Decision-making criteria for reverse triage in hospitalized patients following mass casualty incidents: A systematic literature review

Mass casualty incidents pose substantial challenges to hospital surge capacity and resource management. Reverse triage has been recognized as a critical strategy for increasing bed availability through the early discharge of selected hospitalized patients. However, the absence of a consolidated, evidence-based, and operational framework of decision-making criteria has limited the systematic application of reverse triage in practice. This study aimed to systematically identify, synthesize, and categorize decision-making criteria for reverse triage of hospitalized patients following mass casualty incidents. This systematic literature review was conducted in accordance with the PRISMA 2020 guidelines. A comprehensive search of PubMed, Scopus, and Web of Science databases was performed up to January 31, 2024. Studies addressing decision-making criteria for reverse triage in hospitalized patients were included without restrictions on study design or publication date. Two independent reviewers conducted study screening and data extraction. Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT), and extracted criteria were synthesized through thematic analysis. From 10,131 identified records, 19 studies met the inclusion criteria. A total of 374 initial criteria were extracted and synthesized into 34 final criteria. These criteria were organized into four main categories: (1) non-discharge criteria (12 criteria); (2) criteria for relatively stable patients requiring continued hospitalization (10 criteria); (3) social, environmental, or managerial barriers (9 criteria); and (4) supportive criteria for early discharge (3 criteria). In addition, the criteria were classified into four overarching domains: clinical, resource-related, individual, and other factors. Most included studies were assessed as high quality. This review provides the most comprehensive synthesis of reverse triage decision-making criteria to date and contributes to the standardization of early discharge decision-making in disaster contexts. The identified criteria offer a structured, evidence-informed foundation for the development of hospital discharge protocols and clinical decision support systems, with potential applicability to both mass casualty incidents and routine hospital overcrowding. Future research should prioritize prospective clinical validation of these criteria and explore their implementation across diverse healthcare systems, particularly in resource-limited settings. Systematic review registration: PROSPERO CRD420251007355. • This systematic review identifies decision-making criteria for reverse triage of hospitalized patients after MCIs. • A total of 374 initial criteria were synthesized into 34 final criteria across four major conceptual categories. • The criteria integrate clinical, resource-related, individual, and contextual factors influencing discharge decisions. • The findings support standardization of reverse triage processes to enhance surge capacity and patient safety in crises. • Results provide a foundation for developing clinical decision support systems for reverse triage implementation.