MCI triage: SALT or START?

While the most common medical call scenario is one ambulance crew being dispatched to care for one ill or injured patient, firefighters are occasionally faced with a scene that involves multiple or even many patients. When that occurs, one of the initial actions that should occur is the sorting of those patients based on the severity of their condition. You probably have heard that “triage” comes from the French word “trier,” meaning “separate out.” Napoleon’s surgeon-in-chief, Dominique Larrey, was the first to describe triage in the early 1800s.

The importance of triage when caring for multiple patients cannot be underestimated. The simple act of triage can bring a bit of order to an otherwise chaotic scene. It can give the incident command staff an understanding of the scope of the incident and close the gap between an open incident with nebulous boundaries to one with manageable priorities and finite challenges. It gives a betting indication of just how many ambulances and other resources might be needed.

In terms of patient care, triage is intended to get early care to those who need it most, rather than allow the use of limited resources on less injured patients who may not need them as quickly. It is important to note that the first triage of a patient is not the only assessment they will receive. When resources are available, patients should still have appropriate primary and secondary assessments completed as care is provided. Patient conditions can and do change over time and reassessment is always warranted.

Triage algorithms

In recent years, the most commonly used triage systems in the United States are START and SALT. Which one is right for your service?

The START algorithm was developed in 1983 through the collaboration of the Hoag Memorial Hospital and crews from the Newport Beach Fire Department. Short for Simple Triage and Rapid Treatment, the START protocol categorizes patients into four priority groups within a 30-60 second assessment. The patient is triaged based on their mental, perfusion and respiratory statuses. A pediatric version of the algorithm, JumpSTART, was developed in 1995 to include children up to age 8 years old.

SALT was introduced in 2008 after an expert panel, coordinated by the National Association of EMS Physicians and funded by the CDC, reviewed existing evidence about the triage systems currently in use. The panel also looked to other parts of the world to identify lessons learned from areas that have more experience with terrorism and mass casualty incidents.

The overarching goal of the proceedings was to identify one evidence-based triage protocol that could be used across the county. The group started by identifying 23 model uniform core criteria (MUCC) that a mass casualty triage protocol should have. Since no triage algorithms in use at the time met all 24 criteria, the panel proceeded to develop SALT, a new triage system which is non-proprietary and free to use.

The Sort-Assess-Lifesaving Interventions-Treatment/Triage (SALT) triage system meets all 24 of the MUCC points, including:

• Coverage of all ages and populations
• Simple and easy to remember
• Identification of patients needing life-saving interventions
• Not requiring counting or timing of vital signs
• Not requiring diagnostic equipment
• All patients having an individual assessment regardless of global sorting results

Another big difference between START and SALT triage is that SALT includes a grey or “expectant” category for patients who are still clinically alive but have obvious, massive injuries or other conditions that will almost certainly be fatal. The Expectant category is intended to keep those patients from being triaged Red or Immediate and using resources that could be better assigned to patients with a better chance of living. While many providers are initially concerned about making such a pronouncement, others quickly see how this gives them a better way to do the most good for the greater number of patients. It is important to remind providers that their patients are still given basic comfort care and that they may receive more treatment and even transport to a hospital if additional resources become available later into the incident.

EMS triage guidelines

Since its development, SALT, or – more specifically the Model Uniform Core Criteria, has been endorsed by most of the major national EMS and emergency care organizations, and it is included in new textbooks and educational curricula, as well as the National Model EMS Clinical Guidelines. To date, though, there has been no specific mandate to identify SALT as the singular national triage model. It remains up to state and local authorities to decide for themselves. Understanding that it may take a while to get all organizations in a particular area or region on the same triage algorithm, agencies are encouraged to review the criteria and consider making the switch.

Stay safe out there.