Q1 : Describe Hazard Identification Risk Analysis (HIRA) for 300 bedded children hospital.

Answer : A Hazard Identification Risk Analysis (HIRA) is a risk assessment tool that can be
used to assess which hazards pose the greatest risk in terms of how likely they are to occur and how
great their potential impact may be. There are three reasons why a HIRA is useful to the emergency
management profession:
 It helps emergency management professionals prepare for the worst and/or most likely risks.
 Allows for the creation of exercises, training programs, and plans based on the most likely scenarios.
 Saves time and resources by isolating hazards that cannot occur in the designated area.

THE HIRA PROCESS

There are four steps to create and maintain a HIRA:

a) Hazard Identification - In this step the hazards that could impact a community are separated from
those that cannot. This requires a review of all hazards and their causes to determine whether they
may be a threat to the community. This may require the consultation of the scientific community,
historical records and government agencies.
b) Risk Assessment - In this step the level of risk for each hazard is examined. This may involve
speaking with hazard experts, researching past occurrences and possible scenarios. The likelihood of
the hazard occurring and the potential impacts of the hazard on people, property, the environment,
business and finance and critical infrastructure should be examined.
c) Risk Analysis - The information collected in the risk assessment step will be analysed in this step.
The desired outcome of the risk analysis is the ranking of the hazards. This highlights the hazards
that should be considered a current priority for your emergency management program.
d) Monitor and Review - It is important to remember that a HIRA is an ongoing process and hazards
and their associated risks must be monitored and reviewed.

HIRA FOR A 300 BEDDED PAEDIATRIC HOSPITAL IN MUMBAI

 This is a 300 bedded hospital located in Dadar in Mumbai. The area is at the centre of a very
crowded city area and is prone to flooding and water logging every year. In addition Summers are
hot and humid and the air is always polluted.

Step 1: Hazard Identification: The first step in this process is to identify all possible hazards –
no matter how unlikely, provided a greater than zero chance – that might impact this Children’s
Hospital in Central Mumbai or its surrounding community. A full list of hazards is given below.
Ideally , each hazard should be described in detail.

Natural Hazards Technological Hazards Human Cause Hazards Infrastructure hazard

Flood Critical Infrastructure Child abduction Electric failure
failure
Earthquake Radiological Emergency Missing Patient Fire safety system
failure

Extreme Heat Explosion/Fire Burns Medical gas failure

Pandemic Oil/ Gas Pipeline Explosion Patient relative Violence HVAC failure
Drought Nuclear Facility Emergency Choking/Strangulation IT failure
Landslide Aircraft crash on to hospital Fall from bed Water supply Disruption
Tsunami Building collapse Hazardous spills Lifts failure
Lightening Water Pipeline Break Medication errors Generator Failure
Pollution Water Contamination Electrocution
Food Poisoning

Step 2 : Risk Assessment: Each hazard is scored based on the relative risk it poses. The
risk score is a combination of two dimensions: Probability and Consequence. Consequence is
further broken down into the potential impacts on people, property, finances, and reputation. As
this is a theoretical exercise, scores are guess work . The goal is not to obtain exact measures of
risk, but rather to outline a relative ranking to guide future priorities. The parameters of the
scoring system follow:

Risk = [Probability] x [Sum of Consequences]

 Probability: Probability or Likelihood provides a standardized view of how often a given

hazard event may occur, either in the hospital or its community. The ranking scale is from 1‐
5, with 1 being the lowest possible rank and 5 being the highest. Likelihood is usually based
on a combination of history and best estimates of future frequency of events.

1 – Very Unlikely (but not impossible) to occur within a 100 year period in the hospital or
community.

2 – Unlikely-May occur every 100 years in the hospital or community.

3 – Possible-May occur every 10 years in the hospital or community.

4 – Likely-May occur every year in the hospital or community.

5 – Very Likely -Multiple occurrences per year in the hospital or community

 Consequence: For the purpose of this document, consequence is defined as the anticipated
impact from a given event in a worst‐case scenario. This measure is based upon the logic that it
is always preferable to over‐respond to an emergency. Consequence can be broken down into
four components, each of which is of critical concern to a hospital. These four aspects are human
impact, physical/infrastructure impact, financial impact, and damage to reputation.

