Comparison of START and SALT triage methodologies to reference standard definitions and to a field mass casualty simulation

Salvatore Silvestri, MD; Adam Field, MD; Neal Mangalat, MD; Tory Weatherford, MD; Christopher Hunter, MD, PhD; Zoe McGowan, MD; Zachary Stamile, MD; Trevor Mattox, BS, MS-IV; Tanner Barfield, BS, MS-IV; Aarian Afshari, MD; George Ralls, MD; Linda Papa, MD, MSc

doi:10.5055/ajdm.2017.0255

Authors

Salvatore Silvestri, MD
Adam Field, MD
Neal Mangalat, MD
Tory Weatherford, MD
Christopher Hunter, MD, PhD
Zoe McGowan, MD
Zachary Stamile, MD
Trevor Mattox, BS, MS-IV
Tanner Barfield, BS, MS-IV
Aarian Afshari, MD
George Ralls, MD
Linda Papa, MD, MSc

DOI:

https://doi.org/10.5055/ajdm.2017.0255

Keywords:

MCI, START, SALT, gold standard

Abstract

Objectives: We compared Sort, Assess, Lifesaving Intervention, Treatment/Transport (SALT) and Simple Triage and Rapid Treatment (START) triage methodologies to a published reference standard, and evaluated the accuracy of the START method applied by emergency medical services (EMS) personnel in a field simulation.

Design: Simulated mass casualty incident (MCI). Paramedics trained in START triage assigned each victim to green (minimal), yellow (delayed), red (immediate), or black (dead) categories. These victim classifications were recorded by investigators and compared to reference standard definitions of each triage category. The victim scenarios were also compared to the a priori classifications as developed by the investigators.

Setting: MCI field simulation.

Main outcome measure: Comparison of the correlation of START and SALT triage methodologies to reference standard definitions. Another outcome measure was the accuracy of the application of START triage by EMS personnel in the field exercise.

Results: The strongest correlation to the reference standard was SALT with an r = 0.860 (p < 0.001) and κ = 0.632 (p < 0.001). START and SALT triage systems agreed 100 percent on both black and green classifications. There were significant correlations between the field triage and both START and SALT methods (p < 0.001, respectfully). SALT had a significantly lower undertriage rate (9 percent [95%CI 2-15]) than both START (20 percent [95%CI 11-28]) and field triage (37 percent [95%CI 24-52]). There were no significant differences in overtriage rates.

Conclusions: In our study, the SALT triage system was overall more accurate triage method than START at classifying patients, specifically in the delayed and immediate categories. In our field exercise, paramedic use of the START methodology yielded a higher rate of undertriage compared to the SALT classification.

Author Biographies

Salvatore Silvestri, MD

Program Director, Orlando Health Emergency Medicine Residency, Orlando Regional Medical Center, Orlando, Florida; Associate EMS Medical Director, Orange County EMS System, Orlando, Florida

Adam Field, MD

Resident, Emergency Medicine, University of Arizona, Tucson, Arizona

Neal Mangalat, MD

Clinical Instructor, Department of Emergency Medicine, University of Texas-Houston, Houston, Texas

Tory Weatherford, MD

Fellow, Pediatric Emergency Medicine, Orlando Health, Orlando, Florida

Christopher Hunter, MD, PhD

Health Services Director, Orange County Government, Orlando, Florida; Associate EMS Medical Director, Orange County EMS System, Orlando, Florida

Zoe McGowan, MD

Fellow, Pediatric Emergency Medicine, Orlando Health, Orlando, Florida

Zachary Stamile, MD

Emergency Department, Tuba City Regional Health Care, Tuba City, Arizona; Emergency Department, Flagstaff Medical Center, Flagstaff, Arizona

Trevor Mattox, BS, MS-IV

University of Central Florida College of Medicine, Orlando, Florida

Tanner Barfield, BS, MS-IV

University of Central Florida College of Medicine, Orlando, Florida

Aarian Afshari, MD

Resident, Emergency Medicine, Emory University, Atlanta, Georgia

George Ralls, MD

Public Safety Director, Orange County Government, Orlando, Florida; EMS Medical Director, Orange County EMS System, Orlando, Florida

Linda Papa, MD, MSc

Director of Academic Clinical Research, Attending Emergency Physician, Orlando Regional Medical Center, Orlando, Florida; Professor, University of Central Florida College of Medicine, Orlando, Florida; Associate Professor, Florida State University College of Medicine, Orlando, Florida

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