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METASTART: A Systematic Review and Meta-Analysis of the Diagnostic Accuracy of the Simple Triage and Rapid Treatment (START) Algorithm for Disaster Triage

Published online by Cambridge University Press:  17 December 2021

Jeffrey M. Franc Open the ORCID record for Jeffrey M. Franc [Opens in a new window] ,
Scott W. Kirkland ,
Uirá D. Wisnesky ,
Sandra Campbell  and
Brian H. Rowe
Jeffrey M. Franc*
Affiliation:
Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
Scott W. Kirkland
Affiliation:
Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
Uirá D. Wisnesky
Affiliation:
Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
Sandra Campbell
Affiliation:
J.W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
Brian H. Rowe
Affiliation:
Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada School of Public Health, University of Alberta, Edmonton, Alberta, Canada
*
Correspondence: Jeffrey M. Franc, MD Department of Emergency Medicine University of Alberta Room 736c, University Terrace 8203-112 Street NW Edmonton, AB, Canada, T6G 2T4 Email: jeffrey.franc@ualberta.ca
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Abstract

Introduction:

The goal of disaster triage at both the prehospital and in-hospital level is to maximize resources and optimize patient outcomes. Of the disaster-specific triage methods developed to guide health care providers, the Simple Triage and Rapid Treatment (START) algorithm has become the most popular system world-wide. Despite its appeal and global application, the accuracy and effectiveness of the START protocol is not well-known.

Objectives:

The purpose of this meta-analysis was two-fold: (1) to estimate overall accuracy, under-triage, and over-triage of the START method when used by providers across a variety of backgrounds; and (2) to obtain specific accuracy for each of the four START categories: red, yellow, green, and black.

Methods:

A systematic review and meta-analysis was conducted that searched Medline (OVID), Embase (OVID), Global Health (OVID), CINAHL (EBSCO), Compendex (Engineering Village), SCOPUS, ProQuest Dissertations and Theses Global, Cochrane Library, and PROSPERO. The results were expanded by hand searching of journals, reference lists, and the grey literature. The search was executed in March 2020. The review considered the participants, interventions, context, and outcome (PICO) framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Accuracy outcomes are presented as means with 95% confidence intervals (CI) as calculated using the binomial method. Pooled meta-analyses of accuracy outcomes using fixed and random effects models were calculated and the heterogeneity was assessed using the Q statistic.

Results:

Thirty-two studies were included in the review, most of which utilized a non-randomized study design (84%). Proportion of victims correctly triaged using START ranged from 0.27 to 0.99 with an overall triage accuracy of 0.73 (95% CI, 0.67 to 0.78). Proportion of over-triage was 0.14 (95% CI, 0.11 to 0.17) while the proportion of under-triage was 0.10 (95% CI, 0.072 to 0.14). There was significant heterogeneity of the studies for all outcomes (P < .0001).

Conclusion:

This meta-analysis suggests that START is not accurate enough to serve as a reliable disaster triage tool. Although the accuracy of START may be similar to other models of disaster triage, development of a more accurate triage method should be urgently pursued.

Keywords

disaster medicinemass-casualtyincidentsmeta-analysisSTARTtriage
Type
Systematic Review
Information
Prehospital and Disaster Medicine , Volume 37 , Issue 1 , February 2022 , pp. 106 - 116
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Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of the World Association for Disaster and Emergency Medicine

