Regional Emergency Medical Advisory Committee of New York City
Prehospital Advanced Life Support Protocols
Copyright January 1996 (3/96)

APPENDIX L

TRIAGE / S. T. A. R. T.

Introduction

The S.T.A.R.T. plan (Simple Triage And Rapid Treatment) was developed by the Los Angles County Fire Chiefs to be used in the event of a Multiple Casualty Incident (MCI).

This plan allows EMTs and Paramedics to triage patients at an MCI in 60 seconds or less.

It is based on three (3) observations:

  1. Respirations;
  2. Circulation; and,
  3. Mental Status.

Most trauma patients die within the first hour (Golden Hour) after sustaining their injuries, mostly due to respiratory complications / insufficiency, exsanguination, or CNS trauma.

Review of MCIs and Triage

An MCI is any sudden event or situation that has produced, is believed to have produced, or experience indicates, may produce a minimum of five (5) patients.

Triage is a French word meaning to sort. It's purpose is to identify patients with life threatening injuries and give them immediate treatment and transportation.

Aim of Triage - GREATEST GOOD FOR THE GREATEST NUMBER

Principles of S.T.A.R.T.

The S.T.A.R.T. plan calls for rescuers to correct immediate threats to life:

blocked airways; and

severe arterial bleeding.

The S.T.A.R.T. plan utilizes the METTAG Triage Card, which classifies patients into four (4) distinct areas for treatment.

It is a system that quickly and accurately triages victims into treatment groups.

The plan is simple to learn and retain. It is extremely useful in the MCI setting in that it maximizes the efficiency of the rescuers until additional resources arrive.

Prior to the S.T.A.R.T. plan, triage was solely based on individual judgment. If the injury appeared serious, the patient was placed in a critical treatment area. S.T.A.R.T. provides specific criteria for triage of patients.

How S.T.A.R.T. Works

The Triage Team must evaluate and place the patient's injuries into one of four categories:

DECEASED (BLACK TAG) No spontaneous effective respirations present after one attempt to reposition the airway.

IMMEDIATE (RED TAG) Respirations present only after repositioning of the airway.

Applies to patients with respiratory rates greater than 30 per minute.

Patients whose capillary refill is delayed more than 2 seconds.

The patient fails to follow simple commands.

DELAYED (YELLOW TAG) Any patient who does not fit into the IMMEDIATE category or the MINOR category

MINOR (GREEN TAG) Patients who are separated from the general group at the beginning of the triage operation. These patients are also called the "walking wounded".

These patients are directed to walk away from the scene to a designated safe area.

These patients can also be utilized to control severe bleeding and assist in maintenance of patent airways on those "IMMEDIATE" patients who require it.

PROCEDURE

RESPIRATORY ASSESSMENT:

Every patient will be quickly assessed for respiratory rate and adequacy.

If a patient is not breathing, check for foreign objects causing obstruction in the mouth. Remove dentures if they are loose.

Reposition the head, using cervical spine precautions if this does not delay assessment.

If the above maneuvers do not result in effective spontaneous respirations, TAG THE PATIENT BLACK.

If the patient's respiratory rate is greater than 30 per minute, TAG THE PATIENT RED.

Patients who have respirations less than 30 per minute are NOT TO BE TAGGED AT THIS TIME. THEY ARE TO BE ASSESSED IN THE NEXT CATEGORY.

PERFUSION

The best indicator of adequate perfusion is an assessment of capillary nailbed refill.

Press nailbeds or lips and release. Color should return to these areas within 2 seconds.

If it takes more than 2 seconds, the patient is showing signs of inadequate perfusion AND MUST BE TAGGED RED.

If the color returns within 2 seconds or less, THE PATIENT IS NOT TAGGED UNTIL THE NEXT AREA IS ASSESSED - Mental Status.

If the capillary refill cannot be assessed, palpate the radial pulse. In most cases, if the radial pulse cannot be felt, the systolic blood pressure will be below 80 mm Hg.

Hemorrhage control techniques will be incorporated into this section. Control significant bleeding by direct pressure and elevate the lower extremities.

Utilize the "walking wounded" to assist with hemorrhage control on themselves or other patients.

Mental Status

An evaluation of mental status is performed on patients whose respirations and perfusion are adequate. To test mental status, the rescuer should ask the patient to follow a simple command, e.g., "open and close your eyes" or, "squeeze my hands."

If the patient cannot follow these commands, he/she is TAGGED RED.

If the patient can follow these commands, he/she is TAGGED YELLOW.

Only after all patients have been triaged can patients be treated. The above techniques should take no more than 60 seconds per patient.

Triage Tags

Triage tags are completed during transportation to the hospital or in the Staging Area, if there is time.

To fill out the triage tag properly, follow these instructions:

  1. record time of triage;
  2. record the date;
  3. * record the name of the patient if he/she is conscious and coherent;
  4. * record the home address of the patient if possible;
  5. * record the home city and state of the patient if possible;
  6. record other important information, i.e. medical treatment, history;
  7. record your shield number or EMT number on the bottom line and on the yellow corners;
  8. on the reverse side, record injuries on the diagram;
  9. record vital signs and the time taken in the indicated areas;
  10. paramedics will record IVs and any drugs given;
  11. tear off all colored areas BELOW the determined priority and retain;
  12. attach tag securely to clothing or body so that it is clearly visible.

* Items 3, 4, and 5 may be delayed or accomplished by others while awaiting transportation.

Left and right corners (Ambulance & Cross) are perforated along the lines as shown.

  1. Make sure that your shield or EMT number appears on both corners.
  1. The corner marked with the CROSS is removed in the treatment area prior to removal to a medical facility. These should be given to the person or Supervisor in charge of the Treatment Area.
  1. The corner marked with the AMBULANCE is to be removed prior to the actual transfer of the patient from the Treatment Area to a medical facility. It is to be retained by the crew until the end of the MCI. These are then given to the person or Supervisor in charge of the Transportation Area.

All the initial triage portions of the tags must be retained by the Triage Team and given to the person, or Supervisor, in charge of the Triage Team at the end of the MCI.

TRIAGE / S. T. A. R. T.

SIMPLE TRIAGE AND RAPID TREATMENT

VENTILATIONS

NO YES

POSITION AIRWAY >30/MINUTE <30/MINUTE

NO YES IMMEDIATE

NON-SALVAGEABLE IMMEDIATE ASSESS

PERFUSION

RADIAL PULSE

OR

CAPILLARY REFILL

> 2 SECONDS < 2 SECONDS

CONTROL BLEEDING

IMMEDIATE ASSESS MENTAL STATUS

MENTAL STATUS

FAILS TO FOLLOW CAN FOLLOW

SIMPLE COMMANDS SIMPLE COMMANDS

IMMEDIATE DELAYED

ALL MINOR TAGGED PATIENTS (GREEN TAG OR WALKING WOUNDED) ARE TO BE REMOVED FROM THE SCENE FIRST AND SENT TO A SAFE AREA. THESE PATIENTS CAN ALSO BE USED TO HELP WITH BLEEDING CONTROL OR AIRWAY PROBLEMS ON OTHER PATIENTS.

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