MILITARY MEDICINE, 167, 10:812,2002
Army Nurses' Knowledge Base for Determining
Triage Categories in a Mass Casualty
Guarantor: MAJ Jennifer L. Robison, AN USA
Contributor: MAJ Jennifer L. Robison, AN USA
The timing, location, and participants in a mass casualty sce-
nario cannot be predicted. Nurses may be involved in perform-
ing triage, yet there is no published documentation of military
nurses' ability to triage. A prospective design was used to
describe 82 Army nurses' knowledge base related to designat-
ing triage categories for patients during a mass causality, ex-
amining the relationships among their education and experi-
ence as evaluated by The Darnall Mass Casualty Triage Test
and Demographic Data Form. The most significant areas asso-
ciated with higher scores on the Triage Test were: completion
of Advanced Cardiac Life Support, advanced certification as a
Certified Registered Nurse Anesthetists, Certified Emergency
Nurse, or Critical Care Registered Nurse, and attendance to the
Medical Management of Nuclear Weapons Course. An im-
proved average score for nurses overall was also noted when
compared with previous work with the Darnall MASCAL Triage
Test.
Introduction
IBut,be the
n the military, a trauma surgeonor emergency physician may
idealperson to triagepatients during a mass casualty.
there is nothing ideal about combat. Every engagement,
every battle, every mass casualtyis different. TheArmy chain of
command is structured to overcome the loss of key leaders.
Intrinsic in this concept is the training of registered nurses to
perform triage. No one can predictwhereor when a mass casu-
alty will happen or whowill be available to initiate the triage of
the patients. Nurses may be requiredto perform this duty, and
there is no documentation ofmilitary nurses' ability to triage.
The purpose of this study was to describe mid-level active
duty Army nurses' knowledge base relatedto designating triage
categories for patients during a mass causality (MASCAL) and
the relationships among variable categories ofeducation(formal
education, civilian training courses, and military training
courses) and experience (clinical specialty area, clinical experi-
ence, and military field experience).
Background
Triage is the process ofsortingpatients and classifying them
into categories for priority of care.1 This process is especially
important in MASCAL situations where resources can quickly
become exhausted. For that reason, triage must be used at all
times in the military field medical system. 2
Themost appropriatepersonto triageduringa MASCAL is the
Department ofNursing, Madigan Army Medical Center, Fort Lewis, WA 98431.
The opinions or assertions contained herein are the private views ofthe authors
andarenottobeconstrued as official orreflecting theviews oftheDepartment ofthe
Army or the Department ofDefense.
This manuscript wasreceived for review inJuly 2001 andaccepted for publication
in March 2002.
Military Medicine, Vol. 167, October 2002 812
topic ofa heated debate. Trauma surgeonsand emergency phy-
sicians both feel they are uniquely qualified to coordinate triage
in a MASCAL sttuation.>'? Surgeons argue it is their specific
training that gives them an edge in triage. However, emergency
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care physicians havedisputed the surgeonsrationale by stating
technically advanced surgical expertise is rarelyrequired in the
triage process. 10
Triage during a MASCAL should beginwith the first available
qualified person.11 Some authors havestated this personshould
be an experienced doctor or nurse, familiar with the type of
casualties.v" However, MASCALs happen unexpectedly. Often
the first provider on the scene may not be an experienced phy-
sician. For example, two Navy dentists and a preventive medi-
cineofficer effectively coordinated the initialonsiteefforts at the
disaster scene in the terrorist bombing in Beirut. 13,14
Nurses triage as well. The International Red Cross hospitals
use the head nurse in the role of triage officer." The Interna-
tional Red Cross finds the person with the most experience in
the types ofpatients beingtriaged should be used as the triage
officer regardless of educational status. In Vietnam field hospi-
tals, the head nurse performed the secondary triage. The sec-
ondarytriagewas used to further sort a largegroupof"delayed"
patients.15 Thisexemplifies the continual, fluid processoftriage.
In current practice, oncepatients are initially sorted,they are
moved into one assigned area with other patients of the same
category. They are monitored in a holding area until definitive
care can be provided. 1 Each holding area is staffed by personnel
who provide supportive care and are continually retriaged.!'
This is yet another example of the importance of triage on a
continuum. In the Army, Forward Surgical Teams, 20-person
units, provide lifesaving surgical intervention far forward in
the battlefield where triage is most likely to occur. Although
physicians initiate triage, once they are performing surgery,
the nurses take over emergency care and triage of new
casualties.10,16
Wartime conflicts produceexcellent triage officers from inex-
perienced personnel, but sometimes there is a cost oflife or limb
to the patientwhile the medical staffis learning. 17 Patientcarein
a combatsetting demands flexibility in the use ofclinical skills
by each member of the team." Triage is an ongoing, dynamic
process. Medics usually initiatethe processin the field and it is
constantly re-evaluated and modified at each level thereafter.
TheArmy needs medical providers with solidtriagecapability in
each level ofmedical unit. Without trained staff, the echeloned
medical systemwill fail to provide optimal care.7,8,16 Echeloned
systems provide progressively higherlevels ofcare as the casu-
alty gets further away from combat. No matter what the level of
combat, military medical personnel must be prepared to fulfill
the demands placed upon them.v"
Determining Triage Categories in a MASCAL 813

