SALT is a new mass casualty triage system developed by the federal government. It was originally created for one single purpose with the best of intentions: to standardize the nation on a single initial triage system to ensure interoperability in large-scale multi-jurisdictional mass casualty incidents. SALT is not intended for use as a secondary triage system and it is not to be used to prioritize patients for transport.

01  A Plan Without a Purpose

Terminology Edification:

There are multiple types of triage. Initial triage, the subject of this article and the sole purpose of SALT, is the first contact with the patient in the casualty field. It is where we apply ribbons and obtain the triage count. Secondary triage is the reassessment usually done in the treatment areas using triage tags. Re-triage is when patients later show a change in their acuity category and Transport Triage where medical knowledge or a pre-defined agency protocol is used to prioritize patients for shipment. To reiterate, SALT is not intended to be used for any type of triage other than Initial. So for example, if an agency is using ribbons for initial triage, there would be no need for a SALT triage tag and there would never be an ‘Expectant’ tarp.

All Madness Has a Beginning:

If the issue was not so serious, the process that gave birth to SALT would be comical. Here is an abridged history. In 2006 the CDC funded a group of 24  ‘subject matter experts’, to study the triage systems in use and select the best one for standardization. After evaluating dozens of systems they concluded two things:

1: None are optimal so a new one is needed.

2: There is no standardized triage system in the U.S.

Unfortunately the latter conclusion was in error and it gave rise to the former. The committee, now referred to as the SALT Working Group, picked what they felt were the best-of-breed features of all the triage systems and developed SALT to solve the standardization issue. To their dismay, all EMS agencies they approached to adopt SALT rejected it due to the fact that they, and their neighboring jurisdictions, were using START. By now the Working Group must have realized the interoperability crisis did not exist but must have felt SALT was better for us because they proceeded down a path that would compel agencies to adopt it. In 2009 they grew the size of the Working Group and created a list of criteria an initial triage system must comply with in order to be used in the U.S. To no surprise only SALT met all the criteria. The criteria also made it impractical to modify existing systems to conform.

If You Can’t Dazzle Them With Brilliance...:

The Working Group still needed a compelling argument to convince agencies to adopt SALT so they created one. They used terms like ‘science-based’ and ‘best available evidence’ to position the product and created a list of ‘endorsements’ from 13 organizations. (these organizations actually endorsed only the concept of having a standard triage system -who wouldn’t?).

As a final tool in their marketing quiver they referenced two flawed studies that made it appear there was, in fact, no national standard. Now positioned for a 2011 re-launch of SALT they headed back out, knowing full well that what they would be doing would create fragmentation where it did not exist before.

National map used in SALT documents suggesting no standard triage system exists.

Just the Facts Ma'am:

The data referenced by the Working Group to illustrate the interoperability crisis was contained in two unscientific surveys.

One was from a 2008 EMS survey and the other from one in 2011. In both cases the data was flawed and misinterpreted. The Working Group never fact-checked the data. In all likelihood because by this point they knew what the real results would be.

Fact checking would have been as simple as calling the agencies to verify their data and to call the manufacturers of START triage tags, TSA Associates, MetTag and Disaster Management Systems. Who better to know who uses what than the companies that supply it? The calls were never made. The fact is that in 2008 over 95% of the nation used START and by 2011 that number rose to 98%. Our EMS agencies did know the importance of interoperability and the real data proves it. We were not asleep at the switch as it was suggested.

The Last Straw:

Even with another round of funding and all their ducks in a row the Working Group once again experienced a less than an enthusiastic response. As a final act of desperation the group was able to convince the Federal Interagency Committee on EMS (FICEMS) to ‘give incentives’ by way of federal funding to agencies that adopted the SALT criteria. More disturbing is their path to a nuclear option to force agencies to adopt: disincentives to penalize those that

defer such adoption should be considered a last resort.

- FICEMS July 2013

Damn the Torpedoes:

Now with Big Brother in their back pocket SALT re-emerged. This time as a mandate. Enticing agencies with federal dollars and perpetuating the myth of interoperability they began seeing some traction by agencies that drank the SALT Kool-aid or had close affiliations with the Working Group. The path to fractured interoperability is moving full steam ahead and if not checked in time by sound minds, courage and clear thought it may become unrecoverable.