 Human Impact: The cost of a given event in human terms; lives lost and people injured. This
impact is ranked for each event on a scale of 1 to 5, with 1 being the lowest possible score and 5
being the highest. Some people may be more vulnerable to certain hazards than others due to
many different reasons such as disabilities, economic status and health and are therefore more
likely to suffer from the negative impacts of a hazard. These groups may be more vulnerable to a
hazard due to an inability to self-evacuate or to take the proper safety precautions, susceptible to
a hazard due to their health, or a lack of access to warnings or other reasons that increase their
vulnerability to a specific hazard. Not all people who identify themselves as belong to one of
these groups may be at an increased risk during the occurrence of a hazard, it will depend on the
individual’s specific situation. Here we will be looking at the paediatric group specifically
while assessing this consequence.
1 – Injury or illness unlikely
2 – Low probability of injuries or illness
3 – High probability of injuries or illness
4 – High probability of injuries or illness and low probability of death
5 – High probability of injuries or illness and high probability of death

 Physical Impact: The cost of a given event in terms of loss of the use of hospital property or
equipment, whether destroyed, damaged, or requiring clean‐up. This impact is ranked for each
event on a scale of 1‐5, with 1 being the lowest possible score and 5 being the highest.

1 – Property damage or loss of access unlikely

2 – Minor clean-up or recovery time
3 – Minor damage, temporary loss of access
4 – Major damage, prolonged loss of access
5 – Indefinite loss of access to the affected area; complete rebuild

 Financial Impact: The cost of the impact of a given event in terms of money cost, whether for
repair/replacement or for unbudgeted incident response costs. This also includes insurance
claims, where appropriate. This impact is ranked for each event on a scale of 1 ‐5, with 1 being
the lowest possible score and 5 being the highest.
1 – Negligible
2 - Generates expenditures or an insurance claim under Rs 10 Lakhs
3 – Generates expenditures or an insurance claim of under Rs 50 lakhs
4 – Generates expenditures or an insurance claim of under Rs 1 crore
5 – Generates expenditures or an insurance claim over Rs 10 crore

 Reputation Damage: The cost of the impact of a given event in terms of damage to corporate or
facility reputation. While often overlooked in such exercises, the impacts can affect patient
census, staff recruitment, funding, and fundraising efforts. This impact is ranked for each event
on a scale of 1‐5, with 1 being the lowest possible score and 5 being the highest.
 1 – Reputation unlikely to be affected
2 – Limited negative local media coverage and/or public stigma
3 – Negative regional media coverage and strong public stigma
4 – Negative national media coverage, fundraising and/or recruitment
affected
5 – Permanent association of adverse event with hospital, large effect on
fundraising and/or recruitment

This scoring system yields a minimum total risk score of 4, and a maximum of 100.

RISK MATRIX- Table 1

Hazard Probabilit Consequence score Consequen Risk =A*B Risk

y score ce category Classification
score
(A)
(B)=a+b+c
+d
Human Physical Financial Reputation
(a) (b) (c) (d)
Flood 4 2 3 3 2 10 40 HIGH
Earthquake 1 5 4 4 1 14 14 LOW
Extreme Heat 3 2 1 1 1 5 15 LOW
Pandemic 2 5 1 2 1 9 18 LOW
Drought 3 1 1 1 1 4 12 LOW
Landslide 2 5 5 5 1 16 32 MODERATE
Tsunami 1 5 5 5 1 16 16 LOW
Lightening 3 1 1 1 2 5 15 LOW
Pollution 5 1 1 1 1 4 20 LOW
Critical 2 2 1 3 5 11 22 LOW
Infrastructure
failure
Radiological 2 5 2 4 3 14 28 MODERATE
Emergency
Explosion/Fire 3 5 4 4 4 17 51 HIGH
Oil/ Gas 3 1 1 1 1 4 12 LOW
Pipeline
Explosion
Nuclear 2 5 1 1 1 8 16 LOW
Facility
Emergency
Aircraft crash 1 5 5 1 1 12 12 LOW
on to hospital
Building 1 5 5 5 5 20 40 HIGH
collapse
Water Pipeline 3 1 3 1 3 8 24 LOW
Break
Water 3 4 1 4 4 13 39 HIGH
Contamination
Child 3 2 1 5 5 13 39 HIGH
abduction
Missing 3 3 1 4 5 13 39 HIGH
Patient
 Burns 3 3 1 4 4 12 36 HIGH
Patient 4 3 3 3 1 10 40 HIGH
relative
Violence
Choking/Stran 3 5 1 4 4 14 42 HIGH
gulation
Fall from bed 3 4 1 3 4 12 36 HIGH
Hazardous 1 4 1 3 2 10 10 LOW
spills
Medication 1 4 1 3 2 10 10 LOW
errors
Electrocution 3 5 1 4 4 14 42 HIGH
Food 3 3 1 1 2 7 21 LOW
Poisoning
Electric failure 4 1 1 1 2 5 20 LOW
Fire safety 3 4 1 3 3 12 36 HIGH
system failure
Medical gas 3 5 2 3 5 15 45 HIGH
failure