Materials and Methods
Study subjectswere recruited from nurses attending leader-
ship coursesoffered at FortSamHouston (San Antonio, Texas).
There were 146nurses invited to participate with82 completing
the test and meeting the inclusion criteria.
Inclusion criteria for participation were: active duty nurses
holding the rank offirst lieutenant, captain, or major with 2 to
16yearsofmilitary service in theArmy Nurse Corps. Thiscohort
group reflects the active duty Army nurses that are providing
directpatientcare in both clinical and field environments. They
are the nurses mostlikely to be assigned to assume triage duty
in a MASCAL situation.
patients received four points, delayed patients received three
points, minimal patients received two points, and expectant
patientsreceived onepointfor a correct answer. Wrong answers
were scored bysubtractingthe numberoflevels mistriaged from
the correct answer." Scores were also broken down into
weighted scores for each section of NBC, peace, and combat
scenarios.
Descriptive statistics (means, median, standard deviations,
percentages) were used to describe the sample's knowledge base
oftriage categories. Foreach participant, a totalweighted score
and weighted score for each section (NBC, peace, combat) were
calculated.

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The knowledge base of triage categories was evaluated with
the Darnall MASCAL Triage Test. 6 Thistest wascreated and first
used by emergency physicians at Darnall Army Community
Hospital (Fort Hood, Texas). Theinstrumentis limited to testing
the knowledge base ofmilitary health care providers in the area
of triage categories. The test is designed to present MASCAL
triage scenarios and have the health care provider assign the
patient to the appropriate triage category. Respondents rated
each scenario based on the standard North Atlantic Treaty Or-
ganization system of triage categories to include immediate,
delayed, minimal, or expectant. The Darnall MASCAL Triage
Testconsistsof21 patient cases equally divided into three sim-
ulated types ofmass casualtyevents: combat; nuclear, biologi-
cal, and chemical (NBC); and peacetime scenarios.
The test was developed using current emergency medicine
texts and military publications to provide accurate triage sce-
narioswithcontentvalidity. TheAdvanced TraumaLife Support
text and curriculum were the foundation for the scenarios." By
usingthe sametool, the population ofmedical personnel tested
in the first application of this instrument provides a group to
which results ofthis study could be compared.
Scoring was completed with the weighted scoring system de-
veloped in the original study. Weighted scores were used to
amplify grossly incorrect answers. With this system, immediate
The key concepts being evaluated as independent variables
were measured usingthe Demographic DataForm. Information
obtained from the background characteristics was used to fur-
ther analyze the correlations among the variables. The demo-
graphic form also included the time when the participant had
attendedthe course: within the past 2 years, more than 2 years
ago, or never attended. See Table I for the list of variables
analyzed.
Correlational statistics among all independent variables were
tested. The outcome variable wasknowledge oftriage categories as
manifested byscore onthe Darnell MASCAL Triage Test. Indepen-
dent sample t tests were conducted with dichotomous level data.
Analysis of variance was used to measure differences between
mean scores of groups within variables (i.e., the specialty areas
and certified specialty nurses). When analysis ofvariance identi-
fied a statistically significant difference in meanscores, a Tukey's
post hoc analysis was conducted. Multiple regression analyses
were performed with the significant predictors.
In the courseswhere the testingwas conducted, instructors
agreed to allocate a 3D-minute period oftimefor participants to
complete the triage test and researchquestionnaire. A2-minute
videotape ofthe primary investigator was played before the ad-
ministration ofthe testingtools, which included the purpose of
the study, basic instructions, information on confidentiality,