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References

Ghanbari, V, Ardalan, A, Zareiyan, A, Nejati, A, Hanfling, D, Bagheri, A. Ethical prioritization of patients during disaster triage: a systematic review of current evidence. Int Emerg Nurs. 2019;43:126–132.10.1016/j.ienj.2018.10.004CrossRefGoogle ScholarPubMed
Hogan, DE, Burstein, JL. Disaster Medicine. Philadelphia, Pennsylvania, USA: Lippincott Williams and Wilkins; 2002.Google Scholar
Page, MJ, McKenzie, JE, Bossuyt, PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. PLoS Med. 2021;18(3):1–15.CrossRefGoogle ScholarPubMed
Fey, MK, Gloe, D, Mariani, B. Assessing the quality of simulation-based research articles: a rating rubric. Clin Simul Nurs. 2015;11:496–504.CrossRefGoogle Scholar
Mariani, B, Fey, MK, Gloe, D. The simulation research rubric: a pilot study evaluating published simulation studies. Clin Simul Nurs. 2018;22:1–4.CrossRefGoogle Scholar
Bond, K, Ospina, M, Blitz, S, et al. Interventions to Reduce Overcrowding in Emergency Departments. Technology Report no 67.4. Ottawa, Ontario: Canadian Agency for Drugs and Technologies in Health; 2006.Google Scholar
Higgins, JP, Thomas, J, Chandler, J, et al. Cochrane Handbook for Systematic Reviews of Interventions. Hoboken, New Jersey USA: John Wiley and Sons, Inc.; 2019.CrossRefGoogle Scholar
Wells, G, Shea, B, O’Connell, D, Peterson, J. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomized Studies in Meta-Analyses. Ottawa, Ontario: Ottawa Hospital Research Institute; 2015.Google Scholar
Hong, QN, Fàbregues, S, Bartlett, G, et al. The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Educ Inf. 2018;34(4):285–291.Google Scholar
Pace, R, Pluye, P, Bartlett, G, et al. Testing the reliability and efficiency of the pilot Mixed Methods Appraisal Tool (MMAT) for systematic mixed studies review. Int J Nurs Stud. 2012;49(1):47–53.CrossRefGoogle ScholarPubMed
Devore, J. Probability and Statistics for Engineering and the Sciences. 7th ed. Belmont, California USA: Cengage Learning; 2011.Google Scholar
Egger, M, Smith, GD, Altman, DG. Systematic Reviews in Health Care. London, UK: BMJ Publishing Group; 2001.10.1002/9780470693926CrossRefGoogle Scholar
Arshad, FH, Williams, A, Asaeda, G, et al. A modified simple triage and rapid treatment algorithm from the New York City (USA) fire department. Prehosp Disaster Med. 2015;30(2):199–204.CrossRefGoogle ScholarPubMed
Badiali, S, Giugni, A, Marcis, L. Testing the START triage protocol: can it improve the ability of nonmedical personnel to better triage patients during disasters and mass casualty incidents? Disaster Med Public Health Prep. 2017;11(3):305–309.10.1017/dmp.2016.151CrossRefGoogle Scholar
Ferrandini Price, M, Escribano Tortosa, D, Nieto Fernandez-Pacheco, A, et al. Comparative study of a simulated incident with multiple victims and immersive virtual reality. Nurse Educ Today. 2018;71:48–53.CrossRefGoogle ScholarPubMed
Ingrassia, PL, Colombo, D, Barra, FL, Carenzo, L, Franc, J, Della Corte, F. Impact of training in medical disaster management: a pilot study using a new tool for live simulation. Emergencias. 2013;25(6):459–466.Google Scholar
Ingrassia, PL, Ragazzoni, L, Tengattini, M, Carenzo, L, Corte, FD. Nationwide program of education for undergraduates in the field of disaster medicine: development of a core curriculum centered on blended learning and simulation tools. Prehosp Disaster Med. 2014;29(5):508–515.10.1017/S1049023X14000831CrossRefGoogle ScholarPubMed
Ingrassia, PL, Ragazzoni, L, Carenzo, L, Colombo, D, Gallardo, AR, Corte, FD. Virtual reality and live simulation: a comparison between two simulation tools for assessing mass casualty triage skills. Eur J Emerg Med. 2015;22(2):121–127.CrossRefGoogle Scholar
Izumida, K, Kato, R, Shigeno, H. A Triage Training System Considering Cooperation and Proficiency of Multiple Trainees. Vol 10397 LNCS. (1) Graduate School of Science and Technology, Keio University; (2) Faculty of Science and Technology, Keio University: Springer Verlag; 2017.10.1007/978-3-319-63088-5_7CrossRefGoogle Scholar
