What parameters does the START triage system assess to determine a patients priority in a multiple casualty situation?

Updated January 18, 2017

By Dr. Ken Lavelle, MD, NREMT-P

You are settling in for a busy Saturday night in an urban Fire and EMS department. At approximately 4 a.m. you are dispatched to a working fire in an apartment complex with a report of people trapped. The Battalion Chief arrives and reports a three-story apartment building well involved with jumpers down. Multiple other EMS units are also responding. You arrive and have more than 10 victims, some who have jumped from the upper floors and some that have suffered burns or smoke inhalation. What are your first actions?

Once you determine a safe area to operate, one crew member needs to establish command of the EMS branch while another needs to initiate triage. Triage means "to sort" — to figure out which patients need immediate care and which patients can wait. It is a fundamental action that needs to be implemented whenever medical need is larger than medical resources.

Simple Triage and Rapid Transport method

There is no perfect triage system, but one of the methods available to us is the START (Simple Triage and Rapid Transport) method. START was developed in 1983 by the Newport Beach (Calif.) Fire Department and Hoag Hospital in Newport Beach, California. It is designed to identify problems that could cause death to the patient within one hour, typically breathing problems, head injury or significant bleeding.

Whether to use triage tags or not is debatable. While most agencies will use a triage tag of some sort, there have been some EMS leaders that have questioned whether we should deviate from our usual practice just when the situation is becoming more volatile and chaotic. It may be more beneficial to do things as close to normal as possible. Certainly follow local protocol, but understand the weaknesses of both the use and lack of use of the triage tag. It is my opinion that the benefits of a tag outweigh the drawbacks, especially for accountability purposes.

Direct the walking wounded to casualty collection points

The first step in triage is to clear out the minor injuries and those with low likelihood of death in the immediate future. The best way to do this is to direct in a loud voice (with public address or loudspeaker assistance) for anyone that is injured and needs medical assistance to move to a designated area, a casualty collection point. The walking wounded patients are initially tagged as "green" or "minor." While it is possible that these patients may have serious injuries, if they are able to listen, understand directions and get up and walk on their own to a casualty collection point, the chances of them dying in the next hour is low. As soon as enough medical resources arrive on location, the "green" or "minor" injury patients will need to be re-triaged to look for more serious conditions.

Assess remaining patients

The remaining victims fall into a few categories. They are either:

• Unable to understand your directions; they may not speak English, they may be deaf or they have an altered mental status affecting their ability to understand
• Unable to move due to injury
• Unconscious
• Dead or expectant

Assess respirations

To determine which triage category these patients fall under, we begin by assessing the respirations of the remaining victims. If they are not breathing we can reposition their airway, but if breathing does not begin spontaneously, the victim is tagged as "deceased."

Many EMS providers actually prefer the designation "expectant," which is often used by the military. Initially, if the number of victims largely outnumbers medical staff, it is reasonable to not waste resources on someone in respiratory arrest when other victims may benefit from our actions and be more likely to survive. However if a few minutes later a large number of medical providers arrive on scene, this "black tagged" victim may be able to receive immediate care.

This is how the triage process is so dynamic — it depends on resources. If the patient does start breathing after the airway is repositioned, you can place an oral airway, tag them as "immediate" and move on.

If the patient is breathing, and breathing over 30 times per minute, they are tagged "red" or "immediate." If their respiratory rate is fast they may be in shock, or be in respiratory distress.

Assess perfusion

If they are breathing less than 30 times per minute, the next step is to assess the perfusion or circulation status. This can be done in one of two ways: radial pulse or capillary refill. The problem with capillary refill is that it is largely affected by the environment. A cold night will cause everyone's capillary refill to be delayed, so the presence of a radial pulse can be used instead. The rate does not matter — just its presence or absence of the pulse.

If the radial pulse is absent, the patient is tagged "immediate." We can assume they have one since this patient is breathing, which would not occur for very long if they had no heartbeat at all.

Control any external life-threatening bleeding. I prefer to use a commercial tourniquet with a windlass — it can be placed quickly so you can move on to the next victim.

Assess mental status

If the radial pulse is present, the last criterion to evaluate is mental status. A patient with normal mental status is tagged as "yellow" or "delayed." These victims often are unable to move due to lower extremity injuries or other conditions that prevented them from moving to the "green" section. If they do have confusion or altered mental status, then they are tagged "immediate," as they may have a head injury or other condition that is causing the abnormal level of consciousness.

