Does START Triage Work? An Outcomes Assessment After a Disaster

Abstract

ObjectiveThe mass casualty triage system known as START (Simple Triage and Rapid Treatment) has been widely utilized in the United States since the 1980s. However, no outcomes assessment has been conducted after a disaster to determine whether assigned triage levels match patients' actual clinical status. Researchers hypothesized that START achieves at least 90% sensitivity and specificity for each triage level, and ensures that the most critical patients are transported first to area hospitals. MethodsThe performance of START was evaluated at a train crash disaster in 2003. Patient field triage categories and scene times were obtained from county reports. Patient medical records were then reviewed at all receiving hospitals. Victim arrival times were obtained and correct triage categories determined a priori using a combination of the modified Baxt criteria and hospital admission. Field and outcomes-based triage categories were compared, defining the appropriateness of each triage assignment. ResultsInvestigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventynine patients were over-triaged, three were under-triaged, and 66 patients' outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% CI 15.8-100) and green was 89.3% specific (95% CI 71.8-97.7). The Obuchowski statistic was 0.81, meaning that victims from a higher acuity outcome group had an 81% chance of assignment to a higher acuity triage category. Red patients arrived at hospitals 0.92 hours (95% CI 0.71-1.1) faster than other patients. ConclusionsThis analysis demonstrates poor agreement between triage levels assigned by START at a train crash and a priori outcomes criteria for each level. START ensured acceptable levels of under-triage (100% red sensitivity and 89% green specificity) but incorporated a significant amount of over-triage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.

TRIAGE : Management of the trauma patient

“…Despite its widespread use, START has not been validated. The system has been studied in correlation with clinical outcome as a post-event review of an actual disaster [34][35][36]. …”

“…Neither SALT nor START takes the number of resources or casualties into account. Today, there is evidence indicating that SALT and START can lead to over triage [35,40], and neither are sensitive or specific enough to predict clinical outcome [37].…”

Hospital Bioterrorism Planning and Burn Surge

“…28 The first 12 patients triaged as either ''red tag'' or ''yellow tag'' were transported within the first hour following the explosion. 29 Another 31 ''worried well'' patients were transported within the next several hours to area hospitals, including Rex Healthcare, a 433-bed hospital also located in the area. 30,31 In aggregate, the distribution of injured patients by EMS included approximately 12 to WakeMed, 10 to Rex Hospital (shown in Figure 1 as H4), 11 to WakeMed Cary (shown in Figure 1 as H6), 7 to Duke Raleigh (shown in Figure 1 as H5), and 3 with critical burn injuries to the Burn Center at UNC Hospitals.…”

Tabletop Exercise on Mass Casualty Incident Triage, Does it Work?

“…Accurate triage allows correct identification of those patients who need the most urgent intervention and transport to hospital and those who can wait longer for treatment and those who are so severely injured and will not survive so only palliative care given [2].…”