Mass casualty incidents constitute situations in which the demand for medical interventions significantly exceeds available resources, necessitating rapid and consistent prioritization to maximize survival. In such contexts, decision-making must occur under extreme time pressure, uncertainty, and high cognitive load, where each individual decision directly affects both patient outcomes and resource utilization. While several international systems for mass casualty triage exist, the evidence base remains limited, and no universally adopted framework has been established. Against this background, a Swedish national system has recently been developed through an extensive consensus and design process.
Significant knowledge gaps remain. A central challenge is that triage systems have traditionally been developed as standalone algorithms or decision aids rather than as integrated components of a broader healthcare and preparedness system. Multiple analyses highlight the need for stronger integration between prehospital and in-hospital triage, clearer delineation of responsibilities, and improved alignment with logistics, transportation, and resource allocation across the entire chain of care. These challenges are compounded by the lack of shared structures for documentation, information sharing, and continuous re-triage, which limits possibilities for coordination, follow-up, and organizational learning over time.
Another key dimension concerns implementation and use. Research and field experience indicate that triage systems must be usable by a wide range of actors, including specialist healthcare personnel, other emergency responders, and in some cases laypersons involved in initial response efforts. However, knowledge of how education, training, and experience influence decision quality remains limited. There are also indications that triage decisions in real-world contexts are affected by cognitive biases, contextual factors, and varying adherence to protocols, further underscoring the need for deeper understanding. Beyond these system- and implementation-related challenges, mass casualty triage is fundamentally a cognitive process. Decision-making takes place under conditions characterized by constrained information processing, high stress, and time-critical demands, where working memory capacity, perception, and prior experience influence both assessment and action. There is therefore a need for increased knowledge of how these cognitive factors affect triage accuracy, robustness, and outcomes in real-world events.
By combining experimental studies of decision-making, exercise- and simulation-based evaluations, and analyses at the system and care pathway levels, this research aims to support the development of more accurate, robust, and user-adapted triage systems. Particular emphasis is placed on the interaction between human decision-makers and system design, as well as on ensuring that decision-support tools function effectively under the real-world conditions characteristic of mass casualty incidents, including resource constraints, complexity, and uncertainty.
This research has the potential to strengthen both national preparedness and international knowledge development by establishing evidence-based models for how decisions are made, supported, and implemented in complex disaster contexts. In the longer term, this may contribute to more efficient resource utilization, improved coordination, and increased survival in mass casualty incidents, as well as enhanced healthcare system capacity to manage both routine emergencies and large-scale crises.