Comparing the Accuracy of Mass Casualty Triage Systems When Used in an Adult Population

Objective: To use a previously published criterion standard to compare the accuracy of 4 different mass casualty triage systems (Sort, Assess, Lifesaving Interventions, Treatment/Transport [SALT], Simple Triage and Rapid Treatment [START], Triage Sieve, and CareFlight) when used in an emergency department-based adult population. Methods: We performed a prospective, observational study of a convenience sample of adults aged 18years or older presenting to a single tertiary care hospital emergency department. A co-investigator with prior emergency medical services (EMS) experience observed each subject’s initial triage in the emergency department and recorded all data points necessary to assign a triage category using each of the 4 mass casualty triage systems being studied. Subjects’ medical records were reviewed after their discharge from the hospital to assign the “correct” triage category using the criterion standard. The 4 mass casualty triage system assignments were then compared to the “correct” assignment. Descriptive statistics were used to compare accuracy and over- and under-triage rates for each triage system. Results: A total of 125 subjects were included in the study. Of those, 53% were male and 59% were transported by private vehicle. When compared to the criterion standard definitions, SALT was found to have the highest accuracy rate (52%; 95% CI 43–60) compared to START (36%; 95% CI 28–44), CareFlight (36%; 95% CI 28–44), and TriageSieve (37%; 95% CI 28–45). SALT also had the lowest under-triage rate (26%; 95% CI 19–34) compared to START (57%; 95% CI 48–66), CareFlight (58%; 95% CI 49–66), and TriageSieve (58%; 95% CI 49–66). SALT had the highest over-triage rate (22%; 95% CI 14–29) compared to START (7%; 95% CI 3–12), CareFlight (6%; 95% CI 2–11) and TriageSieve (6%; 95% CI 2–11). Conclusion: We found that SALT triage most often correctly triaged adult emergency department patients when compared to a previously published criterion standard. While there are no target under- and over-triage rates that have been published for mass casualty triage, all 4 systems had relatively high rates of under-triage.