TABLE I
DEMOGRAPHIC DATA FORMVARIABLES

Education Variables
Formal education
Civilian training courses
Military training courses
Combat/trauma courses
NBC courses
Leadership courses
Experience Variables
Clinical specialty area
Professional certifications
Direct patient care
Years of military experience
Field time
Deployed time
BSN or Master's degree
Attendance: ACLS, Basic Trauma Life Support, Advanced Trauma LifeSupport, Trauma Nurse Care
Course, Prehospital Trauma Life Support
Attendance: Combat Anesthesia, Combat Casualty Care Course, Combat Casualty Care Management
Course, Combat Trauma Nurse Course, Deployment Medicine Course, EFMB
Attendance: Medical Defense of Biological Warfare & Infectious Diseases, Medical Effects of Nuclear
Weapons, Nuclear Hazards Training, and Medical Management of Chemical Casualties
Attendance: Officer's Basic Course, Officer's Advanced Course, and Head Nurse Leadership
Development Course
Years by grouped specialty area with direct patient care and nonpatient care roles, total years
nursing experience
Certification in specialty area
Number of hours/week providing direct patient care
Number of years in Army Nurse Corps
Number of months spent in actual field training (training, field exercises, National Training Center,
Joint Readiness Training Center, etc.)
Number of months deployed (Haiti, Bosnia, Desert Shield/Storm, etc.)

Military Medicine, Vol. 167, October 2002

814 Determining Triage Categories in a MASCAL

and a reminder to the participantsthat involvement wasvolun-
tary and that choosing not to participate would not affect the
course they were attending in any way. Completion of the test
was considered consent. After the class viewed the video, the
groupleaderdistributedthe tests to allin attendance. Thegroup
leaderwasthe seniorrankingofficer withinthe group, serving in
an administrative capacity without any supervisory authority
over the group. 19 All efforts were taken to prevent subjectsfrom
feeling participation was mandatory.
tions they held at the time oftesting. Nurses with certifications
as Critical Care Registered Nurses and Certified Emergency
Nurses also showed an association with higher scores having
statistical difference from the other nurses in the total scores
(p = 0.026) via t test.
The Medical Effects of Nuclear Weapons Course was associ-
ated with increased scores in the total weighted score (p =
0.014) and the peace scenario score (p = 0.000) whenanalyzed
with t tests.

Results Discussion
Thescoreson the Darnall MASCAL Triage Testwere analyzed The sample of nurses in the original use of the Darnall

