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

Hendri Purwadi; Katrina Breaden; Christine McCloud; Satriya Pranata

doi:10.14710/nmjn.v11i3.37008

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

- Faculty of Nursing and Health Sciences, Muhammadiyah University of Semarang, Indonesia

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

BibTex Citation Data :

@article{NMJN37008,
    author = {Hendri Purwadi and Katrina Breaden and Christine McCloud and Satriya Pranata},
    title = {The SALT and START Triage System for Classifying Patient Acuity Level:  A Systematic Review},
    journal = {Nurse Media Journal of Nursing},
  volume = {11},
    number = {3},
    year = {2021},
    keywords = {Disaster; effectiveness; mass casualty incidents; SALT triage system; START triage system;},
    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.    },
   issn = {2406-8799},   pages = {413--427}  doi = {10.14710/nmjn.v11i3.37008},
    url = {https://ejournal.undip.ac.id/index.php/medianers/article/view/37008}
}

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

In Vol 11, No 3 (2021): (December 2021)

Recent articles

Workplace Assertiveness of Filipino Hospital Staff Nurses: A Cross-sectional Study Predictors of the Willingness to Promote Advance Care Planning among Nurses in Palliative Care Settings in Yogyakarta, Indonesia The Effect of Islamic Spiritual Mindfulness on Self-Efficacy in Anger Management among Schizophrenic Patients Editorial Back Matter Editorial Front Matter More recent articles

Most cited articles

Effect of Self-Efficacy Enhancing Education Program on Family Caregivers’ Competencies in Caring for Patients with mild Traumatic Brain Injury in Yogyakarta, Indonesia Nursing Students’ Attitudes towards Caring for Dying Patients Review: Anxiety and Quality of life in Patients with Myocardial Infarction Nurses’ Patient Safety Competencies in Aceh Province, Indonesia Correlation between Coping Strategies and Quality of Life among Myocardial Infarction Patients in Nepal More cited articles

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
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
Bettany-Saltikov, J. (2012). How to do a systematic literature review in nursing: A step-by-step guide. McGraw-Hill Education
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
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
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
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
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
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
Dolan, B., & Holt, L. (2013). Accident & emergency e-book: Theory into practice. Elsevier Health Sciences
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
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
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
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
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
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
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
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
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
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
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
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
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
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
PRISMA. (2015). Transparent reporting of systematic reviews and meta-analyses. http://prisma-statement.org/
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
The Joanna Briggs Institute. (2011). Joanna Briggs Institute reviewers manual: 2011 edition. The Joanna Briggs Institute
United Nations for Disaster Risk Reduction. (2015). Disaster Statistics. https://www.unisdr.org/we/inform/disaster-statistics
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
US Department of Health and Human Services. (2019b). START Adult Triage Algorithm. https://chemm.nlm.nih.gov/startadult.htm

Last update:

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
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
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
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
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
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
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
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: 2024-11-21 15:07:16

No citation recorded.

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Journal Author(s) Rights

In order for the Department of Nursing, Faculty of Medicine, Universitas Diponegoro to publish and disseminate research articles, we need non-exclusive publishing rights (transferred from the author(s) to the publisher). This is determined by a publishing agreement between the author(s) and the Department of Nursing, Faculty of Medicine, Universitas Diponegoro. This agreement involves the transfer or licensing of the copyright for publishing to the publisher, while authors still retain significant rights to use and share their own published articles. The Department of Nursing, Faculty of Medicine, Universitas Diponegoro supports the need for authors to share, disseminate, and maximize the impact of their research through these rights in any databases.

As the author(s), you have rights to a wide range of uses of your article, including use by your employing institution or company. These author rights can be exercised without the need to obtain specific permission. Authors publishing in the Nurse Media Journal of Nursing have extensive rights to use their works for teaching and scholarly purposes without needing to seek permission, including:

use for classroom teaching by the author or the author’s institution and presentation at a meeting or conference, including distributing copies to attendees;
use for internal training by the author’s company;
distribution to colleagues for their research use;
use in a subsequent compilation of the author’s works;
inclusion in a thesis or dissertation;
reuse of portions or extracts from the article in other works (with full acknowledgment of the final article);
preparation of derivative works (other than for commercial purposes) (with full acknowledgment of the final article);
voluntary posting on open websites operated by the author or the author’s institution for scholarly purposes;

following the open access license of the Creative Commons CC BY-SA License.

Authors, readers, and third parties can copy and redistribute the material in any medium or format, as well as remix, transform, and build upon the material for any purpose, even commercially, but they must give appropriate credit (including the name of the creator and attribution parties, detailed information about the authors, a copyright notice, an open access license notice, a disclaimer notice, and a link to the material), provide a link to the license, and indicate if changes were made. The publisher will indicate any modification of the material (if any) and retain an indication of previous modifications using a CrossMark Policy and information about Erratum-Corrigendum notifications.

Authors, readers, and third parties can read, print, and download, redistribute or republish the article (e.g., display it in a repository), translate the article, download it for text and data mining purposes, reuse portions or extracts from the article in other works, sell or reuse it for commercial purposes, remix, transform, or build upon the material. They must distribute their contributions under the same license as the original Creative Commons Attribution-ShareAlike (CC BY-SA).

Copyright Transfer Agreement for Publishing (Publishing Right)

The Authors submitting a manuscript do so on the understanding that if accepted for publication, non-exclusive right for publishing (publishing right) of the article shall be assigned/transferred to Publisher of the Nurse Media Journal of Nursing (Department of Nursing, Faculty of Medicine, Universitas Diponegoro).

Upon acceptance of an article, authors will be asked to complete a 'Copyright Transfer Agreement for Publishing (CTAP)'. An e-mail will be sent to the Corresponding Author confirming receipt of the manuscript together with a 'Copyright Transfer Agreement for Publishing' form by online version of this agreement.

Nurse Media Journal of Nursing and Department of Nursing, Faculty of Medicine, Universitas Diponegoro, the Editors and the Editorial Board make every effort to ensure that no wrong or misleading data, opinions or statements be published in the journal. In any way, the contents of the articles and advertisements published in the Nurse Media Journal of Nursing are sole and exclusive responsibility of their respective authors and advertisers.

Please note that even though we ask for a transfer of copyright for publishing (CTAP), our journal Author(s) retain (or are granted back) significant scholarly rights as mentioned before.

The Copyright Transfer Agreement for Publishing (CTAP) Form can be downloaded here: [Copyright Transfer Agreement for Publishing (CTAP) Form NMJN 2024]

The copyright form should be signed electronically and send to the Editorial Office in the form of original e-mail below:

Dr. Meira Erawati (Editor-in-Chief)
Editorial Office of Nurse Media Journal of Nursing
Department of Nursing, Faculty of Medicine, Universitas Diponegoro
Jl. Prof. Soedarto, Tembalang, Semarang, Central Java, Indonesia 50275
Telp.: +62-24-76480919; Fax.: +62-24-76486849
E-mail: media_ners@live.undip.ac.id

(This policy statements has been updated at 24th January 2024)

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

Journal Author(s) Rights

Copyright Transfer Agreement for Publishing (Publishing Right)

OFFICE INFORMATION