Patient tracking

The START system ends up triaging the majority of these patients as "red" or "immediate" rather than "yellow." It is understandable, and to some degree desirable to over-triage in order to make sure we do not miss any serious conditions. Remember to keep track of how many of each patient you have triaged so this can be reported back to the EMS branch director.

As you can see by the above, the amount of equipment that needs to be carried around during triage is minimal — triage tags, oral airways, tourniquets and a method to count the patients triaged.

Once you have triaged the patients, treatment can begin on the most serious victims.

About the author

David Jaslow is director of the Division of EMS and Disaster Medicine at The Albert Einstein Medical Center, a teaching hospital offering a full range of advanced health services to the Philadelphia community and beyond. The center has more than 600 primary care doctors and specialists on staff, with an additional 1,200 affiliated physicians. The Department of Emergency Medicine at the center has staff trained in emergency medical services, special operations medicine, and disaster management. Ken Lavelle is an attending physician at the center, and previously spent 14 years working as a firefighter and EMS provider. He serves as medical director for several agencies in Pennsylvania and New Jersey. This article originally appeared in The Albert Einstein Medical Center Column section, which is sponsored by FireRehab.com, on FireRescue1.com.

1. Koenig KL, Schultz CH. Koenig and Schultz's disaster medicine:comprehensive principles and practices:Cambridge University Press. 2010 [Google Scholar]

2. Vassallo J, Beavis J, Smith JE, Wallis LA. Major incident triage:derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT) Injury. 2017;48(5):992–9. //doi.org/10.1016/j.injury.2017.01.038 PMid:28131484. [PubMed] [Google Scholar]

3. Jenkins JL, McCarthy ML, Sauer LM, Green GB, Stuart S, Thomas TL, et al. Mass-casualty triage:time for an evidence-based approach. Prehospital and disaster medicine. 2008;23(1):3–8. //doi.org/10.1017/S1049023X00005471 PMid:18491654. [PubMed] [Google Scholar]

4. Lerner EB, Schwartz RB, Coule PL, Weinstein ES, Cone DC, Hunt RC, et al. Mass casualty triage:an evaluation of the data and development of a proposed national guideline. Disaster medicine and public health preparedness. 2008;2(S1):S25–S34. //doi.org/10.1097/DMP.0b013e318182194e PMid:18769263. [PubMed] [Google Scholar]

5. Salomone J. Disasters–they're not someone else's problem anymore. Principles &pressures of triage. Panamerican Journal of Trauma. 2007;14(2):44–52. [Google Scholar]

6. Ciottone GR, Biddinger PD, Darling RG, Fares S, Keim ME, Molloy MS. Ciottone's Disaster Medicine:Elsevier Health Sciences. 2015 [Google Scholar]

7. Bhalla MC, Frey J, Rider C, Nord M, Hegerhorst M. Simple Triage Algorithm and Rapid Treatment and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation mass casualty triage methods for sensitivity, specificity, and predictive values. Am J Emerg Med. 2015;33(11):1687–91. //doi.org/10.1016/j.ajem.2015.08.021 PMid:26349777. [PubMed] [Google Scholar]

8. Pollaris G, Sabbe M. Reverse triage:more than just another method. European Journal of Emergency Medicine. 2016;23(4):240–7. //doi.org/10.1097/MEJ.0000000000000339 PMid:26479736. [PubMed] [Google Scholar]

9. Kelen GD, Kraus CK, McCarthy ML, Bass E, Hsu EB, Li G, et al. Inpatient disposition classification for the creation of hospital surge capacity:a multiphase study. The Lancet. 2006;368(9551):1984–90. //doi.org/10.1016/S0140-6736(06)69808-5. [PMC free article] [PubMed] [Google Scholar]

10. Adams MP. In Physicians at War. Springer, Dordrecht: 2008. Triage priorities and military physicians; pp. 215–236. //doi.org/10.1007/978-1-4020-6912-3_13 PMid:18421142 PMCid:PMC2394804. [Google Scholar]

11. Hodgetts T, Hall J, Maconochie I, Smart C. Paediatric triage tape. Pre-Hospital Immediate Care. 1998;2:155–9. [Google Scholar]

12. Coule PL, Horner JA. National disaster life support programs:a platform for multi-disciplinary disaster response. Dental Clinics of North America. 2007;51(4):819–25. //doi.org/10.1016/j.cden.2007.06.006 PMid:17888759. [PubMed] [Google Scholar]

13. Horne S, Vassallo J, Read J, Ball S. UK triage–an improved tool for an evolving threat. Injury. 2013;44(1):23–8. //doi.org/10.1016/j.injury.2011.10.005 PMid:22077989. [PubMed] [Google Scholar]