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by clinical specialty areas. Certified Registered Nurse Anesthe-
tists performed the best. Emergency, intensive care, and obstet-
ric/gynecologic nurses performed slightly below them. The op-
erating room and medical-surgical nurse ranked next.
Psychiatric nurses performed the least well on the triage test.
Therewasa statisticaldifference between groupsfortotalscores
(p = 0.028) and between the groups for the NBC section (p =
0.019) (Table II).
The most significant areas that were associated with higher
scores on the DarnallMASCAL Triage Test were: attendance of
Advanced Cardiac Life Support (ACLS), recent recipients ofthe
Expert Field Medical Badge, (EFMB), career path as Certified
Registered Nurse Anesthetists, certification as an emergency or
critical care nurse (Certified Emergency Nurse and Critical Care
Registered Nurse), and attendance ofthe medical Management
ofNuclear Weapons Course.
ACLS Course showed an increase in participants' total
weighted test score (p = 0.041). Anindependent ttest showed a
mean increase in score of 2.2 points. The average score in-
creasedfrom 49.5 to 51.7.Therewas no significant difference in
when the nurse had taken ACLS, eitherwithin2 years or more
than 2years.Theimportantfactor wascompletion ofthe course.
Holders of the EFMB did not have statistically significant
higher scores on the test, and there was no difference between
subjects who had never earned the EFMB and those subjects
who earned it longer than 2 years previously. However, there
were two nurses whohad earned their EFMB withinthe 2 years
before completing this study. They had superior scores in all
areas with significant differences in the total scores (p = 0.000)
and peace section (p = 0.000).
The Certified Registered Nurse Anesthetists had a notable
association withhigherscoreson the weighted score (p = 0.004)
when a t test was run. They also were associated with higher
scores in the NBC section (p = 0.000) then were the other
nurses.
Participants listed all of the professional nursing certifica-
TABLE II
DARNALL MASCAL TRIAGE TEST SCORES
MASCAL Triage Test consisted of 23 nurses. No demographic
data were included. Theprevious study reported the nurses had
a mediantotal weighted scoreof49.6 The current data support
higherscoreswith a median total scoreof 52, but fine discrim-
inationbetween exacteducation and experience is difficult with
a samplesizeof82. Compared withthe original use ofthis triage
test, Certified Registered Nurse Anesthetists (and two commu-
nity health nurses) performed as well as the physicians. Emer-
gency room, intensive care unit, and obstetric/gynecologic
nurses performed better then the dentists, nurses, and medics
in the previous study. However, statisticalinferences cannotbe
made. Table III provides details ofthe comparison data.
ACLS was the most widely attended course that was associ-
ated with higher triage scores. ACLS is required and more im-
portantly used regularly in manyareas ofnursing, especially in
critical care.TheArmy Nurse Corps believes all nurses are first
and foremost medical-surgical nurses. Additional training and
skillsadd to the nurses' growth. But, in time ofwar, all nurses
shouldbe able to function as medical-surgical nurses. Comple-
tion of ACLS training every 2 years would help to refresh life-
saving knowledge and interventions forall nurses. It was inter-
esting that the nurses who had never attended ACLS (N = 17)
also had no critical care experience. Eighty-nine percent ofthe
medical-surgical nurses attended ACLS, whereas only 60% of
operating nurses and 50°A> of psychiatric nurses attended. At-
tendance to this course maybe associated with a cost-effective
wayto possibly increase nurses' scores on triage tests.
The two participants who had studied for and earned The
EFMB withinthe previous 2 years were associated with higher
scores in all areas. The EFMB is a comprehensive evaluation
and testingprocedure surroundingtriage, treatment, and evac-
uation ofcasualties. Thepreparation forthis badge is thorough,
and the test is comprehensive. Individuals driven to obtainthis
honorput countlesshours intotheir training. It is evident in the
triage scores. Theconcerning aspectwasthe knowledge oftrain-
ingand testingforthe badge appeared to decrease after2 years.

Total Weighted Total Weighted Total Weighted Total Weighted

Score NBC Score Peace Score Combat Score
N 82 82 82 82
Maximum score 60 18 23 19
Mean 51.2561 15.1585 19.5488 16.5488
Median 52.0000 15.0000 20.0000 17.000
SD 2.8580 1.5028 1.2972 1.6266

Military Medicine, Vol. 167, October 2002

Determining Triage Categories in a MASCAL 815

TABLE III
COMPARED WEIGHTED SCORES

Provider N NBC Peace Combat Total Score

Original study"
Emergency physicians 29 17 21 17 55
Surgeons 39 16 20 18 54
General medical officers 28 16 21 17 54
Dentists 31 16 18 16 50
Nurses 23 15 19 15 49
Medics 22 14.5 19 16 49.5
This study
All nurses 82 15 20 17 52

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Community health 2 17 20.5 17 54.5
Certified registered nurse anesthetists 9 16 20 17 53
Emergency room 10 15.5 20 17.5 52
Intensive care unit 14 15.5 20 17 52
OB/GYN 8 15.5 20 17 52
Other 2 16 18.5 17.5 52
Operating room 10 15 20 16.5 50.5
Medical-surgical 23 15 19 17 50
Psychiatric 4 13.5 20 15.5 48

