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Matthew R. Deluhery, MD, E. Brooke Lerner, PhD, Ronald G. Pirrallo, MD, MHSA,
Richard B. Schwartz, MD
526
Deluhery et al. SALT TRIAGE ACCURACY AFTER TRAINING 527
equally completed, the one completed at the latest 8.1 ± 2.0 patients. For those participants who com-
date was used. Paramedics who completed only the pleted both tests (n = 159), there was not a statisti-
second examination were excluded. cally significant difference in scores immediately after
Data were extracted from the survey site into Ex- the training compared with four months after the train-
cel (Microsoft Corp.) and analyzed using SPSS (SPSS ing (Table 1). The participants who completed the first
Inc., Chicago, IL). The initial posttest and four-month test but not the second test had similar initial scores to
posttest results were compared for each paramedic. those who completed both tests (10.8 ± 2.0 compared
Descriptive analysis and paired t-test were used to an- with 10.9 ± 1.9).
alyze data. In general, the participants had extensive experience
in EMS. Approximately half of the participants had
greater than 15 years of EMS experience, while 17%
had seven years or less. Experience in EMS did not ap-
RESULTS pear to affect test scores (Table 2).
A total of 290 of the 320 eligible paramedics (91%) com- Seventy-two percent of the paramedics completing
pleted the initial survey and 193 (60%) completed the both surveys had previously participated in one or
second survey (Fig. 3). Of the participants who com- more mass-casualty drills. The mean number of drills
pleted the initial test, the average score was 82%, a was four. Just over half of the respondents (51%) had
mean (± standard deviation) of 10.7 ± 2.3 correct an- previously responded to an actual MCI. The mean
swers out of 13 total questions. For the 10 patient sce- number of events was two. There was no statistical
narios, the paramedics correctly triaged an average of difference in mean scores on the initial test based on
Question 1: You are one of the first medical responders to arrive at a large-scale mass casualty
event and are asked by the incident commander to initially triage patients using SALT triage, what
is the first step in triage?
286
(99%) Announce loudly for all patients who can to walk to a set point
1 (1%) Start at the farthest away patient and work your way to a set point
3 (1%) Asses all patients that appear to have serious injuries
Question 2: You are one of the first medical responders to arrive at a large-scale mass casualty
event and are asked by the incident commander to perform an individual assessment, what
lifesaving intervention could be done on a young adult who is unresponsive, with agonal breathing,
obvious jugular venous distention (JVD) and a trachea that appears to deviate towards the left
(assume you have the proper training and equipment on hand)?
Question 3: Which of the following patients should be the first to be individually assessed during
as mass casualty incident?
An elderly man who is able to walk but has an obvious deformity to the right upper
1 (1%) extremity
A child who is unable to walk but is screaming for his mother. There are no
4 (1%) immediately obvious injuries, but the child is screaming loudly and sounds injured
285 A young man who is breathing but unresponsive and has a large, swollen left
(98%) lower extremity
FIGURE 2. Initial survey results. Boldfaced answers are the authors’ intended correct responses. CPR = cardiopulmonary resuscitation; SALT =
sort–assess–lifesaving interventions–treatment/transport. ∗ The scenario for patient 5 was found to be ambiguous, so two answers were accepted
as correct.
Deluhery et al. SALT TRIAGE ACCURACY AFTER TRAINING 529
FIGURE 2. Continued.
drill or actual mass-casualty experience (drill p < 0.79; 80% on both the initial and follow-up tests. Although
actual p < 0.86). this is a high rate of correct triage, there is no standard
Thirty-seven (23%) of the participants reported hav- for the expected rate of accurate triage. Prior studies
ing previously heard of SALT triage. However, test of SALT triage have found accuracy rates of 78%3 to
scores were not significantly different when a respon- 81%.4 Studies of other triage systems have found accu-
dent had prior knowledge of SALT triage (p < 0.57). racy rates of 48% to 85%.2,5,6 Of note, our study popu-
The number of correct answers for each question was lation was composed of experienced EMS personnel,
relatively constant between the first and second tests, with the majority having more than 15 years of ex-
with the exception of patient scenario 3. In this ques- perience. This may have contributed to the high test
tion, 82% correctly triaged the patient as “expectant” scores.
on the first test and 45% on the second test, with the The four-month knowledge retention was high in
majority changing their answer to “immediate.” our study group. The test scores were essentially
equivalent on the first and second examinations. This
demonstrates that a 20-minute training and 10-minute
DISCUSSION refresher may be sufficient to teach SALT triage to
The EMS providers in our study accurately applied a highly experienced group of EMS providers. This
SALT triage on an online written test, averaging over is similar to the findings of previous studies using
530 PREHOSPITAL EMERGENCY CARE OCTOBER/DECEMBER 2011 VOLUME 15 / NUMBER 4
FIGURE 2. Continued.
other mass-casualty triage systems, which have shown they participate in a drill after a didactic training
improvement in triage rates after a one-hour didactic session.4 While drills likely improve performance,
session,7 after a two-hour educational session,8 after they are expensive and difficult to coordinate for large
an approximately 30-minute Internet training session,9 groups. In our population, 72% of the respondents
and after being given decision-making materials.10 had previously participated in a mass-casualty drill.
