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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


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.


MCI, START, SALT, gold standard

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