DOI: https://doi.org/10.14710/nmjn.v11i3.37008

The SALT and START Triage System for Classifying Patient Acuity Level: A Systematic Review

*Hendri Purwadi  -  Master Program, College of Nursing and Midwifery, Flinders University, Australia
Katrina Breaden  -  College of Nursing and Midwifery, Flinders University, Australia
Christine McCloud  -  College of Nursing and Midwifery, Flinders University, Australia
Satriya Pranata orcid  -  Faculty of Nursing and Health Sciences, Muhammadiyah University of Semarang, Indonesia
Open Access Copyright (c) 2021 Nurse Media Journal of Nursing
Creative Commons License This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Citation Format:
Abstract

Background: Two common triage systems have been widely used in mass casualty incidents (MCIs) and disaster situations, namely START (simple triage algorithm and rapid treatment) and SALT (sort, assess, lifesaving, intervention, and treatment/transport). There is currently controversy regarding the effectiveness of SALT over the START triage system.

Purpose: This systematic review aims to compare the accuracy of the SALT and START triage systems in disaster and MCI settings.

Methods: The literature was searched using a systematic search strategy for articles published from 2009 to 2020 in the Medline, CINAHL, Web of Science, Scopus, PubMed, ProQuest databases, and the grey literature. This review included simulation-based and medical record-based studies investigating the accuracy and applicability of the SALT and START triage systems in adult and child populations during MCIs and disasters. All types of studies were included. The PRISMA flowchart was used to retain the articles, and the Joanna Briggs Institute critical appraisal tools were used to assess the quality of the reviewed studies.

Results: Of 1,450 articles identified in the search, 10 articles were included. It was found that the START triage system had a wide range and inconsistent levels of accuracy (44% to 94.2%) compared to the SALT triage system (70% to 83%). The under-triage error of the START triage system ranged from 2.73% to 20%, which was slightly lower than the SALT triage system (7.6% to 23.3%). The over-triage error of the START triage system (2% to 53%) was slightly higher than the SALT triage system (2% to 22%). However, the time taken to apply START triage system (70 to 72.18 seconds) was faster than for the SALT triage system (78 seconds).

Conclusion: The START triage system was simpler and faster than SALT. Conversely, the SALT triage system appeared to be slightly more accurate, more consistent, and had a lower rate of under- and over-triage error than START. It appears that neither the SALT nor the START triage system is superior to the other. Further research is needed to establish the most appropriate disaster and MCI triage system, especially for the Indonesian context.

 

Fulltext View|Download
Keywords: Disaster; effectiveness; mass casualty incidents; SALT triage system; START triage system;

Article Metrics:

Article Info
Section: Articles
Language : EN
Recent articles
Workplace Assertiveness of Filipino Hospital Staff Nurses: A Cross-sectional Study The Fluid Management Experience in Patients with Chronic Kidney Disease Undergoing Hemodialysis in Indonesia: A Qualitative Study Psychometric Testing of the Technological Competency as Caring in Nursing Instrument – Revised (English Version Including a Practice Dimension) Editorial Front Matter Editorial Back Matter More recent articles
Most cited articles
The Effect of Dietary and Exercise Self-Management Support Program on Dietary Behavior Exercise Behavior and Clinical Outcomes in Muslim Patients with Poorly Controlled Type 2 DM in a Community Setting in Indonesia Caring Science within Islamic Contexts: A Literature Review Complementary Therapies Used Among Adult Patients with Type 2 Diabetes Mellitus in Aceh, Indonesia Effects of Acupoint Stimulation with Digital Massager of Oxytocin on the Breast Milk Production of Working Mothers The Competencies, Roles and Scope of Practice of Advanced Psychiatric Nursing in Indonesia More cited articles
  1. Badiali, S., Giugni, A., & Marcis, L. (2017). Testing the START triage protocol: Can it improve the ability of non-medical personnel to better triage patients during disasters and mass casualties incidents?. Disaster Medicine and Public Health Preparedness, 11(3), 305-309. https://doi.org/10.1017/dmp.2016.151
  2. Bazyar, J., Farrokhi, M., & Khankeh, H. (2019). Triage systems in mass casualty incidents and disasters: A review study with a worldwide approach. Open Access Macedonian Journal of Medical Sciences, 7(3), 482-494. https://doi.org/10.3889/oamjms.2019.119
  3. Bettany-Saltikov, J. (2012). How to do a systematic literature review in nursing: A step-by-step guide. McGraw-Hill Education
  4. Bhalla, M. C., Frey, J., Rider, C., Nord, M., & Hegerhorst, M. (2015). Simple triage algorithm and rapid treatment and sort, assess, life-saving, interventions, treatment, and transportation mass casualty triage methods for sensitivity, specificity, and predictive values. American Journal of Emergency Medicine, 33(11), 1687-1691. https://doi.org/10.1016/j.ajem.2015.08.021
  5. Cicero, M. X., Overly, F., Brown, L., Yarzebski, J., Walsh, B., Shabanova, V., Auerbach, M., Riera, A., Adelgais, K., Meckler, G., Cone, D. C., & Baum, C. R. (2016). Comparing the accuracy of three pediatric disaster triage strategies: A simulation-based investigation. Disaster Medicine and Public Health Preparedness, 10(2), 253-260. https://dx.doi.org/10.1017/dmp.2015.171
  6. Claudius, I., Kaji, A. H., Santillanes, G., Cicero, M. X., Donofrio, J. J., Gausche-Hill, M., Srinivasan, S., & Chang, T. P. (2015). Accuracy, efficiency, and inappropriate actions using JumpSTART triage in MCI simulations. Prehospital and Disaster Medicine, 30(5), 457-460. https://doi.org/10.1017/s1049023x15005002
  7. Cone, C. D., Serra, C. J., & Kurland, C. L. (2011). Comparison of the SALT and Smart triage systems using a virtual reality simulator with paramedic students. European Journal of Emergency Medicine, 18(6), 314-321. https://doi.org/10.1097/MEJ.0b013e328345d6fd
  8. Cross, K. P., Petry, M. J., & Cicero, M. X. (2015). A better START for low-acuity victims: Data-driven refinement of mass casualty triage. Prehospital Emergency Care, 19(2), 272-278. https://doi.org/10.3109/10903127.2014.942481
  9. Culley, J. M., & Svendsen, E. (2014). A review of the literature on the validity of mass casualty triage systems with a focus on chemical exposures. American Journal of Disaster Medicine, 9(2), 137–150. https://doi.org/10.5055/ajdm.2014.0150
  10. Dolan, B., & Holt, L. (2013). Accident & emergency e-book: Theory into practice. Elsevier Health Sciences
  11. Fink, B. N., Rega, P. P., Sexton, M. E., & Wishner, C. (2018). START versus SALT triage: Which is preferred by the 21 st century health care student?. Prehospital and Disaster Medicine, 33(4), 381-386. https://doi.org/10.1017/S1049023X18000547
  12. Gaul, A. (2016). Mass casualty triage: An in-depth analysis of various systems and their implications for future considerations. University of Pittsburgh. https://repository.globethics.net/handle/20.500.12424/1243919