HVAC failure 3 1 2 2 1 6 18 LOW

IT failure 4 1 2 1 1 5 20 LOW
Water supply 4 1 2 1 1 5 20 LOW
Disruption
Lifts failure 5 5 4 3 4 16 80 HIGH
Generator 4 5 2 4 4 15 60 HIGH
Failure

Step 3 : Risk Analysis (Part A): Once Risk assessment was done, the hazards were
categorised or summarised based on three different risk classifications into high, moderate and low
preparedness priorities.( Shown in Table 1)

High Preparedness Priorities (Top 10; scores 36 – 100): with both a high likelihood of occurrence
and high potential impact on the hospital. High preparedness priorities are hazards that are
candidates for immediate mitigation and preparedness efforts to reduce the likelihood or
consequences of occurrence. Possible risk reduction measures include physical fortification,
redundant pathways, staff training, and acquisition of response resources.

Moderate Preparedness Priorities (scores 26 – 35): Events with either a high likelihood of
occurrence and low magnitude of impact, or low likelihood but high consequence. Such
potential risk exposures should be addressed in terms of mitigation and preparedness activities, after
high priority events, as time and resources become available.

Low Preparedness Priorities (scores 4 – 25): Events with a low incidence of occurrence and
low potential impact, or events which have already received substantial mitigation and
preparedness efforts. These events should be monitored for changes in frequency or
consequence, but do not require immediate action otherwise.

It should be noted that these results do not necessarily take into account mitigation and
preparedness efforts that are already underway. In some cases, sufficient measures may already be
in place. This has been considered when interpreting results.
 Step 3 : ( Part B) RECOMMENDATIONS FOR ACTION

From the risk assessment, we can identify mitigation and preparedness priorities based on the
relative threat each hazard poses. This prioritized list will help to guide and support an annual
cycle of emergency management activities. To begin with however, each hazard should be
assessed for pre-existing risk management strategies already in place. In some cases risk control
measures may already be adequate. In others, residual risk may still require further efforts to be
taken.

Where it is deemed that new risk management strategies are required, it is recommended that
actions be taken to reduce risk working from hazards of highest priority to lowest priority. Where
possible, however, an all‐hazards approach to mitigation and preparedness should be taken, where
the relative risk of multiple hazards can be reduced by a single measure (for example, an extreme
weather plan could cover storms, heavy rains and extreme heat). There are two ways of decreasing
risk: reducing the likelihood and reducing the consequences. Both likelihood and consequence
reduction can be achieved through mitigation measures (such as redundancies in case of failure or
built‐in physical resistance to prevent damage). Consequences can further be reduced through
preparedness measures that allow for a more efficient response (such as written plans to guide
response, staff training to ensure response is executed effectively, and resource acquisition to
support response).

For our 300 bedded paediatric hospital it is recommended that actions be taken to first address
areas where gaps remain between relative risk and mitigation efforts. After high priority hazards
have been reviewed and mitigated, focus can be shifted to moderate priority hazards as allowed by
current resources. In general, assessment should proceed from the highest ranked risks to the lowest.

Children are more vulnerable to certain hazards than and are therefore more likely to suffer from
the negative impacts of a hazard. They are more vulnerable to a hazard due to an inability to self-
evacuate or to take the proper safety precautions. Not all children are equally susceptible to all
the risks, it will depend on the child’s age and specific medical ailment.

