. Triage behavior of first responders (Abstract). Acad Emerg Med. 2004;11(5):588.
3.King, DR, Patel, MB, Feinstein, AJ, Earle, SA, Topp, RF, Proctor, KG. Simulation training for a mass-casualty incident: two-year experience at the Army Trauma Training Center. J Trauma. 2006;61(4):943-948.
4.Lerner, EB, Schwartz, RB, Coule, PL, et al. Mass-casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(Suppl 1):S25-S34.
5.Arnold, T, Cleary, V, Groth, S, Hook, R, Jones, D, Super, G. START. Newport Beach, CA: Newport Beach Fire and Marine Department, 1994.
6.Risavi, BL, Salen, PN, Heller, MB, Arcona, S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care. 2001;5(2):197-199.
7.Frykberg, ER. Triage: principles and practice. Scand J Surg. 2005;94(4):272-278.
8.Jenkins, JL, McCarthy, ML, Sauer, LM, et al. Mass-casualty triage: time for an evidence-based approach. Prehosp Disaster Med. 2008;23(1):3-8.
9.Beekley, AC. Mass casualties in combat: lessons learned. J Trauma. 2007;62(Suppl 6):S39-S40.
10.Waeckerle, JF. Disaster planning and response. N Engl J Med. 1991;324(12):815-821.
11.Armstrong, JH, Frykberg, ER, Burris, DG. Toward a national standard in primary mass-casualty triage. Disaster Med Public Health Prep. 2008;2(Suppl 1):S8-S10.
12.Lerner, EB, Cone, DC, Weinstein, ES, et al. Mass-casualty triage: an evaluation of the science and refinement of a national guideline. Disaster Med Public Health Prep. 2011;5(2):129-137.
13.Sacco, WJ, Navin, DM, Fiedler, KE, Waddell, RK 2nd, Long, WB, Buckman, RF Jr. Precise formulation and evidence-based application of resource-constrained triage. Acad Emerg Med. 2005;12(8):759-770.
14.Zoraster, RM, Chidester, C, Koenig, W. Field triage and patient maldistribution in a mass-casualty incident. Prehosp Disaster Med. 2007;22(3):224-229.
15.Roccaforte, JD. The World Trade Center attack. Observations from New York's Bellevue Hospital. Crit Care. 2001;5(6):307-309.
16.Avitzour, M, Libergal, M, Assaf, J, et al. A multicasualty event: out-of-hospital and in-hospital organizational aspects. Acad Emerg Med. 2004;11(10):1102-1104.
17.Cook, L. The World Trade Center attack. The paramedic response: an insider's view. Crit Care. 2001;5(6):301-303.
18.Hirshberg, A. Multiple casualty incidents: lessons from the front line. Ann Surg. 2004;239(3):322-324.
19.Kahn, CA, Schultz, CH, Miller, KT, Anderson, CL. Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med. 2009;54(3):424-430.
20.Simmons, E, Hedges, JR, Irwin, L, Maassberg, W, Kirkwood, HA Jr. Paramedic injury severity perception can aid trauma triage. Ann Emerg Med. 1995;26(4):461-468.
21.Emerman, CL, Shade, B, Kubincanek, J. A comparison of EMT judgment and prehospital trauma triage instruments. J Trauma. 1991;31(10):1369-1375.
22.Buerk, CA, Batdorf, JW, Cammack, KV, Ravenholt, O. The MGM Grand Hotel fire: lessons learned from a major disaster. Arch Surg. 1982;117(5):641-644.
23.Okumura, T, Takasu, N, Ishimatsu, S, et al. Report on 640 victims of the Tokyo subway sarin attack. Ann Emerg Med. 1996;28(2):129-135.
24.Nufer, KE, Wilson-Ramirez, G, Shah, MB, Hughes, CE, Crandall, CS. Analysis of patients treated during four Disaster Medical Assistance Team deployments. J Emerg Med. 2006;30(2):183-187.
25.Alfici, R, Ashkenazi, I, Kessel, B. Management of victims in a mass-casualty incident caused by a terrorist bombing: treatment algorithms for stable, unstable, and in extremis victims. Mil Med. 2006;171(12):1155-1162.
26.Frykberg, ER, Tepas, JJ 3rd, Alexander, RH. The 1983 Beirut Airport terrorist bombing. Injury patterns and implications for disaster management. Am Surg. 1989;55(3):134-141.
