EDMG541Wk3

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/40040999

Use of SALT Triage in a Simulated Mass-Casualty Incident

Article  in  Prehospital Emergency Care · January 2010

DOI: 10.3109/10903120903349812 · Source: PubMed

CITATIONS

74 READS

8,189

4 authors, including:

Some of the authors of this publication are also working on these related projects:

SALT Triage View project

Peds field triage View project

E Brooke Lerner

Medical College of Wisconsin

203 PUBLICATIONS   6,753 CITATIONS   

SEE PROFILE

Richard B Schwartz

Augusta University

20 PUBLICATIONS   759 CITATIONS   

SEE PROFILE

Ronald G Pirrallo

Medical College of Wisconsin

79 PUBLICATIONS   5,969 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Ronald G Pirrallo on 21 May 2014.

The user has requested enhancement of the downloaded file.

USE OF SALT TRIAGE IN A SIMULATED MASS-CASUALTY INCIDENT

E. Brooke Lerner, PhD, Richard B. Schwartz, MD, Phillip L. Coule, MD, Ronald G. Pirrallo, MD, MHSA

ABSTRACT

Objectives. To determine the accuracy of SALT (sort–assess– lifesaving interventions–treatment/transport) triage during a simulated mass-casualty incident, the average time it takes to make triage designations, and providers’ opinions of SALT triage. Methods. Seventy-three trainees participating in one of two disaster courses were taught to use SALT triage during a 30-minute lecture. The following day they partici- pated in teams, in one of eight simulated mass-casualty in- cidents. For each incident trainees were told to assess and prioritize all victims. Each scenario comprised 28 to 30 vic- tims, including 10 to 11 moulaged manikins and 18 to 20 moulaged actors. Each victim had a card that stated the victim’s respiratory effort, pulse quality, and ability to fol- low commands. Initial and final assigned triage categories were recorded and compared with the intended category. Ten of the victims were equipped with stopwatches to measure the triage time interval. Timing began when the trainee ap- proached the victim and ended when the trainee verbalized his or her triage designation. The times were averaged and standard deviations were calculated. After the drill, trainees were asked to complete a survey regarding their experi- ence. Results. There were 217 victim observations. The ini- tial triage was correct for 81% of the observations; 8% were overtriaged and 11% were undertriaged. The final triage was correct for 83% of the observations; 6% were overtriaged and 10% were undertriaged . The mean triage interval was 28 sec- onds (±22; range: 4–94). Nine percent reported that prior to the drill they felt very confident using SALT triage and 33% were not confident. After the drill, no one reported not feel- ing confident using SALT triage, 26% were at the same level of confidence, 74% felt more confident, and none felt less confident. Before the drill, 53% of the respondents felt SALT triage was easier to use than their current disaster triage protocol, 44% felt it was similar, and 3% felt it was more

Received March 23, 2009, from the Department of Emergency Medicine, Medical College of Wisconsin (EBL, RGP), Milwaukee, Wisconsin; and the Department of Emergency Medicine, Medical College of Georgia (RBS, PLC), Augusta, Georgia. Revision received June 2, 2009; accepted for publication June 9, 2009.

Presented at the National Association of EMS Physicians annual meeting, Jacksonville, Florida, January 2009.

The authors would like to acknowledge the cooperation of the Na- tional Disaster Life Support Foundation in the conduct of this study. Dr Lerner was partially supported by CDC grant R49/CE001175.

The authors report no conflicts of interest. The authors alone are re- sponsible for the content and writing of this paper.