Jain, T, Sibley, A, Stryhn, H, Hubloue, I. Comparison of unmanned aerial vehicle technology-assisted triage versus standard practice in triaging casualties by paramedic students in a mass-casualty incident scenario. Prehosp Disaster Med. 2018;33(4):375–380.10.1017/S1049023X18000559CrossRefGoogle Scholar
Khan, K. Tabletop exercise on mass casualty incident triage, does it work? Heal Sci J. 2009;12(3):1–6.Google Scholar
Lee, JS, Franc, JM, Lee, J. Impact of a two-step emergency department triage model with START, then CTAS, on patient flow during a simulated mass-casualty incident. Prehosp Disaster Med. 2015;30(4):390–396.CrossRefGoogle ScholarPubMed
Lima, DS, De-Vasc Oncelos, IF, Queiroz, EF, et al. Multiple victims incident simulation: training professionals and university teaching. Rev Col Bras Cir. 2019;46(3).Google ScholarPubMed
Loth, S, Cote, AC, Shaafi Kabiri, N, et al. Improving triage accuracy in first responders: measurement of short structured protocols to improve identification of salient triage features. World Med Heal Policy. 2019;11(2):163–176.CrossRefGoogle Scholar
Bolduc, C, Maghraby, N, Fok, P, Luong, TM, Homier, V. Comparison of electronic versus manual mass-casualty incident triage. Prehosp Disaster Med. 2018;33(3):273–278.10.1017/S1049023X1800033XCrossRefGoogle ScholarPubMed
Mills, B, Dykstra, P, Hansen, S, et al. Virtual reality triage training can provide comparable simulation efficacy for paramedicine students compared to live simulation-based scenarios. Prehosp Emerg Care. 2020;24(4):525–536.CrossRefGoogle ScholarPubMed
Navin, DM, Sacco, WJ, Waddell, R. Operational comparison of the Simple Triage and Rapid Treatment Method and the Sacco Triage Method in mass casualty exercises. J Trauma Inj Infect Crit Care. 2010;69(1):215–225.10.1097/TA.0b013e3181d74ea4CrossRefGoogle Scholar
Risavi, BL, Lee, W, Terrell, MA, Holsten, DL. Prehospital mass-casualty triage training-written versus moulage scenarios: how much do EMS providers retain? Prehosp Disaster Med. 2013;28(3):251–256.CrossRefGoogle ScholarPubMed
Riza’i, A, Ade, WRA, Albar, I, Sulitio, S, Muharris, R. Teaching start triage: a comparison of lecture and simulation methods. Adv Sci Lett. 2018;24(9):6890–6892.CrossRefGoogle Scholar
Sapp, RF, Brice, JH, Myers, JB, Hinchey, P. Triage performance of first-year medical students using a multiple-casualty scenario, paper exercise. Prehosp Disaster Med. 2010;25(3):239–245.CrossRefGoogle ScholarPubMed
Schenker, JD, Goldstein, S, Braun, J, et al. Triage accuracy at a multiple casualty incident disaster drill: the Emergency Medical Service, Fire Department of New York City experience. J Burn Care Res. 2006;27(5):570–575.CrossRefGoogle Scholar
Silvestri, S, Field, A, Mangalat, N, et al. Comparison of START and SALT triage methodologies to reference standard definitions and to a field mass casualty simulation. Am J Disaster Med. 2017;12(1):27–33.CrossRefGoogle ScholarPubMed
Simões, RL, Duarte Neto, C, Maciel, GSB, Furtado, TP, Paulo, DNS. Prehospital care to trauma victims with multiple simulated. Rev Col Bras Cir. 2012;39(3):230–237.10.1590/S0100-69912012000300013CrossRefGoogle ScholarPubMed
Wu, Y-L, Shu, C-C, Chung, C-C. A simple method for pre-hospital dispatcher-aided consciousness assessment in trauma patients. J Emerg Med Taiwan. 1999;7(2):69–77.Google Scholar
McCoy, CE, Alrabah, R, Weichmann, W, et al. Feasibility of tele-simulation and Google glass for mass casualty triage education and training. West J Emerg Med. 2019;20(3):512–519.10.5811/westjem.2019.3.40805CrossRefGoogle Scholar
Buono, CJ, Lyon, J, Huang, R, et al. Comparison of mass casualty incident triage acuity status accuracy by traditional paper method, electronic tag, and provider PDA algorithm. Ann Emerg Med. 2007;50(3):s12–s13.CrossRefGoogle Scholar
McElroy, JA, Steinberg, S, Keller, J, Falcone, RE. “Operation continued care: a large mass-casualty, full-scale exercise as a test of regional preparedness.” In: Surgery (United States). Vol 166. Maryland Heights, Missouri USA: Mosby Inc.; 2019:587–592.Google Scholar
