Important Notice: This article may not exhibit the same level of validity as much as the original article does. It`s highly recommended to refer to initial site. This article is originally published in Saint Francis Medical Center (http://www.paems.org/eWebquiz/start/Simple%20Triage%20and%20Rapid%20Transport%20CEU.pdf)


Simple Triage and Rapid Transport (S.T.A.R.T.)

On-Line CEU for the Peoria Area EMS System and  OSF Saint Francis Medical Center’s ED Staff


Triage has always been a challenge during a mass casualty incident (MCI).  There have been many solutions to triage branching from the military to manufacturers of mass casualty equipment.  A retrospective look at many of these triage solutions finds that they are rarely proven.  As EMS moves towards using evidence based medicine, a triage program should have established medical research to confirm that it does work.  Simple Triage and Rapid Treatment (S.T.A.R.T.) is one of those programs.  

  In order to help facilitate communications and an understanding of patient conditions during an MCI, S.T.A.R.T. Triage is utilized by the Peoria Area EMS System, Peoria Hospitals and EMS Trauma Region 2.

  Please note, S.T.A.R.T. Triage is an initial assessment tool and should not be used for extended patient holding areas.  Once patients are received into treatment and holding areas, a more thorough assessment and triage process should be performed.

 Using S.T.A.R.T

Using S.T.A.R.T. Triage during an MCI has been shown to reduce the mortality and morbidity of the incident.  S.T.A.R.T identifies those patients that will die within the first hour.   This includes patients with injuries such as respiratory compromise, shock and altered mental status.  Since S.T.A.R.T. only employs three assessment techniques, this simple triage method can be taught to any one with advanced first aid training or above.  Therefore, triage does not have to be performed by the highest level provider, thus freeing this provider to be utilized in the treatment area. Having a systematic approach to mass casualty management will ensure that essential steps in the process are not forgotten.  First, start with scene size- up.   Before you get into the “thick of things” radio your dispatch center and paint the picture” to the incoming units.  Key items to include in your report would be:

…  Exact location of incident.

… Number of potential casualties

…  Open routes of entry and exit for emergency vehicles

…  Staging areas for emergency vehicles

…  Location of the treatment area

It is essential to have a pre-deployment plan already written for your dispatch to follow.  A pre-deployment plan will result in identifying what amount of equipment and resources you need at your location, based on your casualty count.  This allows you to focus on the incident at hand.   Do not forget to have dispatch notify OSF Medical Communications (655-6770) as soon as possible.  OSF Medical Communications will notify local hospitals for an Emergency Department bed count and notify the EMS office to activate the system wide crisis policy.

             Next, obtain the triage kit from your ambulance.  A well stocked triage kit will be a lifesaver in the first moments of an MCI.  As your partner is coordinating incoming emergency vehicles and resources, it is now time to do triage, the S.T.A.R.T. way.

  S.T.A.R.T. Triage is based on three assessment criteria:

respiration, pulse and mental status.  These criteria will lead you into placing the patient in one of four triage categories.

…  Minor (Green), these patients are the walking wounded and need to be seen at a hospital or prompt care clinic within twelve to twenty-four hours.  Evacuation of these casualties is not usually a priority.  In addition, these patients may be used in assisting EMS providers in patient care.

…  Delayed (Yellow) are those patients who cannot walk due to mental or traumatic injuries.  These patients need to be evacuated to a hospital within two hours.

…  Immediate (Red) are those patients who need transported as soon as possible.  These casualties have life-threatening injuries that must be cared for within one hour. 

…  Deceased (Black) are those patients who are clinically dead with no pulse and no respirations.  This includes patients with obvious mortal injuries such as head injuries with exposed brain matter.

 Triage will present itself with many difficult choices.  The triage officer has to determine the size of the event, number of casualties, injuries of those casualties and then available resources.  This all leads to an assessment of triage.  Patients with traumatic injuries that would present by themselves would have lived; but, in an MCI, where they are one of many, they may die from those same injuries.

The S.T.A.R.T. Triage process

  Direct all patients within the sound of your voice to walk out of the incident area and towards the Minor (green) treatment area.  This may go against protocols by having “trauma” patients walk, but research shows those who can “walk and talk” after an MCI are probably not critically injured.  In fact, very few minor patients will wait for EMS arrival.  80% of all patients in an MCI will self deploy to the closest hospital of choice.  Therefore, on EMS arrival you may have to “corral” those minor patients that are left.  Make sure you have an EMS provider assigned to watch the minor patients in the treatment area.  These patients have a tendency to wonder away or disrupt the medical disaster scene. Next, start where you stand.  Do not go towards patients that look critically injured and thus stepping over those who do not appear injured.  Zigzagging triage patterns will increase the chance of missing patients.  The Triage Officer should only stop triage to open an airway or stop a killer bleed.  Any further treatment will delay triage and could result in the mass of patients not receiving care in a timely manner.  Successful MCI events are won by the creativity of the responding EMS personnel. S.T.A.R.T. also advocates using non-injured victims in basic first aid.  They can help control bleeding or keep and airway open.  In this way trained responders can focus on other tasks at hand. Since the area is now clear of minor patients, it is now time to enter the casualty area.  Everyone in this area will either be Delayed (YELLOW), Immediate (RED) or Deceased (BLACK).  

