Skip to main content Accessibility help

A Comparison Between Differently Skilled Prehospital Emergency Care Providers in Major-Incident Triage in South Africa

  • Annet Ngabirano Alenyo (a1), Wayne P. Smith (a2), Michael McCaul (a3) and Daniel J. Van Hoving (a1)



Major-incident triage ensures effective emergency care and utilization of resources. Prehospital emergency care providers are often the first medical professionals to arrive at any major incident and should be competent in primary triage. However, various factors (including level of training) influence their triage performance.


The aim of this study was to determine the difference in major-incident triage performance between different training levels of prehospital emergency care providers in South Africa utilizing the Triage Sieve algorithm.


This was a cross-sectional study involving differently trained prehospital providers: Advanced Life Support (ALS); Intermediate Life Support (ILS); and Basic Life Support (BLS). Participants wrote a validated 20-question pre-test before completing major-incident training. Two post-tests were also completed: a 20-question written test and a three-question face-to-face evaluation. Outcomes measured were triage accuracy and duration of triage. The effect of level of training, gender, age, previous major-incident training, and duration of service were determined.


A total of 129 prehospital providers participated. The mean age was 33.4 years and 65 (50.4%) were male. Most (n=87; 67.4%) were BLS providers. The overall correct triage score pre-training was 53.9% (95% CI, 51.98 to 55.83), over-triage 31.4% (95% CI, 29.66 to 33.2), and under-triage 13.8% (95% CI, 12.55 to 12.22). Post-training, the overall correct triage score increased to 63.6% (95% CI, 61.72 to 65.44), over-triage decreased to 17.9% (95% CI, 16.47 to 19.43), and under-triage increased to 17.8% (95% CI, 16.40 to 19.36). The ALS providers had both the highest likelihood of a correct triage score post-training (odds ratio 1.21; 95% CI, 0.96-1.53) and the shortest duration of triage (median three seconds, interquartile range two to seven seconds; P=.034). Participants with prior major-incident training performed better (P=.001).


Accuracy of major-incident triage across all levels of prehospital providers in South Africa is less than optimal with non-significant differences post-major-incident training. Prior major-incident training played a significant role in triage accuracy indicating that training should be an ongoing process. Although ALS providers were the quickest to complete triage, this difference was not clinically significant. The BLS and ILS providers with major-incident training can thus be utilized for primary major-incident triage allowing ALS providers to focus on more clinical roles.

AlenyoAN, SmithWP, McCaulM, Van HovingDJ. A Comparison Between Differently Skilled Prehospital Emergency Care Providers in Major-Incident Triage in South Africa. Prehosp Disaster Med. 2018;33(6):575580.


Corresponding author

Correspondence: Annet Ngabirano Alenyo Division of Emergency Medicine Stellenbosch University Francie Van Zijl Dr.Tygerberg HospitalCape Town, South Africa 7505 E-mail:


