Wajima City is located at the tip of the Noto Peninsula, where tourism, fishing, and traditional crafts, such as Wajima-nuri, thrive. With a population of 24,500, Wajima City faces challenges associated with rapid aging, with ~50% of its population being over 65 years old. Medical resources are scarce, with only one midsized hospital providing inpatient care and medical personnel is limited. In addition, the regions faces potential accessibility issues during a major disaster due to the discontinuation of the railroad, and the presence of are few major roads.

During the Noto Peninsula earthquake, 101 people died (three disaster-related deaths) in Wajima City, and 3,289 people were forced to live in evacuation centers because one-third of the buildings had been damaged (Figure 2). In the Monzen area, 922 evacuees spent their time in seven welfare shelters and 27 evacuation centers. During the acute phase of the earthquake, two DMATs, four Japan Medical Association Teams (JMAT), and one Disaster Health Emergency Assistance Team (DHEAT) were dispatched to provide treatment and care based on health status, using the Simple Triage and Rapid Treatment Triage (START) method. Dialysis and ventilator patients were transported to hospitals that were less affected, and the health of evacuees with medical conditions was being monitored by medical teams.

Hiroshima JRAT was first dispatched as an advance team to Monzen area in Wajima City between 25 to 27 January 2024, during the sub-acute phase of the disaster. On the first day of our deployment, we gave a presentation to the medical team explaining the need for rehabilitation support and the activities of the JRAT. Several medical teams were aware of the need for disaster rehabilitation but did not know the specific activities involved. We visited several shelters to assess the environment and the life functioning of evacuees. Notably, evacuees often had not informed the medical team of any fractures, bruises, or other pain from falls. We also identified problems with daily functioning by assessing evacuees and reporting this information to the DMAT and JMAT. In addition, we made environmental adjustments, such as introducing mats for the older adults who were having difficulty standing up and canes for those with an unsteady gait. As a result of these efforts, JMAT consulted us for guidance on ways to triage the life functioning of evacuees. One of the reasons why this type of triage was required was that most of the evacuees were old, and some were unable to continue living in evacuation centers because of advanced disuse syndrome. Therefore, there was an urgent need to identify the care and rehabilitation needs of all evacuees through a simple assessment of their daily functioning. Accordingly, we developed a triage algorithm that enabled an easy assessment of daily life functioning without requiring any knowledge of rehabilitation medicine.

The rehabilitation triage algorithm that we developed is based on the ICF, which enables a simple and efficient assessment of life functioning (Figure 3). It demonstrates whether evacuees can continue to live independently based on their individual life functioning. General triage, as represented by the START method, is classified into five tags (red: highest-priority treatment group; yellow: non-urgent treatment group; green: light treatment group; white: uninjured; and black: death or non-treatment group) (14). Our triage algorithm categorized patients into four triage tags based on their ability to perform three basic activities of daily living (ADLs), including sitting up, standing up from the floor, and one-leg standing. Using our algorithm, an inability to sit up is classified as a red tag and indicates difficulty living in a shelter without assistance. An inability to stand up from the floor is classified as a yellow tag and indicates the need to introduce a bed and handrails on an individual level. One-leg standing for < 2 s is classified as a green tag, signaling the need for group interventions like installing toilets and bath rails and utilizing walkers to mitigate fall risks. Finally, standing on one leg for more than 2 s is classified as a white tag, independent in ADLs. This method of triaging is expected to help standardize rehabilitation support based on life functioning.

Rehabilitation triage requires a simple measurement of ADLs. In medical rehabilitation, the Functional Independence Measure (FIM) is commonly used for assessing ADLs; however, this tool cannot be used in disaster situations because it takes time to measure and requires specialized learning (15). Thus, we were faced with the need to develop a simplified assessment measure that could be performed by teams that do not specialize in rehabilitation, such as DMAT and JMAT. Therefore, we created a system to identify the ability to perform three basic movements: sitting up, standing up from the floor, and standing on one leg (Figure 4).

The ability to sit up is the first movement in all ADLs and has been reported to be associated with ADL independence (16, 17). If an evacuee is unable to get up independently, it will be difficult for him or her to use the toilet without a caregiver. Evacuees who are unable to manage toileting independently are encouraged to seek refuge in welfare shelters, ensuring considerations of dignity and hygiene are upheld.

Standing up from the floor is a simple method of assessing physical function and is a predictor of ADL independence (18, 19). Evacuees who have difficulty standing up from the floor are also unable to use the toilet alone and require a caregiver to maintain hygiene. However, even if a patient has difficulty getting up from the floor, the introduction of a bed often enables him or her to stand up and move independently (18). In our rehabilitation triage method, evacuees who have been introduced to a bed and can then stand up are considered to have a “modified green” triage tag.