Kahn, CA, Schultz, CH, Miller, KT, Anderson, CL. Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med. 2009;54(3):424–430.CrossRefGoogle Scholar
Challen, K, Walter, D. Major incident triage: comparative validation using data from 7th July bombings. Injury. 2013;44(5):629–633.10.1016/j.injury.2012.06.026CrossRefGoogle ScholarPubMed
Crews, CM. Disaster Response: Efficacy of Simple Triage and Rapid Treatment in Mass Casualty Incidents. Thesis. California USA: California State University, Long Beach; 2018.Google Scholar
Curran-Sills, G, Franc, JM. A pilot study examining the speed and accuracy of triage for simulated disaster patients in an emergency department setting: comparison of a computerized version of Canadian Triage Acuity Scale (CTAS) and Simple Triage and Rapid Treatment (START) methods. Can J Emerg Med. 2017;19(5).CrossRefGoogle Scholar
Djalali, A, Carenzo, L, Ragazzoni, L, et al. Does hospital disaster preparedness predict response performance during a full-scale exercise? A pilot study. Prehosp Disaster Med. 2014;29(5):441–447.CrossRefGoogle ScholarPubMed
Ellebrecht, N, Latasch, L. Vorsichtung durch Rettungsassistenten auf der Großübung SOGRO MANV 500: Eine Vergleichende Analyse der Fehleinstufungen. Paramed Triage Dur a Mass Casualty Incid Exerc a Comp Anal Ina Triage Lev Assignments. 2012;15(1):58.Google Scholar
Ersoy, N, Akpinar, A. Triage decisions of emergency physicians in Kocaeli and the principle of justice. Ulus Travma ve Acil Cerrahi Derg. 2010;16(3):203–209.Google ScholarPubMed
Wisnesky, UD, Kirkland, SW, Rowe, BH, Franc, JM. A qualitative assessment of studies evaluating the accuracy of START in disaster triage: a scoping review. Press. 2021.Google Scholar
Alinier, G. A typology of educationally focused medical simulation tools. Med Teach. 2007;29(8):e243–e250.10.1080/01421590701551185CrossRefGoogle ScholarPubMed
Fink, BN, Rega, PP, Sexton, ME, Wishner, C. START versus SALT triage: which is preferred by the 21st century health care student? Prehosp Disaster Med. 2018;33(4):381–386.10.1017/S1049023X18000547CrossRefGoogle ScholarPubMed
Waddell, RK, Navin, M. An objective comparison of the START triage protocols and the Sacco Triage Method. Prehosp Disaster Med. 2009;24(S1):s144.Google Scholar
Hartman, EN, Daines, B, Seto, C, Shimshoni, D, Feldman, ME, Sort, LaBrunda M., Assess, Life-Saving Intervention, Triage with drone assistance in mass casualty simulation: analysis of educational efficacy. Cureus. 2020;12(9):e10572.Google ScholarPubMed
Celik, DH, Mencl, FR, Debacker, M, Kurland, L, Wilber, ST, Frey, JA. Triage performance of school personnel using the SALT system. Prehosp Disaster Med. 2019;34(4):401–406.CrossRefGoogle ScholarPubMed
McKee, CH, Heffernan, RW, Willenbring, BD, et al. Comparing the accuracy of mass casualty triage systems when used in an adult population. Prehosp Emerg Care. 2020;24(4):515–524.CrossRefGoogle Scholar
Wallis, LA, Carley, S. Comparison of pediatric major incident primary triage tools. Emerg Med J. 2006;23(6):475–478.CrossRefGoogle ScholarPubMed
Cuttance, G, Dansie, K, Rayner, T. Paramedic application of a triage sieve: a paper-based exercise. Prehosp Disaster Med. 2017;32(1):3–13.CrossRefGoogle ScholarPubMed
Vassallo, J, Smith, J. Major incident triage and the evaluation of the Triage Sort as a secondary triage method. Emerg Med J. 2019;36(5):281–286.CrossRefGoogle ScholarPubMed
Cross, KP, Cicero, MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61(6):668–676.10.1016/j.annemergmed.2012.12.023CrossRefGoogle ScholarPubMed
Cross, KP, Cicero, MX. Independent application of the Sacco disaster triage method to pediatric trauma patients. Prehosp Disaster Med. 2012;27(4):306–311.CrossRefGoogle ScholarPubMed
McLeod, SL, McCarron, J, Ahmed, T, et al. Interrater reliability, accuracy, and triage time pre- and post-implementation of a real-time electronic triage decision-support tool. Ann Emerg Med. 2020;75(4):524–531.CrossRefGoogle ScholarPubMed
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