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Simple triage and rapid treatment

Simple Triage and Rapid Treatment (START) is a standardized casualty sorting system designed for first responders to rapidly assess and prioritize multiple victims during mass casualty incidents (MCIs), enabling efficient allocation of limited medical resources to maximize survival rates.^[1] Developed in 1983 by the Newport Beach Fire Department and Hoag Hospital in California, START allows triage to be performed in approximately 60 seconds per patient using basic criteria focused on respiration, perfusion, and mental status, making it accessible even for responders with minimal medical training.^[2] The system categorizes patients into four priority levels using color-coded tags: black for deceased or expectant (those unlikely to survive given resource constraints), red for immediate (life-threatening injuries requiring urgent intervention), yellow for delayed (serious but stable conditions that can wait), and green for minor (walking wounded with non-life-threatening issues).^[3] The triage process begins by directing ambulatory patients to a designated minor treatment area, thereby freeing rescuers to focus on non-ambulatory individuals.^[1] For these patients, the RPM assessment is applied: first, evaluate respiration—if the rate exceeds 30 breaths per minute or if breathing is absent even after opening the airway, the patient is tagged immediate or deceased, respectively; next, check perfusion via radial pulse (absent pulse indicates immediate priority); finally, assess mental status—if the patient cannot follow simple commands, they are also classified as immediate, while responsive patients with controlled vital signs are delayed.^[2] In 1996, the original START algorithm was modified by incorporating radial pulse assessment instead of capillary refill to improve accuracy in varied environmental conditions, such as cold weather.^[2] As the most widely adopted MCI triage method in the United States, START emphasizes simplicity and speed but has limitations, including potential for over- or under-triage in complex scenarios and lack of integration with overall resource availability.^[1] Adaptations like JumpSTART extend the system to pediatric patients under age 8 by adjusting respiratory thresholds (15–45 breaths per minute) and using the AVPU scale for mental status, while other variants such as SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) offer more comprehensive, dynamic approaches.^[1] Ongoing training and periodic re-triage are recommended to adapt to evolving scene conditions, underscoring START's role as a foundational tool in emergency medical response protocols.^[3]

Introduction

Definition and Purpose

Simple Triage and Rapid Treatment (START) is a standardized protocol utilized by first responders to quickly classify injured individuals into priority groups during mass casualty incidents (MCIs). Developed as a simple, equipment-independent method, START enables the sorting of victims based on their potential for survival and immediate needs, allowing for efficient allocation of limited medical resources in overwhelming situations.^[4]^[5] The primary purpose of START is to facilitate rapid decision-making, typically within 60 seconds per patient, to prioritize life-saving interventions for those most likely to benefit while deferring care for others until resources become available. This approach optimizes patient outcomes by focusing on treatable conditions that can deteriorate quickly, such as airway obstruction or severe hemorrhage, without requiring advanced diagnostic tools. By emphasizing speed and simplicity, START helps mitigate chaos in high-volume emergencies, ensuring that critical care is directed where it can have the greatest impact.^[4]^[3] At its core, START operates on the principle of using observable, non-invasive criteria to categorize patients into four color-coded groups: black for deceased or expectant (those unlikely to survive given resource constraints), red for immediate (requiring urgent intervention to prevent death), yellow for delayed (serious but not immediately life-threatening injuries that can wait up to several hours), and green for minimal (walking wounded with minor injuries who can assist in their own care). This sorting process relies solely on basic assessments of respiration, perfusion, and mental status, promoting consistency among responders regardless of expertise level.^[5]^[3]^[6] START is primarily applied in pre-hospital environments, such as natural disasters, transportation accidents, or terrorist attacks, where the number of casualties exceeds available personnel and transport capabilities. In these scenarios, the protocol supports initial scene management by first responders, including firefighters and emergency medical technicians, to establish treatment and evacuation priorities before hospital handover.^[4]^[7]

