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Does START Triage Work? The Answer is Clear!
CORRESPONDENCE
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor should not exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial Manager™ (http://www. editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. A Manuscript Submission Agreement (MSA), signed by all authors, must be faxed to the Annals office at the time of submission. Financial association or other possible conflicts of interest should always be disclosed, as documented on the MSA, and their presence or absence will be published with the correspondence. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters will be edited and may be shortened. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers.
0196-0644/$-see front matter Copyright © 2010 by the American College of Emergency Physicians.
Does START Triage Work? The Answer is Clear! To the Editor: The authors of “Does START Triage Work?: An Outcomes Assessment After a Disaster”1 never definitively answered the question. They concluded “there was poor agreement between triage levels assigned by START and a priori outcomes criteria” as 2 of 22 red tagged patients were “truly red,” and 9 of 68 tagged yellow were “truly yellow.”1 This is predictable since a blunt injured START immediate can have survival probability as high as 97%,2 while a START delayed can be as low as 63%. The overlap for penetrating trauma is more dramatic,3 and this is because the START algorithm is flawed. This is illustrated by the “anxious” patient with an accelerated respiratory rate the authors mentioned. This patient, or any with even minor respiratory distress, is accurately tagged immediate under START, as is a patient with serious respiratory distress, accelerated pulse and posturing motor response. These 2 patients do not present remotely the same, and clearly are not the same priority. The authors concluded there was “substantial (53%) overtriage,” including 62 of 120 “truly green” patients tagged red or yellow. This is typical of START. The rate of overtriage in the Madrid bombings was 76%. Of 312 immediates, only 91 were hospitalized and 62 of these were not critically injured.4 The authors concluded there was “an acceptable level of undertriage (100% red sensitivity)” as the 2 truly red patients were tagged red, yet this is inconsequential when one considers the 10-fold rate of overtriage in immediates. Both patients died, Volume , . : June
yet we do not know their priority within the group of 22 reds, and START’s algorithm provides no guidance for finding them, nor adjustment based on resource availability. The authors’ final conclusion was that START was “useful in prioritizing transport of the most critical patients” as the median time-to-treatment reds was about an hour less than for yellows and greens. Were the 2 patients who died the first immediates that arrived at the ED in 45 minutes, or the last, arriving at 2.25 hours and later than 17 yellows? The authors suggest that improved outcome-based assessments of triage performance are needed, and “a better criterion standard would need to consider resource utilization and availability, victim condition, and outcomes to be of significant utility.” This functionality should be in the triage system, not the evaluation methodology. The Sacco Triage Method explicitly considers resources, accurately assesses victim condition and is based on and measured against outcome. While the authors acknowledged that the Sacco Triage Method “exceeded their target of 90% sensitivity and specificity,” they dismissed it as being “overly complex and impractical.” Sacco Triage Method, more accurate at predicting survival probability than the Revised Trauma Score and Injury Severity Scale for blunt2 and penetrating3 trauma, was shown in a large exercise to be simple to learn and more accurate (92%) than START assessments (71%); 16% faster clearing the scene; and better at prioritization–transporting 12 of the 13 most serious patients in the first 6 ambulances, while START transported only 2 of 13 in the first 13 ambulances.5 START does not work. The answer is clear, and there’s a better way to triage. Annals of Emergency Medicine 579
Correspondence D. Michael Navin, MS William J. Sacco, PhD Thomas B. McCord, BS ThinkSharp, Inc. Towson, MD doi:10.1016/j.annemergmed.2009.11.031
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. The authors are officers, directors, and shareholders of ThinkSharp, Inc. ThinkSharp has funded 100% of all original research and the concept and product development associated with the patents pending Sacco Triage Method, which is referenced in this editorial submission. 1. Kahn C, Schultz C, Miller C, et al. Does START triage work?: an outcomes assessment after a disaster. Ann Emerg Med. 2009;54: 424-430. 2. Sacco W, Navin M, Fiedler K, et al. Precise formulation and evidence based application of resource constrained triage. Acad Emerg Med. 2005;12:759-770. 3. Sacco W, Navin M, Fiedler K et al. A new resource-constrained triage method applied to penetrating-injured victims. J Trauma. 2007;63:316-325. 4. Peral Gutierrez de Ceballos J, Turégano-Fuentes F, Perez-Diaz D, et al. 11 March 2004: The terrorist bomb explosions in Madrid, Spain– an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care. 2005;9:104-111. 5. Navin M, Sacco W, Waddell R. Operational comparison of START and the Sacco Triage Method (STM) in mass casualty exercises. J Trauma. In press.
