START vs. SALT: Researching Triage Protocols for Mass Casualty Incidents

When Elizabeth Kuge, OMS II, was an undergraduate student at the University of California – Santa Barbara, a gunman took the lives of six students and injured fourteen others in what became known as the Isla Vista killings. Four years later, another mass shooting occurred at the Borderline Bar and Grill in the city of Thousand Oaks, which was near SD Kuge’s hometown. “I [knew] one of the victims from [the shooting],” she says. “His death made me so upset, I remember thinking, ‘What can I do to spread awareness for mass casualty incidents?’”

SD Kuge learned about several Mass Casualty Incident (MCI) triage algorithms that have been published around the world. Two that stood out to her – and that are widely used in the United States  – are the Simple Triage and Rapid Transport (START) and the Sort, Assess, Lifesaving interventions, Transport (SALT) algorithms.

The START protocol, created in 1983 by the Newport Beach Fire and Marine Department and Hoag Hospital, is one of the first civilian triage systems to have been developed. START uses a triage level and color coding system to help first responders quickly assess a patient’s condition and determine survivability. Patients are labeled as green (minor injuries), yellow (delayed treatment), red (immediate attention), and black (expectant or deceased); they are then regularly reassessed at the scene. Despite a lack of data on its efficacy, the START system is currently the most commonly used triage algorithm by first responders and law enforcement officers in the US.

In response to a lack of evidence of established triage systems, the Centers for Disease Control (CDC) formed an advisory committee in 2006 to analyze existing protocols. The committee determined that no one system was better than the other. They moved to compile the “best” triage practices from those multiple systems, thus developing the SALT algorithm. This algorithm, which also uses a triage level and color coding system, is currently endorsed by the American College of Emergency Physicians. With the SALT algorithm, patients are sorted and given a priority level for individual assessment. The assessment incorporates limited rapid lifesaving interventions such as control of major hemorrhaging and opening of the airway.

“I became interested in researching which of the two protocols, START or SALT, produced the correct number of triage destinations and was the most expeditious in the field,” said SD Kuge. During her first year at RVUCOM, SD Kuge and now second-year students Daniel Horne, Kevin Kuuskevere, David Siemann, and Colin Tsui traveled to San Diego, California with RVU’s Office of Military Affairs. They participated in Cut Suit® Week, a week-long event in which military students from several universities participate in Hyper-Realistic® Training simulations designed to prepare them for high-stress incidents. The event is part of the Intensive Surgical and Trauma Skills Course developed by Strategic Operations, Inc.

SD Kuge and her team presented and taught both protocols to the students, professionals, and faculty that were present. At each simulated MCI, two participating students were designated as triage officers and randomly assigned to use the SALT or START protocols. One of the students from the RVU Triage Research Team, as SD Kuge and her classmates were referred to, followed a student officer as they actively triaged victims.

To create a standardized triage designation for each of the victims, the team of student investigators wrote case scenarios. They then collected triage responses of these scenarios from attending physicians who volunteered at Cut Suit Week. The attending physicians came from a wide variety of specialties including emergency medicine, anesthesiology, general surgery, and family medicine.

After analyzing the responses from the students assigned one of the protocols, SD Kuge and her team concluded that neither SALT nor START were inferior to the other. In fact, it appeared that students preferred using the START triage algorithm for its more straight forward instructions.  

The Triage Team presented their research, titled “Assessing Accuracy and Efficiency of SALT v. START Triage Protocols in a Simulated Mass Casualty Incident,” at RVU’s Research Day in November of 2019 and at the Regional Medical Education Conference in Dallas, Texas. Their research abstract has recently been accepted to present at the Association of Military Osteopathic Physicians and Surgeons Annual Meeting 2020 in Las Vegas, Nevada in early March.

“This project is special because it originated at RVU,” said SD Kuge. It was approved through RVU’s Institutional Review Board, with data collected from RVU’s Office of Military Affairs and assistance from faculty, in particular Dr. David Ross, Director of Rural and Wilderness Medicine Track and Course Director of Military Medicine, and Dr. Anthony LaPorta, Director of the Office of Military Affairs. “The big takeaway [from this project] is that research CAN be done [at RVU], and we have all the resources needed to see a project through to completion.”