Historical Development

The Simple Triage and Rapid Treatment (START) system originated in the early 1980s amid rising concerns over mass casualty incidents (MCIs) in civilian settings, particularly earthquakes and transportation accidents that overwhelmed local emergency responses in California. Developed collaboratively by the Newport Beach Fire Department and staff at Hoag Hospital in Newport Beach, the system aimed to enable rapid patient sorting by first responders with minimal training. Key contributors included Dr. Greg Super, Hoag's medical director of emergency services, and Dr. Carl Schultz, director of disaster medical services at the University of California, Irvine, who refined the approach during a 1983 simulation drill of a bus accident MCI.^[8]^[9]^[10] START built upon longstanding military triage principles, which had evolved since the Napoleonic Wars but were notably formalized during World War II through three-category systems assessing wound severity for efficient battlefield resource allocation. Japanese and French military medical teams in WWII employed such methods to prioritize evacuations and treatments, emphasizing speed over comprehensive diagnosis—a foundation simplified in START for non-military first responders facing urban disasters without advanced equipment. This adaptation addressed the limitations of complex military protocols in civilian contexts, where responders needed a tool completable in under 60 seconds per patient.^[10]^[7] Formalized and first published in 1983, START quickly gained traction through emergency services training programs, spreading across U.S. fire and EMS agencies by the late 1980s due to its simplicity and effectiveness in drills. Early validations occurred via field tests in real incidents, such as a post-1983 SUV rollover and subsequent MCIs, confirming its utility in identifying immediate versus delayed care needs without delaying overall response. By the 1990s, it was integrated into national guidelines, including adoption by the Federal Emergency Management Agency (FEMA) for disaster preparedness curricula, establishing START as a cornerstone of U.S. MCI protocols.^[8]^[11]^[12]

Core Components of START

Triage Classification Process

The Simple Triage and Rapid Treatment (START) classification process begins with an initial walkthrough of the incident scene, where first responders visually assess the situation to estimate the number of patients and identify obvious hazards or priorities before approaching individuals.^[13] This phase allows for a rapid overview without immediate physical contact, enabling the triage officer to request resources based on an approximate patient count, such as one ambulance per five victims.^[13] The process then proceeds in a systematic manner, dividing patients into four color-coded categories—immediate (red), delayed (yellow), minimal (green), and deceased/expectant (black)—to prioritize resource allocation during mass casualty incidents.^[14] These categories reflect the urgency of intervention: red for life-threatening conditions requiring care within minutes, yellow for serious but stable injuries that can wait up to an hour, green for minor injuries allowing delays of several hours, and black for those unlikely to survive given available resources.^[4] The step-by-step workflow emphasizes speed and simplicity, designed to classify each patient in 30 to 60 seconds using primarily voice commands and visual observations to minimize the need for equipment.^[4] First, responders issue a command for all ambulatory patients to walk to a designated collection area; those who respond are immediately tagged as green (minimal) and moved aside for later care, as their ability to follow instructions indicates stability.^[15] For non-ambulatory patients, the assessment focuses on three key areas—respirations, perfusion, and mental status—conducted sequentially from a standing position to cover multiple victims efficiently.^[2] If a patient fails initial checks (e.g., no respiratory effort), they are tagged black; otherwise, further evaluation determines red or yellow status based on the presence of vital signs and responsiveness.^[13] Color-coded triage tags are applied immediately to each patient, often using systems like SMART tags, which include written notes for subsequent responders.^[15] To ensure ongoing accuracy, the initial sorting is followed by secondary triage and reassessment as additional personnel and resources arrive, allowing for dynamic reclassification if a patient's condition changes.^[4] This integration of reassessment occurs in designated treatment areas, where patients from green and yellow categories may be reevaluated for potential upgrades to red if deterioration is observed.^[13] The entire process prioritizes "do the greatest good for the greatest number" by sorting rather than treating on-site, facilitating swift evacuation of higher-priority patients.^[14]