Address correspondence and reprint requests to: E. Brooke Lerner, PhD, Department of Emergency Medicine, Medical College of Wis- consin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226. e-mail: [email protected]

doi: 10.3109/10903120903349812

difficult. After the drill, no one reported that SALT triage was more difficult to use. Conclusion. We found that assess- ments using SALT triage were accurate and made quickly during a simulated incident. The accuracy rate was higher than those published for other triage systems and of similar speed. Providers also felt confident using SALT triage and found it was similar or easier to use than their current triage protocol. Using SALT triage during a drill improved confi- dence. Key words: disaster; triage; emergency medical ser- vices: triage; SALT triage

PREHOSPITAL EMERGENCY CARE 2010;14:21–25

INTRODUCTION

The process of sorting multiple casualties for treat- ment was first described over 200 years ago and to- day is known as mass-casualty triage.1,2 Civilian emer- gency medical services (EMS) providers are routinely trained in a method of prioritizing patients for treat- ment and/or transport. Triage becomes even more crit- ical whenever they are faced with more patients than EMS providers. This can occur during a large-scale dis- aster or may more commonly occur during a smaller event such as a multivehicle crash. Within the United States, the specific system of mass-casualty triage a prehospital care provider uses is largely dependent on local or regional protocols, with little consistency or in- teroperability between jurisdictions.

A recent Centers for Disease Control and Pre- vention (CDC)-sponsored panel developed a pro- posed national guideline for mass-casualty triage called SALT (sort–assess–lifesaving interventions– treatment/transport) triage (Fig. 1).3 They recom- mended that across the United States a uniform stan- dard be adopted so that all EMS providers would use a similar language and process when responding to a mass-casualty event. The proposed guideline incorpo- rated aspects from all of the existing triage systems to create a single overarching guide for unifying mass- casualty triage. This nonproprietary guideline can be used for any patient regardless of age or physical or mental limitations. The concept has been endorsed by many national organizations,4 but scientific validation of the guideline is still needed. Key aspects of SALT triage include a global sorting of patients using voice commands so that individual assessment can be prior- itized, lifesaving interventions are considered first dur- ing individual assessment, and an expectant category is included that is dependent on resource availability.3

The objective of this study was to evaluate SALT triage. This study had three specific aims: 1) to

21

22 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2010 VOLUME 14 / NUMBER 1

FIGURE 1. The SALT triage guideline. LSI = lifesaving intervention; SALT = sort–assess–lifesaving interventions–treatment/transport.

determine trainee accuracy when using SALT triage during a simulated mass-casualty incident, 2) to determine the average time required to make triage designations during individual patient assessment, and 3) to determine trainees’ opinions of SALT triage.

METHODS

This prospective observational study was conducted during two Advanced Disaster Life Support (ADLS) courses. One course was conducted in Augusta, Georgia, in July 2008 and the other in Milwaukee, Wisconsin, in December 2008. The courses had open enrollment and were widely advertised within each community. The Augusta course was held on a mil- itary base and had a combination of military and civilian trainees. The Milwaukee course was held at a Veterans Affairs hospital and had primarily civilian trainees.

During the mass-triage section of each course, the trainees were taught to use the SALT triage method. The SALT triage training was provided as a 30-minute lecture. The training in Augusta was provided by an ADLS-certified instructor who was also a member of the CDC panel that developed SALT. The training in Milwaukee was provided by an ADLS-certified instructor who had had limited previous experience with the SALT triage method. Both presentations used a similar set of slides differing only in the correction of minor typographical errors and improvement in formatting.

The day after the SALT training was provided, all trainees participated in one of eight simulated mass-casualty incidents. The trainees were placed in teams of eight to 11 people and were told that they were responding to a bomb blast at a community concert. Each incident included between 28 and 30 bomb blast victims. Moulaged manikins represented between 10 and 11 of the victims and 18 to 20 moulaged actors were used to represent the remaining victims. Each victim had a card that stated the victim’s respi- ratory effort, pulse quality, and ability to follow com- mands. The actors were also given instructions on how to act out their symptoms, and several were told to dis- rupt the scene by yelling for help, acting intoxicated, or demanding assistance for their friend. The drills were made as realistic as possible with noise, sirens, and other real-life distractions such as interruptions by members of the media and having to deal with a secondary device on one of the victims (i.e., a bomb or gun). The simulated incident in Augusta was con- ducted outside and used a group of teenaged boys as the actors. The Milwaukee session was conducted in a gymnasium with limited lighting and used a variety of community volunteers as victims. Each incident used the same scenario, a bomb blast at a local concert, and the same victims. Because two actors were not avail- able for all drills, a few of the incidents were not able to use all of the patient scenarios.

