START: A Simple Approach to MCI Triage

By Victoria Cleary

Recent high-profile emergency incidents have increased our focus on preparing for multicasualty incidents (MCIs). Whether you’re responding to an overturned bus, a tornado, or a terrorist bombing with many injured victims, do you know where to start? Do you know how to begin the process of identifying the most seriously injured victims and prioritizing their transportation off-scene?

Triage Philosophy
Creating order in the midst of chaos is not an easy task. First responders are overwhelmed with a multitude of conflicting priorities. You need a simple tool to easily and rapidly identify those victims most at risk of early death. Triage is the tool you use when you cannot provide timely care to all victims. Emergency care cannot proceed until you locate, triage, and tag the victims for treatment and transport prioritization. Triage allows responders to do the most good for the greatest number of injured. It is the foundation of good medical management in the setting of a multicasualty incident.
The goal of triage is to rapidly identify the critically injured and prioritize their treatment and transportation. Triage is typically performed when the number of victims exceeds the ability of the rescuers to care for them in a routine manner.

What Can Go Wrong?
If you don’t have a good tool or system for triage, you can expect the following:

  • Triage by emotion, which selects people based on who looks the worst. (Who is covered in blood or moaning the loudest?)
  • First responders or EMTs will use the routine assessment process they normally use on a daily basis. This will be too time-consuming.
  • Victims will remain on-scene for extended periods of time.
  • Critical victims may not be transported first.
  • During the after-incident critique, there will be dissatisfaction with triage.

Who Should Do Triage?
Triage should be simple, easy to use, and easy to learn. EMTs or first responders who are more numerous and arrive at an incident in its early stages should triage. They are also more likely than advanced life support providers to just triage and move on to the next patient. Paramedics and other medical personnel should treat and transport the most critically injured victims.

Keep It Simple
Simple Triage and Rapid Treatment (START) is a rapid primary process that is easy to remember and easy to teach. In 1983, START was developed in Newport Beach, California and was designed to work within the incident command system. The process takes between 30 and 60 seconds per victim. It is based on three simple assessments. No tools, special equipment, or advanced medical knowledge is required. Basic lifesaving measures such as opening airways and controlling external bleeding are performed as needed. Bystanders or the “walking wounded” are used to actually deliver these measures.

Your first step is to direct anyone that can walk to a designated safe place. If they can walk, these victims can be evaluated and tagged by other rescuers when they arrive. This now results in a smaller group of injured to triage, and you can begin your rapid assessment. Use the mnemonic “30-2-Can Do” (respiration less than 30 per minute, capillary refill less than 2 seconds, and the victim can do what you ask). The victim is an “immediate” if any one of these three criteria is not present. When victims can walk and meet this criterion, they are tagged as “minor.” When the victims cannot walk, they are tagged “delayed.” Deviations from these criteria (unconsciousness, rapid breathing, delayed capillary refill, or radial pulse absent) indicate serious injuries. If breathing does not resume when the airway is opened, the victim is tagged “dead/morgue.” In multicasualty incidents, resuscitation is not attempted. START is used across the United States and internationally. It is successful because of its simplicity and ease of use.

As time and resources permit, retriage using traditional physical examination techniques. There will be victims triaged initially as “delayed” who will have significant injuries. Expect and plan for this. Victims who remain at the incident and receive treatment may improve and have their triage category downgraded.

Triage Documentation Categories
START will work with any triage tag. The California Fire Chiefs Association has endorsed a tag that has a START prompt printed on it. This makes it easy to reinforce the triage process every time you use one of the tags. There is no perfect triage tag, but the good ones are easy to understand even if rarely used. Most importantly, a triage tag is a crucial communication and documentation tool and needs to be standardized in a region so all rescuers and medical personnel are familiar with it. Prioritization categories are listed at the bottom of the tag. The categories are Dead/Morgue, Immediate, Delayed, and Minor. Generally, they are located at the bottom of the tag and are also color-coded for ease of use.

Start and the Incident Command System (ICS)
START was designed to work within the ICS. When the first units arrive at a multicasualty incident, they are certainly going to be overwhelmed. There is a temptation to set up the management levels for the incident first, so the operational levels will have supervision when they are assigned. To do this, most organizations have to use personnel from the first or second wave of responding resources. This removes them from the triage/transportation/ treatment provider role, creating a delay in getting victims to the hospital. After 10 to 20 minutes, it’s a sad sight to see many rescuers wearing command vests and setting up their operations while no one is attending the victims.