In reply: We thank Navin, Sacco, and McCord for their comments. They correctly state that we “never definitively answered the question” of whether START works. Our study was designed to objectively consider how START functioned at an actual event. We found that various elements of START worked and others did not. However, an overall “definitive answer” must await further research into such questions as how paramedics choose to assign patients to triage categories, why they deviate from the algorithm, and whether specific components of START and other systems may require revision.1 Navin et al raise additional questions as well. First, they note that use of START resulted in a high rate of overtriage. We agree, and add that most triage systems (not just mass casualty systems) function similarly. The American College of Surgeons Committee on Trauma considers trauma patients, the group on which the Sacco Triage Method was based, to have an acceptable field overtriage rate of 25-50%.2 Next, they ask about the transport priority for the 2 “true reds” in our study. These patients both left the scene within the 580 Annals of Emergency Medicine
first 7 ambulances, which is reasonable. In actual disasters, unlike exercises, it is not possible to know when these patients will be found, extricated, and prepared for transport compared to other victims. Therefore, it is not expected that all severely injured patients will leave the scene first. Information regarding specific times for these events was not available for review in our study. Finally, they state that the Sacco Triage Method was shown to be superior to START in a large exercise. We cannot argue this point, as the citation has not yet been published at the time of this writing. However, we would suggest a few points of caution. No exercise can truly simulate a mass casualty event, so conclusions drawn from such comparisons have limited value. Although the authors have published 2 peer-reviewed articles describing the development of the Sacco Triage Method and asserting its superiority, the underlying data comes from a trauma registry rather than mass casualty events.3,4 This is problematic as it lacks applicability to the general population and contains a significant risk that the derived model overfits the data. Notably, every published article on the Sacco Triage Method has been funded and written by the principals of ThinkSharp, Inc., the company that sells the Sacco Triage Method. This raises the specter of a significant conflict of interest. We cannot say if this clear conflict has any bearing on their interpretation of our data, nor if this conflict affected the original published findings on the Sacco Triage Method in which fully one-third of the Delphi panel used to help define the Sacco Triage Method were authors on the paper. However, it is apparent that for the Sacco Triage Method to successfully move beyond preliminary research and into actual outcomes-based evaluation, investigation by a credible, objective team of scientists not affiliated with the selling of the product would be of great benefit. Otherwise, healthy skepticism will continue to limit its acceptance. Christopher A. Kahn, MD, MPH Carl H. Schultz, MD Department of Emergency Medicine University of California, Irvine Irvine, CA Ken T. Miller, MD, PhD Department of Emergency Medicine University of California, Irvine Orange County Fire Authority Irvine, CA Craig L. Anderson, PhD Department of Emergency Medicine University of California, Irvine Irvine, CA doi:10.1016/j.annemergmed.2009.12.025
Volume , . : June
Guidelines for Letters to the Editor Annals welcomes letters to the editor, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor should not exceed 500 words and 5 references. They should be submitted using Annals’ Web-based peer review system, Editorial Manager™ (http://www. editorialmanager.com/annemergmed). Annals no longer accepts submissions by mail. Letters should not contain abbreviations. A Manuscript Submission Agreement (MSA), signed by all authors, must be faxed to the Annals office at the time of submission. Financial association or other possible conflicts of interest should always be disclosed, as documented on the MSA, and their presence or absence will be published with the correspondence. Letters discussing an Annals article must be received within 8 weeks of the article’s publication. Published letters will be edited and may be shortened. Authors of articles for which comments are received will be given the opportunity to reply. If those authors wish to respond, their reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers.
0196-0644/$-see front matter Copyright © 2010 by the American College of Emergency Physicians.
Does START Triage Work? The Answer is Clear! To the Editor: The authors of “Does START Triage Work?: An Outcomes Assessment After a Disaster”1 never definitively answered the question. They concluded “there was poor agreement between triage levels assigned by START and a priori outcomes criteria” as 2 of 22 red tagged patients were “truly red,” and 9 of 68 tagged yellow were “truly yellow.”1 This is predictable since a blunt injured START immediate can have survival probability as high as 97%,2 while a START delayed can be as low as 63%. The overlap for penetrating trauma is more dramatic,3 and this is because the START algorithm is flawed. This is illustrated by the “anxious” patient with an accelerated respiratory rate the authors mentioned. This patient, or any with even minor respiratory distress, is accurately tagged immediate under START, as is a patient with serious respiratory distress, accelerated pulse and posturing motor response. These 2 patients do not present remotely the same, and clearly are not the same priority. The authors concluded there was “substantial (53%) overtriage,” including 62 of 120 “truly green” patients tagged red or yellow. This is typical of START. The rate of overtriage in the Madrid bombings was 76%. Of 312 immediates, only 91 were hospitalized and 62 of these were not critically injured.4 The authors concluded there was “an acceptable level of undertriage (100% red sensitivity)” as the 2 truly red patients were tagged red, yet this is inconsequential when one considers the 10-fold rate of overtriage in immediates. Both patients died, Volume , . : June