  13. Hart, A., Nammour, E., Mangolds, V., & Broach, J. (2018). Intuitive versus algorithmic triage. Prehospital and Disaster Medicine, 33(4), 355-361. https://doi.org/10.1017/s1049023x18000626
  14. Jeppesen, E., Cuevas-Østrem, M., & Gram-Knutsen, C. (2020). Undertriage in trauma: An ignored quality indicator?. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 28, 34. https://doi.org/10.1186/s13049-020-00729-6
  15. Jones, N., White, M. L., Tofil, N., Pickens, M., Youngblood, A., Zinkan, L., & Baker, M. D. (2014). Randomized trial comparing two mass casualty triage systems (JumpSTART versus SALT) in a pediatric simulated mass casualty event. Prehospital Emergency Care, 18(3), 417-423. https://doi.org/10.3109/10903127.2014.882997
  16. Kahn, C., Schultz, C., Miller, K. T. & Anderson, C. (2010). Does START triage work? The answer is Ccear! reply. Annals of Emergency Medicine, 55(6), 580-581. https://doi.org/10.1016/j.annemergmed.2009.12.025
  17. Kahn, C., Schultz, C. H., Miller, K. T., & Anderson, C. (2009). Does START triage work? An outcomes assessment after a disaster. Annals of Emergency Medicine, 54(3), 424-430.e421. https://doi.org/10.1016/j.annemergmed.2008.12.035
  18. Lee, C. H. (2010). Disaster and mass casualty triage. The Virtual Mentor : VM, 12(6), 466-470. https://doi.org/10.1001/virtualmentor.2010.12.6.cprl1-1006
  19. Lee, C. W., McLeod, S. L., Van Aarsen, K., Klingel, M., Franc, J. M., & Peddle, M. B. (2016). First responder accuracy using SALT during mass-casualty incident simulation. Prehospital and Disaster Medicine, 31(2), 150-154. https://doi.org/10.1017/S1049023X16000091
  20. Lerner, E. B., McKee, C. H., Cady, C. E., Cone, D. C., Colella, M. R., Cooper, A., Coule, P. L., Lairet, J. R., Liu, J. M., Pirrallo, R. G., Sasser, S. M., Schwartz, R., Shepherd, G., & Swienton, R. E. E. (2015). A consensus-based gold standard for the evaluation of mass casualty triage systems. Prehospital Emergency Care, 19(2), 267-271. https://doi.org/10.3109/10903127.2014.959222
  21. Lerner, E. B., Schwartz, R. B., Coule, P. L., & Pirrallo, R. G. (2010). Use of SALT Triage in a simulated mass-casualty incident. Prehospital Emergency Care, 14(1), 21-25. https://doi.org/10.3109/10903120903349812
  22. Lin, Y. K., Niu, K. Y., Seak, C. J., Weng, Y. M., Wang, J. H., & Lai, P. F. (2020). Comparison between Simple Triage and Rapid Treatment and Taiwan Triage and Acuity Scale for the emergency department triage of victims following an earthquake-related mass casualty incident: a retrospective cohort study. World Journal of Emergency Surgery: WJES, 15(1), 20. https://doi.org/10.1186/s13017-020-00296-2
  23. Nowell, L. S., Norris, J. M., White, D. E., & Moules, N. J. (2017). Thematic analysis: Striving to meet the trustworthiness criteria. International Journal of Qualitative Methods, 16(1), 1-13. https://doi.org/10.1177/1609406917733847
  24. Polit, D. F. (2017). Resource manual for nursing research : Generating and assessing evidence for nursing practice (10th ed.). Wolters Kluwer Health Lippincott Williams and Wilkins
  25. PRISMA. (2015). Transparent reporting of systematic reviews and meta-analyses. http://prisma-statement.org/
  26. Silvestri, S., Field, A., Mangalat, N., Weatherford, T., Hunter, C., McGowan, Z., Stamile, Z., Mattox, T., Barfield, T., Afshari, A., Ralls, G., & Papa, L. (2017). Comparison of START and SALT triage methodologies to reference standard definitions and to a field mass casualty simulation. American Journal of Disaster Medicine, 12(1), 27-33. https://doi.org/10.5055/ajdm.2017.0255
  27. The Joanna Briggs Institute. (2011). Joanna Briggs Institute reviewers manual: 2011 edition. The Joanna Briggs Institute
  28. United Nations for Disaster Risk Reduction. (2015). Disaster Statistics. https://www.unisdr.org/we/inform/disaster-statistics
  29. US Department of Health and Human Services. (2019a). SALT mass casualty triage algorithm (Sort, Assess, Lifesaving Interventions, Treatment/Transport). https://chemm.nlm.nih.gov/salttriage.htm
  30. US Department of Health and Human Services. (2019b). START Adult Triage Algorithm. https://chemm.nlm.nih.gov/startadult.htm