Victims who are seriously ill or critically injured have a narrow time frame known by trauma care professionals as the “Golden Hour,” the optimum limit from time of injury to surgery at a hospital. Medical studies have demonstrated that survival rates are highest when surgical interventions take place within one hour. This is why the emphasis is on rapid triage and transportation rather than building a management structure.

Remember, it is not necessary to assign midmanagement positions until the maximum span of control is exceeded. An incident commander should assign first-arriving operational units to hands-on functions as much as possible. Typically, the required management functions are command, triage/treatment, transportation, and communications. Organizing these functions will have a positive effect on the speed with which you will be able to triage, transport, and treat your patients. This is referred to as the “bottom up” approach to ICS. Evaluate what needs to be done before you transport a victim and it becomes clear where initial resources need to be assigned.

Build from the Bottom Up

  • Before you can send a victim to a hospital, you need an available ambulance and a hospital destination from an area coordinator.
  • Before you can get a hospital destination, you need to know what category and how many victims are loaded in an ambulance.
  • Before you can identify what triage category the victims are, they must be tagged and carried to the ambulance loading area.
  • Before they can be tagged, they must be triaged.

Typical Problems at MCIs
Does this look familiar?

  • Failure to triage.
  • Failure to retriage.
  • Slow movement and collection of victims.
  • Inappropriate care.
  • Transportation delays.
Triage is the crucial first step that can prevent these problems.

Psychological Considerations
Rescuers are not immune to the psychological impacts of a disaster. People who perform triage feel as if they are “playing God” in deciding who gets immediate care, who must wait, and who gets none. The additional stress of triaging coworkers or family members greatly increases the emotional toll.

During the incident, rotating triage teams and treatment teams to other assignments can shorten the exposure and decrease the emotional stress. Critical incident stress professionals should monitor all incident personnel to help reestablish the emotional well-being of the rescuers.

Pediatric Triage
Management of injured children at an MCI is challenging. Injured children tug at our heartstrings and most likely will be triaged by emotion as “immediate.” Even if uninjured, they require supervision and protection. If their caretakers are injured or not available, rescuers must assume this task.

Prioritizing children over more critically injured adults denies resources to those who need them most. One of the reasons START was developed was to provide an objective tool for prioritizing care for victims. Objectivity assists us in doing the most good for the most people.

Until 1995, there was no triage process that specifically addressed the unique anatomy and physiology of children. Dr. Lou Romig, a pediatric emergency physician based in Florida, developed JumpSTART in response to this need. JumpSTART is a tool based on START but adapted to the uniqueness of the pediatric victim. JumpSTART was designed for children who are under the age of eight or who weigh less than 100 pounds.

JumpSTART adaptations include the following:

  • 5 rescue breaths after opening the airway if the child was not breathing.
  • A respiratory rate of less than 15 or greater than 45 categorizes the child as immediate.
  • Perfusion is determined by checking a distal pulse.
  • Mental status is evaluated based on levels of responsiveness as the age and development of the child allow. The assessment prompt AVPU can help you remember what you need to evaluate. The letters stand for alert, verbal stimuli, painful stimuli, and unconscious.

There are variations between START and JumpSTART parameters used to determine a triage category, but the outcome is the same. For instance, alterations in mental status are both classified as “Immediate.” Other differences occur with younger children who are unable to walk, who are unable to obey commands, or who are not breathing but who have a pulse. The apneic child is given 5 rescue breaths and a pulse check before being tagging as deceased. With this simple intervention, a child could be saved.

Triage is the basic tool you need to manage victims at a multicasualty event. It helps rescuers reduce the emotions and stress of a large-scale event and improve efficiency by having an objective tool at the ready.

If START and JumpSTART are not available in your area, I strongly suggest you bring these systems to the attention of your training officer. Ask for them to be evaluated for implementation.

Victoria Cleary is the EMS manager for the Newport Beach (CA) Fire Department. She has been involved in prehospital care since 1975 as a clinician, educator, and manager. She is one of the co-developers of the START triage system.

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