Operational Comparison of START to STM

The Sacco Triage Method (STM) was proven to dominate START in parallel mass casualty exercises. STM proved to be more accurate, more consistent, more efficient at clearing the scene, and much more effective at identifying and prioritizing patients by severity than START in parallel mass casualty exercises with 99 trauma patients.

Most severely injured patients were cleared from the scene more quickly under STM

• Under START
  • only 2 of the 12 most serious patients were in the first 13 ambulances, and left the scene within the first 47 minutes
  • the 3 most serious patients left by bus, after 16 ambulances
  • 16 of the first 28 patients to depart the scene had normal physiology
    
• Under STM
  • the 12 most serious patients left the scene within 31 minutes and in the first 7 ambulances
  • 17 of the 20 most serious patients left by ambulance; only 1 of 28 patients who left by ambulance had normal physiology

Tagging was more accurate under STM

• 27% percent of patients were tagged incorrectly under START even though START has been the protocol for 12 years and participants were given a 20 minute refresher training prior to the drill
• 9% of patients were tagged incorrectly under STM, even though participants had never heard of STM prior to the drill and received only 20 minutes of training.

The time to clear the scene was 16% less under STM.

• Under START, the last patient left 63 minutes after the onset of the exercise
• Under STM, the last patient left at 53 minutes.

Both START and STM would have taken longer to clear the scene in an actual incident if measures had to be taken, rather than read from cards.

Methodological Comparison of START to STM

	START	STM
Objective	Do the greatest good for the greatest number subjective; not well defined can’t be measured can’t be reproduced	Maximize the expected number of survivors objective outcome driven, measured by lives saved precise mathematical formulation
Research	No peer review. No published data analysis. No prospective study to substantiate benefits to victims.	Evidence based, analysis of 102,000 victims from PA Trauma Outcome study database.  Scores correlated to survival probability. AEM Publication August 2005.
Triage Strategy	Immediates first, then Delayeds No formal guidance within categories. No consideration of resources – not scalable. Practiced protocol is worst-first within category, subjectively determined	Precise priority assignment of victims to transport and hospitals based on timing and availability of resources. Produces regional resource impact plan. Outcome based, custom, and simulation generated triage rules guide initial triage
Frequency of use	Used for exercises and MCIs.	Scoring used everyday on every trauma patient.  Supports outcome tracking and performance evaluation.
Medical Validity	Medically invalid due to wide overlap between expected survivability of Immediates and Delayeds	Evidence based. Explicit correlations between victim physiology and expected survival probability.
Outcome	Triage strategy non reproducible.  Projected survivorship outcomes not measurable. Randomly generated triage is equally as effective as START in simulations.	Maximizes expected survivorship. Simulations show potential to increase survivorship as much as 500%.