Last update:

  1. The correlation between nurses' knowledge of triage and the accuracy of triage level interpretation in the emergency department

    Chanif Chanif, Nursalam Nursalam, Sriyono Sriyono, Lukluk Yuniasari, Satriya Pranata, Yunie Armiyati. Scripta Medica, 54 (4), 2023. doi: 10.5937/scriptamed54-46121

  2. Proceedings of the 1st Lawang Sewu International Symposium 2022 on Health Sciences (LSISHS 2022)

    Maria Ulfah Kurnia Dewi, Nuke Devi Indrawati, Shofia Ulviyana, Eno Noventa Rahma Dhani, Ratna Dylla Andini. Advances in Health Sciences Research, 60 , 2023. doi: 10.2991/978-94-6463-132-6_25

  3. Evaluating Ten Second Triage: A Novel Multi‐Agency Prehospital Triage Tool for Major Incidents

    Louise Davidson, James Vassallo, Phil Cowburn, Dave Bull, Chris Moran, Holly Carter. Journal of Contingencies and Crisis Management, 33 (1), 2025. doi: 10.1111/1468-5973.70025

  4. Evaluation of a new prehospital major incident triage tool: Informing current UK practice

    Louise Davidson, James Vassallo, Phil Cowburn, Dave Bull, Chris Moran, Holly Carter. International Journal of Disaster Risk Reduction, 111 , 2024. doi: 10.1016/j.ijdrr.2024.104740

  5. Effective Simulation Methods Improve Student Skills in Performing Basic Life Support

    Hadi Kusuma Atmaja, Mira Utami Ningsih, Erien Luthfia, Muhammad Hasbi, Satriya Pranata. Journal of Health Sciences, 16 (02), 2023. doi: 10.33086/jhs.v16i02.3788

  6. Behavioral Activation, Mindfulness Exercises, and Loving-Kindness Meditation Exercises as Effective Therapies to Reduce Stress among Nursing Students’ during COVID-19 Pandemic

    Dwi Mulianda, Ainnur Rahmanti, Margiyati Margiyati, Novita Wulan Sari, Endro Haksara, Satriya Pranata. Open Access Macedonian Journal of Medical Sciences, 10 (G), 2022. doi: 10.3889/oamjms.2022.8695

  7. Nursing student's experiences of Role-Play Scenario-Based Disaster Triage (START) training: A qualitative research

    Bilge Kalanlar, Gülnur Akkaya. Nurse Education Today, 141 , 2024. doi: 10.1016/j.nedt.2024.106307

  8. Discovering Elements and Developing Strategies to Implement the Tailored Care Education for Patients with Diabetes through A Systematic Review

    Satriya Pranata, Shu-Fang Vivienne Wu, Tsae-Jyy Tiffany Wang, Shu-Yuan Liang, Yeu-Hui Chuang, Kuo-Cheng Lu, Khoiriyah Khoiriyah. Nurse Media Journal of Nursing, 12 (1), 2022. doi: 10.14710/nmjn.v12i1.44336

  9. Accessibility of e-EWSS versus Manual EWSS for Detecting the Emergency Condition among Patients with Coronavirus Disease 2019: A Survey Research on Register Nurse in Indonesia

    Hadi Kusuma Atmaja, Satriya Pranata, Kartarina Augustin, Erien Luthfia. Open Access Macedonian Journal of Medical Sciences, 10 (G), 2022. doi: 10.3889/oamjms.2022.8678

Last update: 2025-04-30 07:05:46

No citation recorded.