One-legged standing is widely used as a simple method for assessing balance capacity and is strongly associated with fall risk (20–23). The cut-off time for standing on one leg has varied from 3 to 30 s in previous studies (20, 21), and we struggled to identify an appropriate cut-off value for our assessment. Eventually, we decided to set a strict cut-off value of 2 s because our goal was to broadly identify those at risk of falls and provide them with rehabilitation assistance. Evacuation centers often lack barrier-free environments, and some evacuees have fallen and sustained injuries like broken bones on steps or between toilets and bathrooms. Installing handrails on steps and introducing walking aids such as wheelchairs and canes can enable safe mobility and prevent low activity by maintaining opportunities for self-care.

For evacuees who triage as red or yellow, individualized rehabilitation programs are needed to improve disuse syndrome and ADLs. For evacuees who triage as white or green, group exercise is recommended to prevent disuse syndrome and deep vein thromboses. In addition, role-playing in shelters, such as cooking, washing clothes, cleaning, and carrying goods, can improve activity levels and maintain opportunities for interpersonal interactions, which can prevent secondary disabilities such as isolation and depression.

Our proposed rehabilitation triage algorithm was accepted by the medical teams in the Monzen area, and we lectured them on how to triage the evacuees. All medical teams then split up and triaged all evacuees in the district. Seven medical teams were able to complete the triaging of all evacuees at 27 evacuation centers in 1 day using this triage system. As a result, we identified four red and eight yellow evacuees (Figure 5). Based on the experience in the Monzen area, the Ishikawa JRAT responsible for disaster rehabilitation in the Noto Peninsula earthquake adopted the Rehabilitation Triage Algorithm. The Ishikawa JRAT is recommended utilizing our triage algorithm for JRATs dispatched to take charge of disaster rehabilitation after the Noto Peninsula earthquake.

In our experience in the Monzen area, upon our arrival, the evacuation list had already been prepared and the health status of evacuees had already been assessed, as the disaster had progressed to the subacute phase. If it had been in the acute phase, however, life triage would have taken precedence, and rehabilitation triage would have been a lower priority. In addition, rehabilitation triaging of all evacuees requires a temporary investment of many human resources. If multiple medical teams had not been dispatched, as in this case, it would have been difficult to perform rehabilitation triage within a short period of time. This case report also has some limitations as it is an observation of a new triage algorithm. It has not been compared to other triage systems, it has not been externally validated, and there is no clear follow-up to assess its effectiveness in long-term outcomes.

In the sub-acute phase of a major earthquake, rehabilitation support based on triage of not only life but also function was an urgent issue. The rehabilitation triage algorithm we have developed is characterized by the fact that it does not require special tools and can be used by non-rehabilitation professionals to easily classify function. The START method, which is commonly used for primary triage, aims to determine treatment priorities quickly by means of a simple physical assessment. The Physiological and Anatomical Triage (PAT) method, used as a secondary triage, confirms physiological and anatomical lethality. Our rehabilitation triage differs from the START and PAT methods in the purpose and target of triage. The present case study showed that even non-rehabilitation professionals can immediately identify red and yellow evacuees by assessing their actual behavior. In addition, the number of people with triage tags in each evacuation center can be ascertained to clarify the number of cots, handrails, and portable toilets needed, leading to the establishment of an efficient support system. Our experience with disaster rehabilitation in the Noto Peninsula earthquake highlighted the importance of raising awareness of disaster rehabilitation and standardizing assessments and interventions in order to maintain the ADLs of disaster victims and prevent disaster-related deaths.

Assessment tools and intervention methods for disaster rehabilitation are not yet well established. Based on our experience, a rehabilitation triage algorithm is imperative to establish a method for rehabilitation support based on simplified assessments. In addition, personnel must be trained to appropriately practice rehabilitation triage and support. The ability of JRAT to act immediately in the event of a disaster has been determined by an agreement with each individual prefecture. However, we believe that positioning JRAT activities at the national level within disaster medicine is a shortcut to protecting people's health and rebuilding disaster victims' lives. In the future, we plan to develop a system that can triage using video motion capture on smartphones, enabling rehabilitation triage to be performed without a medical team. It is also necessary to establish a system to easily tabulate triage results at each local shelter. Such a system would make it possible to efficiently determine the number of people entering welfare shelters, the number of beds needed in each shelter, and the amount of welfare equipment required, such as portable toilets and handrails.