Therewereonlytwonurses whohad recently earned the EFMB,
but their scores were statisticallyhigher than the others.
Overall, the nurses with the best score profile werethe Certi-
fied Registered Nurse Anesthetists (N = 9). It is hypothesized
that their extensive training in lifesaving proceduresand airway
managementproved beneficial in triage knowledge base. These
nurses had scores comparable to those ofthe physicianstested
in the original workbyJanousek et al.6 in 1999, whichindicates
advance practice nurses may be appropriate to triage in a
MASCAL situation in place of physicians. However, Certified
Registered NurseAnesthetistshaveskillsthat needto be used in
other aspects of a MASCAL, namely, airway management and
providing anesthesia intraoperatively. These nurses would be
excellent resources to assist with training and program devel-
opment for triage courses.
Almost as interesting as the factors that improved the triage
scores are the number of courses that had no statistical signifi-
cancein improving scores, manydirectly related to triage, combat,
and NBC training. (See Table I for a complete listofcourses.) Many
participants had completed military training courses; however, the
only the Medical Effects ofNuclear Weapons coursewas notedto
result in higher scores.
There was onlyone question directly related to nuclear situ-
ations on the triagetest. However, the nurses whohad attended
the Medical Effects of Nuclear Weapons course had an associa-
tionwith increasedscoresin all areas ofthe test (with statistical
significance in the total score and peace section).
Information presentedin these courses maybe presentedin a
theoretical vs. practical format that might not have a lasting
impact on students. The CombatCare Casualty Course is very
interactive with a full mock MASCAL as the capstone exercise.
However, it did not lead to improved results. The keyto training
for a successful knowledge base may be frequent refresher
courses or specific annual requirements.
Limitations
Possible limitations ofthis study werethe sample size, heter-
ogeneity of the nurses attending the courses, the inherent lim-
itations ofa paper and penciltest, the case presentations them-
selves, and the possibility of group work." Nonparticipation
may have been chosen because the participants did not feel
comfortable with their triage knowledge and skills.
The nurses requesting and selected to attend these courses
are generally on a career track in the Army. Theytend to be well
trained and have a wide varietyof experiences. A problem with
the Demographic Data Formwas the responses werelimited to
specific answers on the form. However, the optionswerebroad,
and the toolwas used effectively in the past."
Paper and pencil tests are limited and may not accurately
reflect howa subject will perform under stress. Reliability ofthe
triagetest maybe an issue, as the test had onlybeen used once
previously. Also, the developers of the test did note that some
providers might interpret the scenarios variably, resulting in
lower scores."
The primaryinvestigator was not at the test site. The testing
was donein a groupsetting,but independentworkwas expected
and leftto the honor ofthe officers. Thepotentialforgroupwork
could affect scores.
Conclusions
Nurseswill be required to perform triagein a MASCAL situa-
tion, either as a first responder or re-evaluating as the patient's
status and severity ofillnessor injurychanges.Thisinvestigator
recommends increasing ACLS attendance as the most cost-
effective course fornurses to attend to increase their knowledge
base. Research needs to be conductedto identify what aspect of
ACLS provides positively impacted triage scores. Does it reflect
the typeofnurses whotake the courseor is the processin which
ACLS is taught the key factor? Could triage training be more
successfulwith an algorithm type system as in the ACLS prep-
aration? ACLS has been associatedwith higher scores on tests
of knowledge base of triage categories and can be used in the
clinical setting as well.
Othertarget groupsthat needto be addressed are field nurses
and reserve Army Nurse Corps Officers. The sample in this
study had littleexperience or training either in field exercises or

Military Medicine, Vol. 167, October 2002

816
deploying withmedical field units. Reserve units are an integral
part ofthe Army medical team and their skilllevel and training
should be in linewith their active duty counterparts. Adminis-
tering the Darnall MASCAL Triage Test to these nurses may
provide different results.
Triage is a dynamic process. All military medical personnel
need to be competent in triage. Research, training, and evalua-
tionoftriagecapabilities ofthe medical providers must continue
to be an ongoing priority ofthe Army Medical Department ofthe
u.s. Army.
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