An observer who was identified as an instructor monitored the drill and recorded the initial and final assigned triage categories for each simulated victim.

Lerner et al. SALT TRIAGE IN SIMULATED MASS-CASUALTY INCIDENT 23

The initial assigned triage category was the category that was assigned by the first trainee who assessed the patient. The final assigned triage category was the cat- egory that was assigned at the end of the drill. Dur- ing the drill the victims’ conditions did not change, but frequently other members of the trainee respon- der group would identify what they perceived as er- rors in triage and change the victim’s designation. The initial and final triage categories were then com- pared with the intended triage category for each sim- ulated victim. The percentage of correct assignments was determined along with 95% confidence intervals (CIs).

Ten of the victims were selected to measure the time required to individually assess the patient. The actors operated stopwatches themselves, while the manikins were timed by an instructor who was observing the drill and providing information on the manikin’s con- dition. Timing began when the trainee approached the victim and ended when the trainee verbalized his or her triage designation or applied a triage tag. The recorded times were averaged and the standard devia- tions were calculated. Trainees were told that the drill was being studied, but they were not told that they were being timed.

After the drill debriefing, trainees were asked to complete an optional retrospective before-and-after survey measuring the degree of self-reported compe- tence before and after the drill. The survey explored trainees’ confidence with SALT and ease of use as well as basic demographic information. The survey had been previously pilot-tested. Results were analyzed using descriptive statistics.

This study was considered exempt from institutional review board review by the institutional review boards at the Medical College of Georgia and the Medical Col- lege of Wisconsin.

RESULTS

Seventy-three (73) trainees participated in the two ADLS courses. There were 43 trainees at the Augusta course, including 16 physicians, 10 nurses, five prehos- pital care providers, five physician’s assistants, three pharmacists, and four people from other backgrounds. There were 30 trainees at the Milwaukee course, in- cluding 11 physicians, six nurses, eight prehospital care providers, one nurse/prehospital care provider, and four people from other backgrounds.

Overall, 63% of the trainees reported having prior drill experience. The mean number of prior drills for those with prior experience was 7 (minimum 1 and maximum 60). Twenty-nine percent of the trainees had prior actual mass-casualty incident experience. The mean number of prior mass casualty incidents for those with prior experience was 3 (minimum 1 and maximum 15). Twenty-one percent of the trainees re-

TABLE 1. First Assigned Triage Category Compared with the Intended Category

First Assigned Triage Category

Intended Category Dead Expectant Immediate Delayed Minimal

Dead 13∗ 3 0 0 0 Expectant 1 12∗ 1 0 0 Immediate 1 3 48∗ 6 0 Delayed 0 0 8 37∗ 8 Minimal 0 0 0 10 66∗

∗Indicates the correct assignment.

ported that they had heard of SALT triage prior to tak- ing the course.

During the eight simulated mass-casualty triage in- cidents, 235 victim observations were studied. Eigh- teen were excluded because the role was incorrectly acted by the actor victim (3), the victim was incorrectly moulaged (4), the victim was carrying a secondary de- vice (5), the victim was not triaged during the allotted time (5), or the observer did not record the triage cate- gory (1).

Overall, the initial triage was correct for 81% (95% CI: 75%–86%) of the observations; 8% were overtriaged and 11% were undertriaged (Table 1). The final triage was correct for 83% (95% CI: 78%–88%) of the observa- tions; 6% were overtriaged and 10% were undertriaged (Table 2). During the course in Augusta, the final triage designation was correct for 86% of the observations; 7% were overtriaged and 7% were undertriaged. Dur- ing the course in Milwaukee, the final triage designa- tion was correct for 80% of the observations; 13% were overtriaged and 7% were undertriaged.