STEP 4 : MONITOR AND REVIEW:

HIRA is a process which needs to be monitored and reviewed on a regular basis. Measures taken to
reduce likelihood or consequences of hazard events may fall under the scope of a variety of hospital
groups, such as Emergency Preparedness, Maintenance, Security, Occupational Health and
Safety, etc. For each risk reduction measure, one department or position should be given primary
accountability. Progress should be reviewed at monthly intervals and this risk assessment should be
updated annually to reflect changes in risk with the results serving to assist in the identification of
future priorities for emergency preparedness activities.
 Q2 : Describe Disaster Triage?
Answer : Triage can be defined as the process of categorizing and sorting patients by the severity of the
condition, the availability of medical and transport facilities in a mass casualty scenario in order to
maximize survivors. It is a complex process of the patient being rapidly and systematically graded
according to the severity of the disease and injury. Disaster is a state which overwhelms the response
capacity of the community. It is a situation that places considerable demand on the medical resources
and services. Triage is the process of sorting patients based on the acuity of their condition.

 Historical perspective
The word triage comes from the French word- trier – which means to separate out, shift or
select. Napoleon’s surgeon marshal, Baron Dominique Jeanne Larry first described triage in
modern times. His priorities were military rather than medical and soldiers with minor wounds were
given the highest priority so that they could be quickly treated and returned to the battlefield.

 Goal of Disaster Triage:

Do the greatest possible for the greatest number of casualties.

 Why do we need to do Disaster triage?

o There are multiple victims with various presentations, and it is not possible for the health
infrastructure to deal with all of them simultaneously
o Medical and surgical cases all may present together
o There is no normal end point
o The principal of first come first treat cannot be applied here as many patients turn up
simultaneously
o Conditions are austere and resources are limited

 TYPES OF DISASTER TRIAGE

 There are many types of triage systems in the world; however, there is no general or universal
consensus on how triage should be performed. As triage is a dynamic procedure, there is no fixed
rule for it. Accordingly, these systems may be designed based on such criteria as vital signs, patient's
major problems, or the resources and facilities needed to respond to the patient needs. One of the
most important features of a standard triage system is its simplicity in performing and reliability. In
other words, the most effective triage is a method that is easy for staffs to perform, does not need to
classify patients and injured people by complex criteria and at the same time determine the prognosis
of the patients at an optimal level.
1. Simple Triage
2. Advanced Triage
3. Integrated triage
o MASS
o START
o SALT
4. Over Triage
5. Under triage
6. Reverse triage
7. Military Triage
8. Sieve Triage
 9. CESIRA protocol
10. Homebush triage

 SIMPLE TRIAGE
o Done by the EMTs
o Done at the site of the mass casualty scene
o Patients categorized as
 Those who need critical attention and immediate transport to hospital
 Those with less severe injuries
o Done before the transport arrives
o After triaging each patient is labelled to identify, display assessment findings and identify
priorityof medical need and transport
 Use colored flagging tape
 Marker pens
 Preprinted card called triage tags

 ADVANCED TRIAGE
o Done by doctors or specially trained nurses
o Patients sorted based on their likelihood of survival
o Some seriously injured people may be selected to not receive advanced treatment because
they are unlikely to survive
o Used to divert scarce resources away from patients with poor chance of survival to those
who are more likely to live
o Done in settings where the medical professionals decide that available medical resources are
not sufficient to treat all the people who need help

 OVER TRIAGE

o It is the overestimating of the severity of an illness or injury.

o Example: categorizing a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or Priority 1
(Immediate).
o Acceptable over triage rates - up to 50% in an effort to avoid under triage.

 UNDER TRIAGE
o It is the underestimating the severity of an illness or injury.
o Example - categorizing a Priority 1 (Immediate) patient as a Priority 2 (Delayed) or Priority 3
(Minimal).
o Acceptable under-triage rates have been deemed 5% or less.

 INTEGRATED TRIAGE

o Continuous integrated triage is an approach to triage in mass casualty situations which is both
efficient and sensitive to psychosocial and disaster behavioural health issues that affect the
number of patients seeking care (surge), the way a hospital or healthcare facility deals with
that surge (surge capacity) and the overarching medical needs of the event.
 o Continuous integrated triage combines three forms of triage with progressive specificity to
most rapidly identify those patients in greatest need of care while balancing the needs of the
individual patients against the available resources and the needs of other patients.

 MASS TRIAGE- MOVE, ASSESS, SORT , SEND

o Performed in the hot zone and the aim is to do maximum good for maximum people

o Can be done by trained paramedics

o The responders should be wearing adequate and appropriate PPE as per the scenario

o The responder will speak or call out:-

o MOVE: “Everyone who can hear me and needs medical attention, please move to a
designated area now!” This is for those who are ambulatory to separate out

 For the Non-ambulatory , the responder says “Everyone who can raise an arm or leg,
please do so ”

o ASSESS : Once the sorting is done, the responder quickly sorts the remaining patients and
does the triage
o SORT: victims. Reassess! Keep re assessing because status can change
 Green ( Minimal ) Ambulatory patients
ø ( no impaired function, can self-treat or be cared for my non- professional )
ø Walking Wounded
ø Abrasions, contusions, minor lacerations etc.
ø Routine treatment within 24 hours
 Yellow ( Delayed )
ø Can wait for care after simple first aid ( I.e., wounds dressed, splints applied )
ø Clearly need medical attention, but should not decompensate rapidly if care
is delayed.
 Red ( Immediate )
ø Critical Patients who are seriously injured but have a good chance of survival
if treated immediately
ø They have an obvious threat to life and limb
ø There are complications in their Airway/breathing/circulation
ø Need to be treated within 2 hours
 Black ( Deceased or Expectant )
ø Expectant; This patient shows obvious signs of death.
ø Included are – unresponsive patients with no pulse – or with catastrophic
head injuries and / or chest injuries.
o SEND :- victims are sent ( evacuated ) both safely & promptly to the designated holding area
/ or treatment area. or
 Victims are treated and released at the scene. or
 Sent to hospitals or secondary treatment facilities or
 Sent to morgue facilities if so required
 START ( SIMPLE TRIAGE AND RAPID TRANSPORT)

o Start was developed in the 1980s in US in California, and it is one of the first civilian triad
systems.

o There is, however, some evidence that START can lead to over triage of patients in a real
time mass casualty setting.

o Why START?
 Because START is easily learned, it can be easily remembered. There are clear cut
decision processes and it relies only on the basic life support skills of the responders.
 So the first thing the responder says is - if you can walk, go and stand there.
 The next step is to take a deep breath. Ensure that the scene around is safe and start
the triage of all the patients that were not able to move and spend about 60 seconds
per patient.
 Start with Airway and breathing.

START FLOWCHART
 PROBLEMS WITH START:

o Potential problems with children as in children apnea are due to primary respiratory issue and
therefore perfusion can be maintained, and child can be salvaged unlike in adults where
respiratory arrest is mostly due to a circulatory arrest.
o Therefore, a respiratory rate of plus or minus 30 may be either over triage or under triage in
children depending on their age.
o Capillary refill may not adequately reflect peripheral hemodynamic status in a cool
environment stop. Obeying commands may not be an appropriate gauge of mental status for
younger children. Therefore we need a Paediatric Disaster triage tool. We must also
remember that paediatric multi casualty triage may be affected by the emotional state of that
triage responder.
 JumpSTART PEDIATRIC MCI TRAIGE:

o This was developed by Lou Romig, a paediatric emergency physician and is in is now
widespread use throughout USA and Canada and it’s also being taught to in many other
countries around the world.
o Initially they started with ages of 1-8. Because it was said that less than one year of age, the
child is less likely to be ambulatory. And by the age of eight and beyond, the physiology of
the child more or less starts equating to that of an adult. However sometimes children's age
and looks do not match. And therefore it was decided that if a victim appears to be a child,
use jumpSTART. If a victim appears to be a young adult, use START.

JumpSTART FLOWCHART
o So for jumpSTART for the ambulatory patients, identify and direct all ambulatory patient to
assemble in the designated green area for Secondary Triage and treatment.
o Begin assessment of the non-ambulatory patients as you come to them.
o Remember that all children carried to the green area by other ambulatory victims must be first
assessed by medical personnel in that area.
o Next step is jumpSTART BREATHING .
 If patient is breathing spontaneously, go on to the next step assessing respiratory rate.
If apnoeic, or with very irregular breathing, open the airway using standard
positioning techniques. If positioning results in resumption of spontaneous
respiration, tag the patient as IMMEDIATE and move on.
 If no breathing after airway opening, check for peripheral pulse. If no pulse, tag
patient as DECEASED/NON SALVAGEABLE and move on.
 If there is a peripheral pulse, give five mouth to barrier ventilation. If apnoea persists
tag patient as DECEASED/NON SALVAGEABLE and move on.
 If breathing resumes after the jump start tag, patient as IMMEDIATE and move on.
o Next step, jumpSTART RESPIRATORY RATE.
 If respiratory rate is between 15 to 45 per minute, proceed to assess perfusion. If
respiratory rate is less than 15 or more than 45 per minute or irregular tag patient as
IMMEDIATE and move on.
o JumpSTART PERFUSION.
 If peripheral pulses palpable, proceed to assess mental status.
 