Patient Assessment Criteria

The patient assessment criteria in the Simple Triage and Rapid Treatment (START) system form the clinical foundation for categorizing victims during mass casualty incidents, relying on quick, observable indicators to evaluate respiratory effort, perfusion status, and mental responsiveness without the need for medical equipment. Developed in 1983 by the Newport Beach Fire Department and Hoag Hospital in California, these criteria enable first responders to perform evaluations in under 60 seconds per patient using only sight, touch, and voice, ensuring applicability in chaotic, resource-limited environments.^[2]^[16] Respiratory assessment is the initial step, focusing on breathing adequacy as a primary indicator of immediate life threats. Responders first check if the patient is breathing; if not, they position the head to open the airway and clear any obstructions—if breathing does not resume, the patient is classified as non-survivable (black). If breathing begins after this intervention or if the patient was already breathing but at a rate greater than 30 breaths per minute, the patient is tagged as immediate (red), signaling potential respiratory compromise or shock. Normal respirations (10-30 per minute) allow progression to perfusion checks.^[3]^[2] Perfusion evaluation follows normal respirations, assessing circulatory status through palpable radial pulse to identify inadequate blood flow. Responders palpate the radial pulse at the wrist for 5-10 seconds; absence or irregularity indicates immediate (red) categorization due to likely hypovolemic shock. If a radial pulse is present, the patient is directed toward delayed (yellow) or minimal (green) categories, depending on subsequent mental status.^[3]^[2]^[4] Mental status assessment concludes the evaluation for patients passing prior steps, using simple verbal commands to gauge neurological function and responsiveness. Commands such as "follow my finger with your eyes" or "squeeze my hands" are given; failure to obey indicates altered mental status, warranting an immediate (red) tag due to potential head injury or hypoxia. Ability to follow commands classifies the patient as delayed (yellow) if other assessments indicate marginal stability, or minimal (green) if all prior assessments are normal. This step relies entirely on voice and observation, avoiding any tools to maintain speed and simplicity.^[3]^[2] The resulting category assignments prioritize resource allocation: red for immediate (life-threatening injuries that are survivable with prompt intervention, such as severe respiratory distress or uncontrolled hemorrhage); yellow for delayed (serious injuries not immediately fatal, like fractures or controlled bleeding, treatable after reds); green for minimal (walking wounded with superficial injuries requiring little care); and black for deceased or expectant (obvious death or unsurvivable conditions, such as agonal respirations without response to airway maneuvers). These categories, refined in subsequent validations like the 1996 modification substituting radial pulse for capillary refill, ensure systematic sorting integrated into the overall triage workflow.^[2]

Implementation

Treatment and Evacuation Procedures

Following triage classification in the Simple Triage and Rapid Treatment (START) system, immediate actions prioritize life-saving interventions for patients categorized as immediate (red), focusing on airway, breathing, and circulation (ABC) stabilization to enhance survival potential in resource-limited mass casualty incidents.^[1] For these patients, rescuers provide rapid interventions such as opening the airway, administering oxygen if available, controlling severe bleeding through direct pressure or tourniquets, and splinting major fractures to prevent further injury during movement.^[3] These measures are kept minimal during initial triage to maintain the system's speed, with more comprehensive care deferred to casualty collection points (CCPs) once established.^[17] Evacuation sequencing adheres strictly to triage priorities to optimize outcomes, with red-tagged patients transported first to designated trauma centers capable of advanced care, often using a "load-and-go" approach to minimize on-scene delays.^[1] Yellow-tagged patients, who have serious but non-immediate injuries, receive delayed interventions such as intravenous fluids or wound dressing at CCPs before transport, allowing reds to be cleared without competition for ambulances.^[17] Green-tagged patients, with minor injuries, are directed to self-evacuate or receive minimal aid like bandaging before being transported last, typically via non-ambulance resources if needed; black-tagged patients, deemed expectant or deceased, remain in place to conserve resources for viable cases.^[3] This sequencing ensures that transport assets are allocated efficiently, distributing patients across multiple facilities to prevent overload.^[12] Resource allocation integrates color-coded triage tags to guide personnel and vehicles directly to high-priority patients, facilitating rapid identification amid chaos and enabling incident command systems to coordinate "load-and-go" transports without re-assessment delays.^[17] Tags, often made from durable materials like plastic or cloth, are affixed to patients to signal their category (red, yellow, green, black) from a distance, directing ambulances, helicopters, or ground teams to reds first while yellows and greens are grouped for bulk handling.^[3] This visual system aligns with broader incident command structures, where transportation leaders track bed availability at receiving hospitals to balance the load.^[1] Documentation on triage tags captures essential handoff information, including a unique patient identifier, triage category, basic vital signs (such as respiratory rate and pulse), and any initial interventions performed, ensuring continuity of care upon arrival at medical facilities.^[17] The tag's design often includes detachable sections for logging transport details like destination hospital and departure time, which are retained by the receiving team to inform ongoing treatment without redundant assessments.^[12] This structured recording supports accountability and allows for re-triage if patient conditions evolve during evacuation.^[5]

