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 13 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 of 13 most serious patients left the scene within 31 minutes and in the first 6 ambulances
    • Only 1 of the first 28 patients to depart the scene had normal physiology.

Tagging was more accurate under STM

  • 28% 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.

Surveyed providers FALSELY believe START to be more accurate, faster at clearing the scene, and better at prioritizing patients!

Methodological Comparison of START to STM





Do the greatest good for the greatest number

Not specific; subjective

can’t be measured

can’t be reproduced; no formulation of problem

Maximize the expected number of survivors

Explicit; objective

outcome driven, measured by lives saved

reproducible; precise mathematical formulation


Not evidence based

No peer review of concept;
Data analysis shows immediates range in survival probability to 97% with large overlap with delayeds
Retrospective studies show poor performance:

  • Madrid bombing – 312 immediates – only 91 hospitalized, only 28 with critical injuries
  • Glendale train crash  - only 2 of 22 reds were truly immediates; 8 of 68 yellows were truly delayed.                  

Extensive tabletop with 70 EMS teams shows randomness in tagging and triage

  • 45 of 45 patients listed as top 10 priority;
  • 40 of 45 patients listed as lowest 3 priority
Number of reds ranged from 4 to 44!

Evidence based.      
(database of over 250,000 trauma patients) 

Six peer reviewed publications

Scores correlated to survival probability, by age group, for blunt, penetrating, and blast overpressure trauma.

Predictive assessments - more accurate at predicting survival probability than revised trauma score and injury severity scale

Reliable prioritizations; optimal resource allocations

Study shows dominance of STM in assessments, time to clear the scene, and patient prioritization.

Triage Strategy

Immediates, then Delayeds

static strategy – does not change with size of incident or availability of resources

No formal guidance within categories. Tacitly assumes all reds are the same.

No consideration of resources. Tacitly assumes every incident is the same

Practiced protocol is worst-first within category, subjectively determined. (Simulations show this is the worst possible strategy when resource constrained!)

Precise priority assignment of victims to transport and hospitals by score based on resource timing/availability

dynamic strategy – based on scene and resources

Produces incident action and regional resource impact plan.

Outcome based, custom, and simulation generated triage rules guide initial triage 

Triage strategy dynamic based on patient mix and resources so as to maximize expected survivors

Frequency of use

Exercises and MCIs only.

Seamless triage – scoring used everyday on every trauma patient

Providers use same protocol for daily use or MCI.

Evidence based medevac dispatch cuts flights, reduces mortality

Enables routine outcome and performance tracking.

Medical Validity

NIMS Compatibility:      “START does not consider resources and does not determine an optimal triage strategy…”  FEMA

SALT Requirements:               no consideration of resources; poor differentiation of patient acuities; not predictive, not reliable, not measurable, not scalable; not used every day

NIMS Compatibility
Formally reviewed by FEMA. SMEs cited “many advantages over START” and “compatible with many NIMS concepts”

SALT requirements: Measurable; scalable; considers resources; used everyday; more accurate at predicting acuity than RTS and ISS; reliable due to objectivity