Asking the Obvious:

One would think that at some point it would have been better to consider taking what already existed and simply modify it as opposed to attempting to change the national standard. The cost to retrain an entire nation of CERTs, EMS agencies and Civil Support Teams alone is staggering and the time frame equally daunting. It is a certainty many agencies will see SALT has no verifiable value and will elect not to have the federal government tell them how to care for its population and choose to stay with what they know works. Any way you look at it, no good can come of it. So what of modifying START instead, if, in-fact, the ‘science-based’ data really justifies it? START has modified before and it can be again as warranted. One example of this is START’s early modification of bleeding control (tourniquets) long before the wars overseas gave rebirth to the concept. Capillary refill has also given way to palpable pulse as the preferred method of checking perfusion and JumpSTART evolved to optimize pediatric care.

Different But the Same:

Both SALT and START use global sorting that starts with a call for the walking wounded. SALT differs only in the requirement that the walking be assessed last and still patients first. There is no science to support that process and it has inherent detriments that can be proven, so in combining the systems we’ll just keep global sorting as it is in START.

Next is life-saving-intervention (LSI). Surprisingly the two systems are virtually identical. Both require hemorrhage control and airway management. (SALT does not clarify what airway management entails but eludes allowing for NPAs). So we add the option of NPAs to START.
Chest decompressions? There is no MCI evidence this has a net outcome benefit - but sure, add that option to START as well. Antidotes? The Working Group got it wrong on this. You can’t conduct triage in level A gear. So we leave that mistake out.(This subject is covered in a separate white paper for those that need it).

The final topic on LSI is pediatric rescue breaths only in SALT and rescue breaths plus AVPU evaluation in JumpSTART. Do we really want to shed AVPU? OK, so we do away with JumpStart and add two rescue breaths to START for peds.

Now on to Assessment. The only difference is the order of Mental and the way respiratory rate is gauged. With regard to Mental, most of us are already doing mental checks as we approach the patient anyway. It’s only third on START’s list because it gave us RPM. So fine, move ‘M’ to the top and, loose the mnemonic and the assessment are the same.

START uses ‘over 30’ respirations as opposed to SALT’s ‘respiratory distress’ because novice responders, such as CERT members, may not properly recognize distress. Seasoned responders already use respiratory distress. For those reasons we keep it at ‘over 30’.

The only items remaining are the resource-dependent Expectant category and the Assessment priority. Should Expectant stay or should it go? That’s a healthy discussion to have. Proper MCI protocol is to always reassess the Blacks so maybe we already have it. The point here is that in the time it took to read this we were able to fix what we have as opposed to breaking what we’ve spent over a decade building. This is the type of dialogue we wish the Working Group included local EMS agencies in. Why they did not remains a mystery.

The Single System Advantage:

Because SALT is only for initial triage, an agency that adopts it would need to utilize a different system for secondary triage. Those that use START would now need to employ two different algorithms. Triage should be looked at as an ongoing consistent process - not a mix of algorithms. One would be wise to question the wisdom of an entity that professes the latter.

The Irony of it All

Suppose for a moment there was an interoperability problem. Would SALT really solve it? Even the Working Group admits that initial triage occurs early on. By the time units from other jurisdictions arrive on-scene, initial triage will most likely be completed. At least it should be or we have a much larger problem than just triage. This begs the question, what problem was SALT supposed to solve in the first place?

The justification for developing SALT was based off an assessment that our nation was using numerous triage systems and that in the event of a large-scale MCI there would be no commonality - resulting in confusion and a derogation in patient care. A noble cause to be sure.

In actuality, the assessment that a standardized triage process did not exist was based off a misinterpretation of data that was never fact-checked. The truth is, the basis for SALT’s justification to live does not exist. More troublesome is the sadly ironic fact that SALT is now creating the one problem it was tasked to solve - a lack of interoperability between neighboring jurisdictions.

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