Application in Mass Casualty Incidents

In mass casualty incidents (MCIs), the Simple Triage and Rapid Treatment (START) system integrates with the National Incident Management System (NIMS) framework, enabling first responders to secure the scene and establish a dedicated triage area for rapid victim assessment and categorization once immediate threats are neutralized.^[1]^[18] START has been applied in high-profile MCIs, such as the 2017 Las Vegas shooting, where over 800 individuals were injured or killed. However, widespread self-transport to hospitals limited prehospital triage by EMS teams, with only about 25% of victims triaged on scene, and the system proved inadequate in this scenario due to patients arriving untriaged, leading to challenges in prioritizing critical care and evacuation.^[19]^[20]^[21] Training in START is commonly provided to EMS personnel in U.S. jurisdictions, typically delivered through simulation-based drills that mimic MCI conditions to build proficiency, with protocols emphasizing team roles; for example, some local guidelines recommend deploying one triage team (often two personnel) per 10 patients to ensure efficient scene coverage without overwhelming resources.^[1]^[22]^[23] Practical challenges in MCI deployment include the risks of over-triage (assigning non-critical patients to higher priorities) and under-triage (missing severe cases), particularly in evolving scenes; meta-analyses of field and simulation studies report START accuracy rates around 73%, with over-triage at 14% and under-triage at 10%, highlighting the importance of repeated practice to enhance reliability.^[24]

Variations and Adaptations

Modifications for Special Populations

The Simple Triage and Rapid Treatment (START) protocol includes adaptations for special populations to account for physiological variations and vulnerabilities in mass casualty incidents, ensuring more accurate categorization and equitable resource allocation. For pediatric patients, the JumpSTART system serves as a key modification of START, specifically designed for children under 8 years of age. Developed in 1995 by Dr. Lou E. Romig at Miami Children's Hospital, with a revised version published in 2001, JumpSTART adjusts assessment criteria to better suit young patients' developmental and physiological differences.^[25] Instead of evaluating the ability to follow simple commands for mental status, JumpSTART employs the AVPU scale (Alert, responds to Verbal stimuli, responds to Pain, Unresponsive) to determine responsiveness.^[26] Perfusion assessment involves checking for a palpable peripheral pulse; if absent, the patient is tagged immediate (red).^[27] Adaptations for elderly patients and pregnant individuals focus on adjusted physiological thresholds and comorbidity considerations to avoid under-triage. In geriatric trauma care, older adults may exhibit a normal respiratory rate up to 25 breaths per minute, prompting informal guidelines to lower the upper threshold for abnormal respirations (e.g., >25/min as a potential indicator of distress, compared to >30/min in standard START) and to factor in preexisting conditions like frailty or cardiovascular disease.^[28] For pregnant patients, protocols emphasize special considerations such as gestation beyond 20 weeks, which may warrant higher priority due to risks to both mother and fetus, alongside evaluation of reversible obstetric complications.^[29] In special environments like chemical, biological, radiological, or nuclear (CBRN) incidents, START is modified to incorporate exposure assessment, such as evaluating contamination levels or agent-specific symptoms before standard vital signs checks, to prioritize decontamination and mitigate secondary harm.^[30] Additionally, elements of the SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) triage system are integrated with START to address potentially reversible causes in the black (deceased/expectant) category; SALT's expectant designation allows re-evaluation for salvageable patients with limited resources, such as those responding to basic interventions, improving outcomes in resource-constrained scenarios.^[31] These modifications promote equity across populations by tailoring assessments to unique needs, with implementation supported through updated training modules in established protocols, including the 2021 American College of Surgeons guidelines that highlight special considerations for vulnerable groups like children, pregnant individuals, and those with high-resource needs.^[32]