Hide All

Conflicts of interest: none



Hide All
1. Lax, P, Prior, K. Major incident pre-hospital care. Surgery (Oxford). 2015;33(9):419423.
2. Baker, MS. Creating order from chaos: Part I: triage, initial care, and tactical considerations in mass casualty and disaster response. Mil Med. 2007;172(3):232236.
3. Vassallo, SLJ, Horne, LCS, Ball, S, Whitley, LJ. UK triage the validation of a new tool to counter an evolving threat. Injury. 2014;45(12):20712075.
4. Bostick, NA, Subbarao, I, Burkle, FMJ, Hsu, EB, Armstrong, JH, James, JJ. Disaster triage systems for large-scale catastrophic events. Disaster Med Public Health Prep. 2008;2 Suppl 1:S35S39.
5. Jenkins, JL, McCarthy, ML, Sauer, LM, et al. Mass-casualty triage: time for an evidence-based approach. Prehosp Disaster Med. 2008;23(1):38.
6. Helenis, M. Major incident medical management and support: the practical approach at the scene. Emerg Nurse. 2012;20(3):9.
7. Benson, M, Koenig, KL, Schultz, CH. Disaster triage: START, then SAVE--a new method of dynamic triage for victims of a catastrophic earthquake. Prehosp Disaster Med. 1996;11(2):117124.
8. Martí, R, Robles, S, Martín-Campillo, A, Cucurull, J. Providing early resource allocation during emergencies: the mobile triage tag. J Netw Comput Appl. 2009;32(6):11671182.
9. Frykberg, ER. Triage: principles and practice. Scand J Surg. 2005;94(4):272278.
10. Frykberg, ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53(2):201212.
11. Van Laarhoven, JJEM, Lansink, KWW, Van Heijl, M, Lichtveld, RA, Leenen, LPH. Accuracy of the field triage protocol in selecting severely injured patients after high energy trauma. Injury. 2014;45(5):869873.
12. Postma, ILE, Weel, H, Heetveld, MJ, et al. Patient distribution in a mass casualty event of an airplane crash. Injury. 2013;44(11):15741578.
13. Postma, ILE, Weel, H, Heetveld, MJ, et al. Mass casualty triage after an airplane crash near Amsterdam. Injury. 2013;44(8):10611067.
14. Fitzharris, M, Stevenson, M, Middleton, P, Sinclair, G. Adherence with the pre-hospital triage protocol in the transport of injured patients in an urban setting. Injury. 2012;43(9):13681376.
15. Wong, C, Lui, C, So, F, Tsui, K TS. Prevalence and predictors of under-diversion in the primary trauma diversion system in Hong Kong. Hong Kong J Emerg Med. 2013;20(5):276286.
16. Robertson‐Steel, I. Evolution of triage systems. EMJ. 2006;23(2):154155.
17. Van Hoving, D, Lategan, H, Wallis, L, Smith, W. The epidemiology of major incidents in the Western Cape Province. South African Medical Journal. 2015;105(10):831.
18. Annual Report: 1 April 2016 to 31 March 2017; Provincial Disaster Management Centre. Cape Town, South Africa; 2017. Accessed November 4, 2017.
19. Mackway-Jones, K. Major Incident Medical Management and Support: The Practical Approach at the Scene. Hoboken, New Jersey: Wiley-Blackwell; 2011:89102.
20. Smith, W. Triage in mass casualty situations. CME. 2012;30(11):413415.
21. Statistics South Africa: Mid-year population estimates. Pretoria. July 2017; Accessed November 4, 2017.
22. Statistics South Africa. Census 2011 Municipal Report – Western Cape. Pretoria: SSA, 2012. Accessed September 4, 2014.
23. Deluhery, MR, Lerner, EB, Pirrallo, RG, Schwartz, RB. Paramedic accuracy using SALT triage after a brief initial training. Prehospital Emerg Care. 2011;15(4):526532.
24. Lee, CWC, McLeod, SL, Van Aarsen, K, Klingel, M, Franc, JM, Peddle, MB. First responder accuracy using SALT during mass-casualty incident simulation. Prehosp Disaster Med. 2016;31(2):150154.
25. Sapp, RF, Brice, JH, Myers, JB, et al. Triage performance of first-year medical students using a multiple-casualty scenario, paper exercise. Prehosp Disaster Med. 2010;25(3):239245.
26. Challen, K WD. Major incident triage: comparative validation using data from 7th July bombings. Injury. 2013;44(5):629633.
27. Carron, PN, Taffe, P, Ribordy, V, et al. Accuracy of prehospital triage of trauma patients by emergency physicians: a retrospective study in western Switzerland. Eur J Emerg Med. 2011;18(2):8693.
28. Kilner, T HF. Triage decisions of United Kingdom police firearms officers using a multiple-casualty scenario paper exercise. Prehosp Disaster Med. 2005;20(1):4046.
29. Nilsson, A, et al. Improved and sustained triage skills in firemen after a short training intervention. Scandinavian J Trauma, Resuscitation, and Emerg Med. 2015;23:81.
Recommend this journal

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

Prehospital and Disaster Medicine
  • ISSN: 1049-023X
  • EISSN: 1945-1938
  • URL: /core/journals/prehospital-and-disaster-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Type Description Title
Supplementary materials

Alenyo et al. supplementary material

 Word (19 KB)
19 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed