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TABLE 18-3 Projection of Health Care and Mechanical Ventilation Utilization in Moderate and Severe Pandemic
Influenza Scenarios*

Characteristic Moderate (1958/68-like) Severe (1918-like)
Illness 90 million (30% of population) 90 million (30% of population)

Outpatient medical care 45 million (50% of illness) 45 million (50% of illness)

Hospitalization 865,000 9,900,000
ICU care 128,750 1,485,000

Mechanical ventilation 64,875 742,500

Deaths 209,000 1,903,000
*Projection based on extrapolation from past pandemics in the United States. These estimates do not include the potential positive impact of
medical and nonmedical interventions that were not available in the past pandemics (HHS, 2005).
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at any given time (McNeil, 2006). The availability of the remaining 5,000 venti-
lators for the entire U.S. represents a critical shortage in ventilators and qualified
personnel to manage the surge in demand.

Triage Systems for Mass Casualty Incidents

Triage can be defined as a process using predetermined criteria to assign individu-
triage: A process that uses
predetermined criteria to assign als from a large pool of people for grouping and making decisions. The principles
individuals from a large pool of of triage were used as early as during Napoleon’s wars (1799–1815). Earlier military
people for grouping and making
decisions. triage placed a high priority on less wounded soldiers who could be returned to the
battlefield (Mitchell, 2008).
Today, triage puts a high priority of care on those severely ill individuals who are
most likely to survive. There are many triage systems and algorithms (Lerner, 2008),
and three representative systems are discussed in the following sections.

Prehospitalization triage systems. The most widely used prehospitalization triage al-
gorithm in the U.S. is the START (Simple Triage and Rapid Treatment) system.
START: the Simple Triage and
Rapid Treatment algorithm START is a simple triage and rapid treatment algorithm suitable for use by first re-
that is based on three param- sponders. It is based on three parameters: respiration, perfusion, and mental status
eters: respirations, perfusion, and
mental status (RPM). The pediatric (RPM). The pediatric version is known as JumpSTART.
version is known as JumpSTART. START was developed by the Newport Beach Fire and Marine Department
and Hoag Hospital in Newport Beach, California in 1983. Modifications to
START were made in which radial pulse substituted the capillary refill time.
The pediatric version Figure 18-2 shows the algorithm of the START triage system (Benson et al.,
of START is known as
JumpSTART. 2006; cert-la.com, 2011).
While START is one of the most common triage systems, there is limited scien-
tific evidence to validate the effectiveness or accuracy of START or other triage sys-
tems. In 2008, a multidisciplinary committee reviewed 9 existing mass casualty tri-
age systems (7 adult- and 2 pediatric-specific systems), and it used the best available

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