14. Garner A, Lee A, Harrison K, Schultz CH. Comparative analysis of multiple-casualty incident triage algorithms. Annals of emergency medicine. 2001;38(5):541–8. //doi.org/10.1067/mem.2001.119053 PMid:11679866. [PubMed] [Google Scholar]

15. Smith W. Triage in mass casualty situations. Continuing Medical Education. 2012;30(11):413–5. [Google Scholar]

16. Nocera A, Garner A. Australian disaster triage:a colour maze in the Tower of Babel. Australian and New Zealand journal of surgery. 1999;69(8):598–602. //doi.org/10.1046/j.1440-1622.1999.01643.x PMid:10472919. [PubMed] [Google Scholar]

17. Benson M, Koenig KL, Schultz CH. Disaster triage:START, then SAVE—a new method of dynamic triage for victims of a catastrophic earthquake. Prehospital and disaster medicine. 1996;11(2):117–24. //doi.org/10.1017/S1049023X0004276X PMid:10159733. [PubMed] [Google Scholar]

18. evacuation flights directly from Bali C. The Bali bombing:civilian aeromedical evacuation. The Medical Journal of Australia. 2003;179(7):353–6. PMid:14503899. [PubMed] [Google Scholar]

19. ACoSCo T. Resources for optimal care of the injured patient. Chicago: American College of Surgeons; 2006. [Google Scholar]

20. Sacco WJ, Navin DM, Fiedler KE, Waddell RK, II, Long WB, Buckman RF., Jr Precise formulation and evidence-based application of resource-constrained triage. Academic emergency medicine. 2005;12(8):759–70. //doi.org/10.1197/j.aem.2005.04.003 PMid:16079430. [PubMed] [Google Scholar]

21. Abbasi Dolat Abadi Z, Hosseini SMR, Atighechian G, Pour-Sheikhian M, Delkhosh M. Triage in Disaster. Iranian Journal of Cardiovascular Nursing. 2013;2(2):58–68. [Google Scholar]

22. Brandt C, Coffee T, Yurko L, Yowler C, Fratianne R. Triage of minor burn wounds:avoiding the emergency department. The Journal of burn care &rehabilitation. 2000;21(1):26–8. //doi.org/10.1097/00004630-200021010-00006. [PubMed] [Google Scholar]

23. Ahuja RB, Bhattacharya S. ABC of burns:Burns in the developing world and burn disasters. BMJ:British Medical Journal. 2004;329(7463):447. //doi.org/10.1136/bmj.329.7463.447 PMid:15321905 PMCid:PMC514214. [PMC free article] [PubMed] [Google Scholar]

24. González PA, Delgado RC, Alvarez TC, Gonzalo GG, Monzon CM, Corres NP, et al. The development and features of the Spanish prehospital advanced triage method (META) for mass casualty incidents. Scandinavian journal of trauma, resuscitation and emergency medicine. 2016;24(1):63. //doi.org/10.1186/s13049-016-0255-y PMid:27130042 PMCid:PMC4850631. [PMC free article] [PubMed] [Google Scholar]

25. Cannon M, Roitman R, Ranse J, Morphet J. Development of a mass-gathering triage tool:an Australian perspective. Prehospital and disaster medicine. 2017;32(1):101–5. //doi.org/10.1017/S1049023X16001242 PMid:27928973. [PubMed] [Google Scholar]

26. Dyer CB, Regev M, Burnett J, Festa N, Cloyd B. SWiFT:a rapid triage tool for vulnerable older adults in disaster situations. Disaster medicine and public health preparedness. 2008;2(S1):S45–S50. //doi.org/10.1097/DMP.0b013e3181647b81 PMid:18769267. [PubMed] [Google Scholar]

27. Alexander D, Masini E, Mugnai L. Integrated Emergency Management for Mass Casualty Emergencies. 2013:101. [Google Scholar]

28. Tian L, Fang Z, Xiao H, Li L, Li Y. Value of triage early warning score for trauma patients in an emergency department. Zhong nan da xue xue bao Yi xue ban= Journal of Central South University Medical sciences. 2015;40(5):549–57. [PubMed] [Google Scholar]

29. Wallis L, Gottschalk S, Wood D, Bruijns S, De Vries S, Balfour C. The cape triage score-a triage system for South Africa. South African Medical Journal. 2006;96(1):53–6. PMid:16440113. [PubMed] [Google Scholar]