yet we do not know their priority within the group of 22 reds, and START’s algorithm provides no guidance for finding them, nor adjustment based on resource availability. The authors’ final conclusion was that START was “useful in prioritizing transport of the most critical patients” as the median time-to-treatment reds was about an hour less than for yellows and greens. Were the 2 patients who died the first immediates that arrived at the ED in 45 minutes, or the last, arriving at 2.25 hours and later than 17 yellows? The authors suggest that improved outcome-based assessments of triage performance are needed, and “a better criterion standard would need to consider resource utilization and availability, victim condition, and outcomes to be of significant utility.” This functionality should be in the triage system, not the evaluation methodology. The Sacco Triage Method explicitly considers resources, accurately assesses victim condition and is based on and measured against outcome. While the authors acknowledged that the Sacco Triage Method “exceeded their target of 90% sensitivity and specificity,” they dismissed it as being “overly complex and impractical.” Sacco Triage Method, more accurate at predicting survival probability than the Revised Trauma Score and Injury Severity Scale for blunt2 and penetrating3 trauma, was shown in a large exercise to be simple to learn and more accurate (92%) than START assessments (71%); 16% faster clearing the scene; and better at prioritization–transporting 12 of the 13 most serious patients in the first 6 ambulances, while START transported only 2 of 13 in the first 13 ambulances.5 START does not work. The answer is clear, and there’s a better way to triage. Annals of Emergency Medicine 579
Correspondence D. Michael Navin, MS William J. Sacco, PhD Thomas B. McCord, BS ThinkSharp, Inc. Towson, MD doi:10.1016/j.annemergmed.2009.11.031
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. The authors are officers, directors, and shareholders of ThinkSharp, Inc. ThinkSharp has funded 100% of all original research and the concept and product development associated with the patents pending Sacco Triage Method, which is referenced in this editorial submission. 1. Kahn C, Schultz C, Miller C, et al. Does START triage work?: an outcomes assessment after a disaster. Ann Emerg Med. 2009;54: 424-430. 2. Sacco W, Navin M, Fiedler K, et al. Precise formulation and evidence based application of resource constrained triage. Acad Emerg Med. 2005;12:759-770. 3. Sacco W, Navin M, Fiedler K et al. A new resource-constrained triage method applied to penetrating-injured victims. J Trauma. 2007;63:316-325. 4. Peral Gutierrez de Ceballos J, Turégano-Fuentes F, Perez-Diaz D, et al. 11 March 2004: The terrorist bomb explosions in Madrid, Spain– an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital. Crit Care. 2005;9:104-111. 5. Navin M, Sacco W, Waddell R. Operational comparison of START and the Sacco Triage Method (STM) in mass casualty exercises. J Trauma. In press.
In reply: We thank Navin, Sacco, and McCord for their comments. They correctly state that we “never definitively answered the question” of whether START works. Our study was designed to objectively consider how START functioned at an actual event. We found that various elements of START worked and others did not. However, an overall “definitive answer” must await further research into such questions as how paramedics choose to assign patients to triage categories, why they deviate from the algorithm, and whether specific components of START and other systems may require revision.1 Navin et al raise additional questions as well. First, they note that use of START resulted in a high rate of overtriage. We agree, and add that most triage systems (not just mass casualty systems) function similarly. The American College of Surgeons Committee on Trauma considers trauma patients, the group on which the Sacco Triage Method was based, to have an acceptable field overtriage rate of 25-50%.2 Next, they ask about the transport priority for the 2 “true reds” in our study. These patients both left the scene within the 580 Annals of Emergency Medicine
first 7 ambulances, which is reasonable. In actual disasters, unlike exercises, it is not possible to know when these patients will be found, extricated, and prepared for transport compared to other victims. Therefore, it is not expected that all severely injured patients will leave the scene first. Information regarding specific times for these events was not available for review in our study. Finally, they state that the Sacco Triage Method was shown to be superior to START in a large exercise. We cannot argue this point, as the citation has not yet been published at the time of this writing. However, we would suggest a few points of caution. No exercise can truly simulate a mass casualty event, so conclusions drawn from such comparisons have limited value. Although the authors have published 2 peer-reviewed articles describing the development of the Sacco Triage Method and asserting its superiority, the underlying data comes from a trauma registry rather than mass casualty events.3,4 This is problematic as it lacks applicability to the general population and contains a significant risk that the derived model overfits the data. Notably, every published article on the Sacco Triage Method has been funded and written by the principals of ThinkSharp, Inc., the company that sells the Sacco Triage Method. This raises the specter of a significant conflict of interest. We cannot say if this clear conflict has any bearing on their interpretation of our data, nor if this conflict affected the original published findings on the Sacco Triage Method in which fully one-third of the Delphi panel used to help define the Sacco Triage Method were authors on the paper. However, it is apparent that for the Sacco Triage Method to successfully move beyond preliminary research and into actual outcomes-based evaluation, investigation by a credible, objective team of scientists not affiliated with the selling of the product would be of great benefit. Otherwise, healthy skepticism will continue to limit its acceptance. Christopher A. Kahn, MD, MPH Carl H. Schultz, MD Department of Emergency Medicine University of California, Irvine Irvine, CA Ken T. Miller, MD, PhD Department of Emergency Medicine University of California, Irvine Orange County Fire Authority Irvine, CA Craig L. Anderson, PhD Department of Emergency Medicine University of California, Irvine Irvine, CA doi:10.1016/j.annemergmed.2009.12.025
Volume , . : June