27.Garner, A, Lee, A, Harrison, K, Schultz, CH. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001;38(5):541-548.
28.Meredith, W, Rutledge, R, Hansen, AR, et al. Field triage of trauma patients based upon the ability to follow commands: a study in 29,573 injured patients. J Trauma. 1995;38(1):129-135.
29.Cushman, JG, Pachter, HL, Beaton, HL. Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma. 2003;54(1):147-155, discussion 154-155.
30.Feliciano, DV, Anderson, GV Jr, Rozycki, GS, et al. Management of casualties from the bombing at the centennial olympics. Am J Surg. 1998;176(6):538-543.
31.Aylwin, CJ, König, TC, Brennan, NW, et al. Reduction 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):2219-2225.
32.Hupert, N, Hollingsworth, E, Xiong, W. Is overtriage associated with increased mortality? Insights from a simulation model of mass-casualty trauma care. Disaster Med Public Health Prep. 2007;1(Suppl 1):S14-S24.
33.Hirshberg, A, Frykberg, ER, Mattox, KL, Stein, M. Triage and trauma workload in mass-casualty: a computer model. J Trauma. 2010;69(5):1074-1082.
34.Husum, H, Gilbert, M, Wisborg, T, Van Heng, Y, Murad, M. Respiratory rate as a prehospital triage tool in rural trauma. J Trauma. 2003;55(3):466-470.
35.Holcomb, JB, Salinas, J, McManus, JM, Miller, CC, Cooke, WH, Convertino, VA. Manual vital signs reliably predict need for life-saving interventions in trauma patients. J Trauma. 2005;59(4):821-829.
36.McManus, J, Yershov, AL, Ludwig, D, et al. Radial pulse character relationships to systolic blood pressure and trauma outcomes. Prehosp Emerg Care. 2005;9(4):423-428.
37.Eastridge, BJ, Salinas, J, McManus, JG, et al. Hypotension begins at 110 mm Hg: redefining “hypotension” with data. J Trauma. 2007;63(2):291-299.
38.Hasler, RM, Nüesch, E, Jüni, P, Bouamra, O, Exadaktylos, AK, Lecky, F. Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: Multicentre cohort study. Resuscitation. 2012;83(4):476-481.
39.Almogy, G, Luria, T, Richter, E, et al. Can external signs of trauma guide management?: Lessons learned from suicide bombing attacks in Israel. Arch Surg. 2005;140(4):390-393.
40. The Learning Pyramid. Accessed December 6, 2012.
41.Arthur, W Jr, Bennett, W Jr, Stanush, PL, McNelly, TL. Factors that influence skill decay and retention: A quantitative review and analysis. Hum Perform. 1998;11(1):57-101.
42.Patel, VL, Glaser, R, Arocha, JF. Cognition and expertise: acquisition of medical competence. Clin Invest Med. 2000;23(4):256-260.
43.Harden, RM. Developments in outcome-based education. Med Teach. 2002;24(2):117-120.
44.Larsen, DP, Butler, AC, Roediger, HL 3rd. Test-enhanced learning in medical education. Med Educ. 2008;42(10):959-966.
45.Karpicke, JD, Roediger, HL 3rd. The critical importance of retrieval for learning. Science. 2008;319(5865):966-968.
46.Kerfoot, BP, Fu, Y, Baker, H, Connelly, D, Ritchey, ML, Genega, EM. Online spaced education generates transfer and improves long-term retention of diagnostic skills: a randomized controlled trial. J Am Coll Surg. 2010;211(3):331-337.
47.Bell, HS, Kozakowski, SM, Winter, RO. Competency-based education in family practice. Fam Med. 1997;29(10):701-704.
48.Paukert, JL, Richards, BF. How medical students and residents describe the roles and characteristics of their influential clinical teachers. Acad Med. 2000;75(8):843-845.
49.Schmidt, RA, Björk, RA. New conceptualizations of practice: Common principles in three paradigms suggest new concepts for training. Psychol Sci. 1992;3(4):207-217.
50.Arthur, W Jr, Bennett, W Jr, Edens, PS, Bell, ST. Effectiveness of training in organizations: a meta-analysis of design and evaluation features. J Appl Psychol. 2003;88(2):234-245.
51.Ford, JK, Quiñones, M, Sego, D, Speer Sorra, JS. Factors affecting the opportunity to perform trained tasks on the job. Pers Psychol. 1992;45:511-527.
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