30. Wolf P, Bigalke M, Graf BM, Birkholz T, Dittmar MS. Evaluation of a novel algorithm for primary mass casualty triage by paramedics in a physician manned EMS system:a dummy based trial. Scandinavian journal of trauma, resuscitation and emergency medicine. 2014;22(1):50. //doi.org/10.1186/s13049-014-0050-6 PMid:25214310 PMCid:PMC4237929. [PMC free article] [PubMed] [Google Scholar]

31. Cone DC, Serra J, Kurland L. Comparison of the SALT and Smart triage systems using a virtual reality simulator with paramedic students. European journal of emergency medicine. 2011;18(6):314–21. //doi.org/10.1097/MEJ.0b013e328345d6fd PMid:21451414. [PubMed] [Google Scholar]

32. De Lorenzo RA, Porter RS. Tactical emergency care:Military and operational out-of-hospital medicine. Prentice Hall; 1999. [Google Scholar]

33. Romig LE. Pediatric triage. A system to JumpSTART your triage of young patients at MCIs. JEMS:a journal of emergency medical services. 2002;27(7):52–8. 60-3. [PubMed] [Google Scholar]

34. Bostick NA, Subbarao I, Burkle FM, Hsu EB, Armstrong JH, James JJ. Disaster triage systems for large-scale catastrophic events. Disaster medicine and public health preparedness. 2008;2(S1):35–9. //doi.org/10.1097/DMP.0b013e3181825a2b PMid:18769264. [PubMed] [Google Scholar]

35. Gilboy N, Travers D, Wuerz R. Re-evaluating triage in the new millennium:A comprehensive look at the need for standardization and quality. Journal of emergency nursing:JEN:official publication of the Emergency Department Nurses Association. 1999;25(6):468–73. //doi.org/10.1016/S0099-1767(99)70007-3. [PubMed] [Google Scholar]

36. Powers R, Daily E. International disaster nursing. New York: Cambridge Universiry Press; 2010. Disaster triage. //doi.org/10.1017/CBO9780511841415. [Google Scholar]

37. Emerman CL, Shade B, Kubincanek J. A comparison of EMT judgment and prehospital trauma triage instruments. The Journal of trauma. 1991;31(10):1369–75. //doi.org/10.1097/00005373-199110000-00009 PMid:1942145. [PubMed] [Google Scholar]

38. Wuerz RC, Milne LW, Eitel DR, Travers D, Gilboy N. Reliability and validity of a new five-level triage instrument. Academic emergency medicine :official journal of the Society for Academic Emergency Medicine. 2000;7(3):236–42. //doi.org/10.1111/j.1553-2712.2000.tb01066.x PMid:10730830. [PubMed] [Google Scholar]

39. Eitel DR, Travers DA, Rosenau AM, Gilboy N, Wuerz RC. The emergency severity index triage algorithm version 2 is reliable and valid. Academic emergency medicine :official journal of the Society for Academic Emergency Medicine. 2003;10(10):1070–80. //doi.org/10.1197/S1069-6563(03)00350-6. [PubMed] [Google Scholar]

40. Wuerz RC, Travers D, Gilboy N, Eitel DR, Rosenau A, Yazhari R. Implementation and refinement of the emergency severity index. Academic emergency medicine :official journal of the Society for Academic Emergency Medicine. 2001;8(2):170–6. //doi.org/10.1111/j.1553-2712.2001.tb01283.x PMid:11157294. [PubMed] [Google Scholar]

41. Gerber Zimmerman P, McNair R. Triage nursing secrets Missouri. Mosby Inc; 2006. Triage essence and process. [Google Scholar]

42. Fernandes CM, Tanabe P, Gilboy N, Johnson LA, McNair RS, Rosenau AM, et al. Five-level triage:a report from the ACEP/ENA Five-level Triage Task Force. Journal of emergency nursing:JEN :official publication of the Emergency Department Nurses Association. 2005;31(1):39–50. quiz 118. [PubMed] [Google Scholar]

43. Hay E, Bekerman L, Rosenberg G, Peled R. Quality assurance of nurse triage:consistency of results over three years. The American journal of emergency medicine. 2001;19(2):113–7. //doi.org/10.1053/ajem.2001.21317 PMid:11239253. [PubMed] [Google Scholar]

44. Lampi M, Vikstrom T, Jonson CO. Triage performance of Swedish physicians using the ATLS algorithm in a simulated mass casualty incident:a prospective cross-sectional survey. Scand J Trauma Resusc Emerg Med. 2013;21:90. //doi.org/10.1186/1757-7241-21-90 PMid:24355021 PMCid:PMC3878199. [PMC free article] [PubMed] [Google Scholar]

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Classification of the injured people according to the Homebush Triage Standard