There were a total of 58 timed victim observations because six times were not recorded; three victims were not triaged, so no time could be determined; and one victim was excluded from the time segment of the study. This victim participated in the Milwaukee course and was excluded from the analysis because the actor was told by the course observer/controllers to demand that the providers help her friend first. The actor was observed as being very insistent and distract- ing to the trainees, leading to extremely long triage times that ranged from 133 to 180 seconds. The over- all mean triage interval was 28 seconds (standard de- viation 22; minimum 4, maximum 94) (Fig. 2). If the

TABLE 2. Final Assigned Triage Category Compared with the Intended Category

Final Assigned Triage Category

Intended Category Dead Expectant Immediate Delayed Minimal

Dead 15∗ 2 0 0 0 Expectant 2 11∗ 0 0 0 Immediate 1 2 40∗ 4 0 Delayed 0 0 9 47∗ 8 Minimal 0 0 0 8 68∗

∗Indicates the correct assignment.

24 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2010 VOLUME 14 / NUMBER 1

FIGURE 2. Frequency of observation for each range of time to triage.

excluded victim’s data had been included, the overall average would have increased to 34 seconds. During the Augusta course the mean triage interval was 27 seconds (standard deviation 23). During the Milwau- kee course the mean triage interval was 30 seconds (standard deviation 21).

Of the 73 trainees who participated in the two courses, 70 (96%) completed the retrospective survey. Prior to the drill, 33% did not feel confident using SALT triage and 32% were confident or very confident using SALT. After the drill, none of the respondents did not feel confident using SALT triage, 26% were at the same level of confidence, 74% felt more confident, and none felt less confident (Table 3). Before the drill, more than half, 53%, thought SALT was easier to use than their current disaster triage protocol and 3% thought it was more difficult to use than their current disaster triage protocol (Table 4). After the drill, no respondents re- ported that SALT was more difficult to use than their current disaster triage protocol. Further, 77% did not change how easy they felt SALT triage was to use, 18% thought it was easier after the drill, and 5% thought it was similar rather than easier to use after the drill. Twenty-three participants had prior actual disaster ex- perience, and of those none thought SALT triage was harder to use than their current triage protocol.

DISCUSSION

This study found that trainees who were taught to use SALT triage had a high rate of accuracy. The 83% accuracy rate that was seen in this study is comparable to, if not better than, what has been reported when

TABLE 3. Change in Confidence before the Drill Compared with after the Drill

Confidence after the Drill

Confidence Prior Very Somewhat Not to the Drill Confident Confident Confident Confident

Very confident 6 0 0 0 Confident 6 10 0 0 Somewhat confident 7 16 2 0 Not confident 2 7 14 0

Simple Treatment and Rapid Transport (START) triage has been studied. These studies have shown that accuracy ranged from 48%5 to 75%.6 Further, 79% of the trainees had not heard of SALT triage prior to the training that was provided as part of the studied courses, and 37% had never before participated in a disaster drill. This indicates that SALT triage has the potential of being readily learned and correctly used with minimal training.

The mean of 28 seconds to make a triage designa- tion while individually assessing a victim is compa- rable to, if not better than, other systems. A previous study found that START triage had a mean triage time of 30 seconds and the Sacco triage method using the RPM (respiratory rate, pulse, motor) score had a mean triage time of 45 seconds.7 It is hypothesized that the triage time using SALT triage might be reduced be- cause it does not require an estimation of the victim’s pulse or respiratory rate. However, additional research is needed to make this determination.

Two-thirds of trainees thought SALT triage was eas- ier to use than their current triage protocol. More im- portantly, of those who had prior actual mass-casualty incident experience, none of them felt that SALT triage was harder to use than their current triage protocol. This indicates that providers will not have difficulty changing to meet the SALT triage guideline.