Alternative and Similar Triage Systems

The SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) triage system, developed through an expert panel coordinated by the National Association of EMS Physicians and funded by the Centers for Disease Control and Prevention (CDC) in 2008, offers a structured alternative to START for mass casualty incidents.^[31] Unlike START, which focuses primarily on rapid physiological assessment without integrated interventions, SALT incorporates immediate lifesaving steps—such as opening airways or controlling hemorrhage—prior to full patient evaluation, aiming to stabilize critical cases more proactively during the initial sort phase.^[33] This approach addresses START's limitation in deferring treatments, with studies indicating SALT achieves higher overall accuracy in classifying immediate and delayed patients compared to START in simulated scenarios.^[34] The modified START (mSTART), introduced by the New York City Fire Department in 2015, represents an adaptation of the original START framework rather than a wholly distinct system. It incorporates an intermediate "orange" category between immediate (red) and delayed (yellow) to better stratify patients with moderate needs, thereby reducing over-triage rates that can overwhelm resources in START applications. Validation studies from the system's development demonstrate overall triage accuracy of 91% among experienced providers and a marked decrease in over-triage for intermediate cases, from 17.3% under original START to 1.5% with mSTART.^[35] Other similar systems include the UK's Triage Sieve, a color-coded protocol akin to START that prioritizes patients based on mobility, respiration, circulation, and mental status, but with explicit consideration of injury mechanisms such as blast or crush effects to refine categorization in diverse incidents.^[36] In military contexts, Tactical Combat Casualty Care (TCCC) integrates START-like triage elements—emphasizing rapid assessment of airway, breathing, and circulation—within its phased care model (care under fire, tactical field care, and evacuation) to prioritize casualties on the battlefield amid ongoing threats.^[37] START continues to dominate U.S. mass casualty triage, serving as the primary method in the majority of prehospital responses according to national guidelines and usage patterns. However, SALT is increasingly adopted in integrated emergency systems for its emphasis on interventions, reflecting a shift toward more dynamic protocols in evolving disaster preparedness frameworks.^[1]^[31]

Evaluation and Challenges

Strengths and Limitations

The Simple Triage and Rapid Treatment (START) system offers several key strengths that make it a foundational tool in mass casualty incidents (MCIs). Its design emphasizes simplicity and speed, enabling assessments in under 60 seconds using just four objective criteria—respirations, perfusion, mental status, and ability to walk—which facilitates rapid sorting of large numbers of patients without requiring advanced medical equipment or extensive resources.^[38] This cost-effectiveness and lack of technological dependencies allow for easy implementation in resource-limited environments.^[38] Furthermore, START can be effectively taught to non-medical personnel through just-in-time training, significantly improving triage accuracy among first responders and lay providers.^[39] In simulated settings, the system demonstrates high inter-rater reliability, with sensitivity rates around 85% and specificity around 86%, supporting consistent categorization across users.^[38] Despite these advantages, START has notable limitations rooted in its streamlined approach, which prioritizes speed over nuanced clinical detail. The system's respiratory assessment relies solely on rate rather than effort or quality, potentially under-triaging conditions like early respiratory distress or issues critiqued in early evaluations for missing subtle abnormalities.^[39] It also overlooks potentially reversible conditions, such as tension pneumothorax, which may lead to expectant (black) categorization despite treatable potential, as the criteria do not incorporate interventions like decompression during initial triage.^[40] Without modifications, START performs poorly for special populations, including pediatrics and the elderly, where physiologic norms differ and over-triage risks increase due to emotional or assessment biases.^[39]^[38] Operational evidence highlights further challenges in START's evidence base. Field accuracy typically ranges from 70% to 80%, but this drops significantly in chaotic MCIs involving low light, noise, or high stress, where overtriage can reach 81% and overall accuracy falls to around 45%.^[41]^[38] The system does not account for surge capacity constraints or psychological factors influencing provider decisions, often leading responders to revert to clinical judgment over strict protocol adherence.^[39]^[41] Validations from the 2010s confirm persistent gaps, particularly in non-trauma events, where sensitivity and specificity remain lower than in trauma-focused simulations, underscoring outdated critiques of its adaptability.^[39]

Recent Developments and Research

In 2021, the American College of Surgeons (ACS) revised its National Guidelines for the Field Triage of Injured Patients, introducing new criteria such as active bleeding requiring tourniquet or wound packing to identify high-risk patients for transport to trauma centers. These updates focus on individual injured patients in standard EMS responses and include considerations for hemorrhage control, but do not address mass casualty triage protocols.^[32]^[42] A July 2025 review in Cureus analyzed strategies for mass casualty incidents based on 300 simulated events in Pakistan from 2010 to 2024, finding an association between START use and lower mortality rates compared to other methods (χ² = 14.23, p < 0.001). Natural disasters showed the highest mortality at 17.2% among MCI types.^[43] Ongoing research explores alternatives to START, such as the SALT system, which a 2021 Mayo Clinic overview described as replacing START with more comprehensive assessments, including a gray category for expectant patients and reducing undertriage by 9% in some comparisons.^[44] Protocols in regions like Maryland continue to incorporate START for MCI triage as of July 2025.^[45] These evolutions highlight efforts to refine MCI responses for diverse scenarios.

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