If no peripheral pulses present in the least injured limb tag patient as IMMEDIATE
and move on.
o JumpSTART MENTAL STATUS.
 Use the AVPU scale to assess mental status.
 If alert, responsive to verbal commands or appropriately responsive to pain tag as
DELAYED and move on.
 If Inappropriately responsive to pain or unresponsive tag as IMMEDIATE and move
on.

 MODIFICATIONS IN JumpSTART:

o Modification for children who cannot move or who are non-ambulatory. These will include
infants who normally cannot walk yet, Children with developmental delays, children with
acute injuries )preventing them from walking before the incident) and children with chronic
disabilities.
o So the modification for non-ambulatory children is evaluate using the jump start algorithm. If
there is any RED criteria tag is RED.
o If the patient satisfy YELLOW criteria - if significant external signs of injury are found (that
is deep penetrating wounds, severe bleeding, severe burns, amputation, distended tender
abdominal) label as yellow.
o Label as green if no significant external injury.
o Individuals with special healthcare needs may also be Mass Casualty Incident victims.
Patient’s limitations in ambulation and communication and differentiation between acute and
chronic neurological conditions are the main challenges in the trials of children with special
needs and disabilities.
o At all stages of Triage, it is important to remember that unless clearly suffering from injuries
incompatible with life, victims who are tagged in the black category should be reassessed
once the critical interventions have been completed for the red and yellow patients.

 SALT (SORT -ASSESS- LIFE SAVING INTERVENTIONS -TREATMENT/ TRANSPORT.

o More recently, in response to the lack of scientific data regarding the efficacy of mass
casualty triage system, the CDC formed an Advisory Committee to analyse the existing
systems and recommended national standard for disaster trials.
o Because the literature did not conclusively identify any existing triage system as optimal, the
expert panel developed SALT by combining the best features of the existing systems.
o SALT is endorsed by several national organizations, including the American College of
Emergency Physicians , The American College of Surgeons Committee on Trauma and the
American trauma society.

SALT ALGORITHM
 START V/S SALT
o Both have the potential for over triage
o The SALT Triage system seems to combine a lot of other disaster triage protocols in its
development and the application takes a more scientific and data driven approach.
o In the the global sorting method the triage officers can quickly establish three zones and
potentially use the walking wounded to help other individuals at the scene.
REVERSE TRIAGE:

Reverse triage is a method that is commonly used during emergencies and disasters. In reverse
triage, injured people with fewer damages and minor injuries are at the priority of receiving services. This is
also used in cases, where the treatment team or soldiers, during the war, are injured. Moreover, this
kind of triage system is used in the disaster and emergencies, where medical resources are limited,
with the aim of returning people as quickly as possible and helping other people. Reverse triage is
also a way to increase the capacity of the emergency unit of the hospital during disasters. Accordingly,
those patients with mild injuries and those supposed to be without any medical complications for at
least 96 hours after discharge are at the top of the discharge list.

MILITARY TRIAGE:

The main goal of the military triage is to treat and return more injured soldiers to the battlefield. In this
method, immediate and rapid classification of the injured people is based on the type and severity of the
injury, the probability of survival, as well as the priority of treatment in order to provide the best health care
services for the largest number of people. Most military triage systems use T (Treatment) codes including
T1, T2, T3, T4 and dead to classify the injured individuals, while others use P (Priority) codes including P1,
P2, P3 and P-hold .

SIEVE TRIAGE :
Similar to the START method, this method, which is used in parts of Europe, Australia, and the United
Kingdom, first uses the walking filter to examine the injured individual, and uses four tags encompassing
red, yellow, green and black tags to classify the injured patients .

CESIRA PROTOCOL:

This method was designed in 1990. In this method, the injured people fall into three red, yellow and green
classes. The red class includes people, who are unconscious and in shock, have bleeding, and ineffective
breathing. The yellow class involves patients with fractures of the bones and other injuries, and the green
class includes injured people, who can walk.

HOMEBUSH TRIAGE:

This method was designed in 1999 in Australia, which attempts to integrate the triage protocols in that
country. This method is based on START and SAVE triage systems and includes 5 classes of triage.
Although the application of this system was documented in 2002, there are no data on its accuracy and its
impact on specific consequences like other triage systems.