When you come to a patient, first assess their respirations.  For patients who present with a respiratory rate of less then 30 - move on to the next part of the S.T.A.R.T. algorithm.  For those patients with a respiratory rate greater than 30 - tag the patient Immediate (RED) and move on to the next patient. (NOTE: If the patient is not breathing, open the airway, to see if spontaneous respirations start.  If no respirations resume, tag the patient Deceased (Black).)

The perfusion check in S.T.A.R.T. can be completed in various ways.  Use the most accurate way to check perfusion that you can.  Perfusion checks can be completed by skin color and temperature, capillary refill or pulse check at the radial (a non-perfusing radial pulse would present as no pulse or pulse rate greater than 120 / min).  All these indicators are based on the patient’s perfusion status.  If the patient is perfusing, move on to the next part of the S.T.A.R.T. algorithm.  If the patient fails the perfusion check, tag the patient Immediate (RED) and move on to the next patient. Last is the check of mentation.  Since head injuries are the number one killer in mass casualties, mental status check is included in S.T.A.R.T.  If the patient can follow a simple command, like “touch your nose” and answer a simple question like “what day is it?”, they would be categorized Delayed (Yellow). If the patient cannot answer questions or follow commands appropriately, head injury is assumed and patient is tagged Immediate (RED).

As you can see S.T.A.R.T. Triage is rapid and easy to learn. Remember,  S.T.A.R.T. Triage should only be used for the initial triage.  When patients enter a treatment area, a more thorough assessment should be performed.  A secondary type of triage should be used if patients are on scene for a prolonged time.  There are very few models to follow concerning this.  One such model is the California system called SAVE (see web links) that can be used for catastrophic events.

 The Triage Tag

If your agency utilizes S.T.A.R.T. Triage, ensure that you have the adequate triage supplies for initiation.  Older triage tags may not be S.T.A.R.T. compliant and will not work as affectively or may confuse first responders who where taught S.T.A.R.T. Triage. The Triage tag is designed to be a patient care record, a patient tracking device and a prompt for the first responder.  If utilized affectively, the tag will be a tool during the MCI event.  


 Remember, during an MCI, it is critical to rapidly identify all injured patients and categorize them appropriately.  This is the best way to ensure that everyone receives the care they need during the MCI.    Training and the proper triage equipment prior to the incident will enable you to do your job in a chaotic

environment, more affectively.

When placing tags on victims, it is a good idea to use identical colored tape (as the triage category).  In this way, critical patients are more visible to the patient transport team. The Peoria Area EMS System uses the Arizona Triage kit which is designed for S.T.A.R.T. Video Demonstration of S.T.A.R.T. Triage  

Web Sites to References:

S.T.A.R.T. Triage (http://www.start-triage.com/ )

 The Triage Tag (http://www.citmt.org/start/tag.htm)




Almogy, Gidon MD; Luria, Tal MD; Richter, Elihu MD, PhD; Pizov, Reuven MD; Bdolah-Abram, Tali MSc; Mintz, Yoav MD; Zamir, Gideon MD; Rivkind, AvrahamI. MD, FACS.  “Can External Signs of Trauma Guide Management?: Lessons Learned From Suicide Bombing Attacks in Israel” Archives of Surgery  140.4  (2005):  390-393

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  11.2  (1996)  117-124

Bledsoe, Porter, Cherry.  Paramedic Care: Special Considerations / Operations.    Upper Saddle River: Prentice Hall, 2001

Newport Beach Fire Department.  Simple Triage and Rapid Transport: The Race Against Time.  Newport Beach: Newport Beach Fire Department  (2004)

Okie, Susan, MD.  “Traumatic Brain Injury in the War Zone”  New England  Journal of Medicine   352.20  (2005):  2043-2047

Pulse, Pulse: ICS for EMS 464-1204.  Carroliton: Fire and Emergency Training  Network (DEC 2004)

Walker, Peter; Wisner, Ben; Leaning, Jennifer; Minear, Larry   “Smoke and    Mirrors: Dificentcies in Disaster Funding”  British Medical Journal  330.7485  (2005);  247-250