Does START Triage Work? An Outcomes Assessment After a Disaster
Presented as an oral abstract at the Society for Academic Emergency Medicine annual meeting, Chicago, IL, May 2007.
Received 21 September 2008; received in revised form 5 December 2008; accepted 19 December 2008. published online 06 February 2009.
Refers to article:
Mostly Dead: Can Science Help With Disaster Triage?
, 16 March 2009
Jonathan L. Burstein
Annals of Emergency Medicine
September 2009 (Vol. 54, Issue 3, Page 431) Full Text |
Full-Text PDF (85 KB)
Study objective
The mass casualty triage system known as simple triage and rapid treatment (START) has been widely used 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 hypothesize 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.
Methods
The 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.
Results
Investigators 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. Seventy-nine patients were overtriaged, 3 were undertriaged, 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% confidence interval [CI] 16% to 100%) and green was 89.3% specific (95% CI 72% to 98%). 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. The median arrival time for red patients was more than 1 hour earlier than the other patients.
Conclusion
This 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 undertriage (100% red sensitivity and 89% green specificity) but incorporated a substantial amount of overtriage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.
aDepartment of Emergency Medicine, University of California, Irvine, Orange, CA
Address for correspondence: Christopher A. Kahn, MD, MPH, Department of Emergency Medicine, University of California, Irvine, 101 The City Drive, South, Route 128-01, Orange, CA 92868; 714-456-5239, fax 714-456-5390
Author contributions: CAK and CHS conceived the study and designed the trial. CAK obtained research funding. CAK and CHS supervised the conduct of the trial and data collection. CAK, CHS, and KTM undertook recruitment of participating centers and collected data. CAK, CHS, and CLA managed the data, including quality control. CLA provided statistical advice on study design and analyzed the data, with assistance from CAK and CHS. CAK drafted the article, and all authors contributed substantially to its revision. CAK and CHS take responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This article was supported by an F32 fellowship training grant from the Agency for Healthcare Research and Quality, awarded to Christopher Kahn, #HS-15768.
Publication date: Available online February 5, 2009.
ABSTRACT