This study also determined that after initial didac- tic training, a minority of trainees felt very confident using SALT. After using SALT triage in a drill, all of the participants had some level of confidence using SALT triage, and almost a third felt very confident us- ing it. This indicates that it is likely very important for trainees to be given experience using a triage system

TABLE 4. Change in Ease of Use before the Drill Compared with after the Drill

After the Drill

SALT SALT SALT Is More Prior to the Drill Is Easier Is Similar Difficult

SALT is easier 32 3 0 SALT is similar 10 19 0 SALT is more difficult 2 0 0

Lerner et al. SALT TRIAGE IN SIMULATED MASS-CASUALTY INCIDENT 25

rather than simply being provided with a didactic lec- ture. However, additional research should be done to determine the optimal required training to be prepared to respond to a mass-casualty incident.

Interestingly, minimal differences in the results were found between the Augusta and the Milwaukee drills, even though the instructors had very different experi- ence levels with SALT. The Augusta instructor was one of the creators of SALT and the Milwaukee instructor had only limited experience with SALT. This may in- dicate that SALT is relatively easy to teach, although further research and evaluation are needed. However, this may also be due to the differences in the circum- stances of the two drills (e.g., the differences in light- ing) or some other unknown factor.

LIMITATIONS

This study was conducted during a simulated exer- cise. The findings may not be the same as what would be seen during a real mass-casualty incident. Further, the accuracy of the triage categories was based on the SALT triage category definitions, which have not been correlated to survival or patient outcome. This study was not capable of correlating triage category with patient outcome, so it was not possible to determine whether using SALT triage will improve patient out- come. This study was also limited to trainees in one of two ADLS courses. These trainees may not be gen- eralizable to all of the types of responders who might be trained to use SALT triage, and we cannot report on the accuracy of different provider types. The ret- rospective self-assessment survey is designed to re- duce “response shift” that can confound the validity of traditional self-ratings. This instrument is a well- established instrument to assess the effectiveness of teaching interventions.8 The victims who timed the triage decision making were told to begin the timer when the responder “approached them”; this may have introduced some variability in timing since vic- tims may have interpreted this instruction differently. Further, although we used a variety of patient types

for timing including two that needed lifesaving inter- ventions, in a real incident these times may be longer if more lifesaving interventions are applied.

CONCLUSION

Trainee victim assessments made using SALT triage during a simulated disaster drill were found to be accurate. Providers with minimal experience and training were able to make quick and accurate triage decisions. The accuracy rate was higher than those published for the START triage system and of similar speed. Providers also felt confident using SALT triage and found it was similar to or easier to use than their current triage protocol. Using SALT triage during a drill improved confidence in its use. More work is needed, but SALT triage appears to be a promising triage tool for mass-casualty incidents.

References

1. Hoey BA, Schwab CW. Level I center triage and mass casualties. Clin Orthop Relat Res. 2004 May;(422):23–9.

2. Kennedy K, Aghababian RV, Gans L, Lewis CP. Triage: tech- niques and applications in decision making. Ann Emerg Med. 1996;28:136–44.

3. Lerner EB, Schwartz RB, Coule PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(suppl 1):S25– S34.

4. SALT mass casualty triage. Disaster Med Public Health Prep. 2008;2(4):245–246.

5. Risavi BL, Salen PN, Heller MB, Arcona S. A two-hour interven- tion using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care. 2001;5:197–9.

6. Kahn C, Schultz C, Miller K, Anderson C. Does START triage work? An outcomes-level assessment of use at a mass casualty event [abstract]. Acad Emerg Med. 2007;14(suppl 1):S12a–S13a.

7. Sacco WJ, Navin DM, Fiedler KE, Waddell RK 2nd, Long WB, Buckman RF Jr. Precise formulation and evidence-based application of resource-constrained triage. Acad Emerg Med. 2005;12:759–70.

8. Pirrallo RG, Wolff M, Simpson DE, Hargarten SW. Analysis of an international EMS train-the-trainer program. Ann Emerg Med. 1995;25:656–9.

Copyright of Prehospital Emergency Care is the property of Taylor & Francis Ltd and its content may not be

copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.

View publication stats