Of note, a previous study showed that providers’ It is unclear from our study what effect prior MCI
comfort with mass-casualty triage increases when drill participation may have had on provider comfort
TABLE 1. Overall Study Results for Those Participants (n = 159) Who Completed Both Tests
First Test Second Test
Number of Correct Standard Number of Standard Difference in Confidence
Answers Deviation Correct Answers Deviation Score p-Value Interval
Overall questions out of 13 10.9 1.9 11.0 1.9 0.1 <0.770 −0.3 to 0.3
Patient scenarios out of 10 8.3 1.7 8.3 1.4 0.0 <0.565 −0.4 to 0.2
Deluhery et al. SALT TRIAGE ACCURACY AFTER TRAINING 531
information. More research is needed on how fre- 3. Cone DC, Serra J, Burns K, MacMillan DS, Kurland L, Van
quently mass-casualty triage refresher training should Gelder C. Pilot test of the SALT mass casualty triage system.
Prehosp Emerg Care. 2009;13:536–40.
be offered.
4. Lerner EB, Schwartz RB, Coule PL, Pirrallo RG. Use of SALT
Clearly the ability to correctly triage patients dur- triage in a simulated mass-casualty incident. Prehosp Emerg
ing an online written scenario may not represent one’s Care. 2010;14:21–5.
ability to triage patients in a true MCI. Retrospec- 5. Kahn CA, Schultz CH, Miller KT, Anderson CL. Does START
tive studies have examined triage accuracy during an triage work? An outcomes assessment after a disaster. Ann
MCI,5,11–14 but no study has compared triage perfor- Emerg Med. 2009;54:424–430.e1.
6. Garner A, Lee A, Harrison K, Schultz CH. Comparative analy-
mance during a written scenario test with triage per- sis of multiple-casualty incident triage algorithms. Ann Emerg
formance during a real MCI. It is unknown how the Med. 2001;38:541–8.
paramedics who completed the study training sessions 7. Sanddal TL, Loyacono T, Sanddal ND. Effect of JumpSTART
will perform during an MCI. training on immediate and short-term pediatric triage perfor-
mance. Pediatr Emerg Care. 2004;20:749–53.
8. Risavi BL, Salen PN, Heller MB, Arcona S. A two-hour interven-
CONCLUSION tion using START improves prehospital triage of mass casualty
incidents. Prehosp Emerg Care. 2001;5:197–9.
Following a short didactic course, paramedics were 9. Baez AA, Sztajnkrycer MD, Smester P, Giraldez E, Vargas LE.
able to accurately perform SALT triage during a writ- Effectiveness of a simple Internet-based disaster triage edu-
cational tool directed toward Latin-American EMS providers.
ten scenario. Four months after the training, they had
Prehosp Emerg Care. 2005;9:227–30.
retained their understanding of and accuracy using 10. Kilner T, Hall FJ. Triage decisions of United Kingdom police
SALT triage. It appears that a brief educational tool firearms officers using a multiple-casualty scenario paper exer-
was effective for training EMS providers in SALT cise. Prehosp Disaster Med. 2005;20:40–6.
triage. 11. Beyersdorf SR, Nania JN, Luna GK. Community medical re-
sponse to the Fairchild mass casualty event. Am J Surg.
1996;171:467–70.
References 12. Kahn CA, Schultz CH, Miller KT, Anderson CL. Does START
triage work? An outcomes-level assessment of use at a mass
1. Jenkins JL, McCarthy ML, Sauer LM, et al. Mass-casualty triage: casualty event. Acad Emerg Med. 2007;14:S12a–S13a
time for an evidence-based approach. Prehosp Disaster Med. 13. Asaeda G. The day that the START triage system came to a
2008;23:3–8. stop: observations from the World Trade Center disaster. Acad
2. Lerner EM, Schwartz RB, Coule PL, et al. Mass casualty triage: Emerg Med. 2002;9:255–6.
an evaluation of the data and development of a proposed na- 14. Malik ZU, Pervez M, Safdar A, Massod T, Tariq M. Triage and
tional guideline. Disaster Med Public Health Prep. 2008;2(suppl management of mass casualties in a train accident. J Coll Phys
1):S25–S34. Surg Pak. 2004;14:108–11.
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