Simple triage and rapid treatment (START) is a

triage In medicine, triage () is a practice invoked when acute care cannot be provided for lack of resources. The process rations care towards those who are most in need of immediate care, and who benefit most from it. More generally it refers to prio ...

method used by

first responder A first responder is a person with specialized training who is among the first to arrive and provide assistance or incident resolution at the scene of an emergency, such as an accident, disaster, medical emergency, structure fire, crime, or terr ...

s to quickly classify victims during a mass casualty incident (MCI) based on the severity of their injury. The method was developed in 1983 by the staff members of

Hoag Hospital Hoag is a surname. Notable people with the surname include: * Arthur Hoag (1921–1999), American astronomer * Bob Hoag, American record producer and songwriter *Charles Hoag (1808–1888), American scholar and teacher; first school master of Minn ...

and

Newport Beach Fire Department Newport Beach is a coastal city in South Orange County, California. Newport Beach is known for swimming and sandy beaches. Newport Harbor once supported maritime industries however today, it is used mostly for recreation. Balboa Island draws v ...

located in

California California is a U.S. state, state in the Western United States, located along the West Coast of the United States, Pacific Coast. With nearly 39.2million residents across a total area of approximately , it is the List of states and territori ...

, and is currently widely used in the

United States The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territorie ...

.START Adult Triage Algorithm. Radiation Emergency Medical Management: REMM (US Department of Health and Human Services). http://www.remm.nlm.gov/startadult.htm

Classification

First responders using START evaluate victims and assign them to one of the following four categories: * Deceased/expectant (black) * Immediate (red) * Delayed (yellow) * Walking wounded/minor (green) Lerner EB, Schwartz RB, Coule PL, et al. "Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline." ''Disaster Medicine and Public Health Preparedness'' 2(Suppl. 1) 2008, pp S25-S34. The colors correspond to

triage tag A triage tag is a tool first responders and medical personnel use during a mass casualty incident. With the aid of the triage tags, the first-arriving personnel are able to effectively and efficiently distribute the limited resources and provide ...

s, which are used by some agencies to indicate each victim's status, although physical tags are not necessary if patients can be physically sorted into different areas.Benson M, Koenig KL, Schultz CH. "Disaster Triage: START, then SAVE--A New Method of Dynamic Triage for Victims of a Catastrophic Event." ''Disaster Medicine and Public Health Preparedness'' 11(2) 1996, pp 117-124. Responders arriving to the scene of a mass casualty incident may first ask that any victim who is able to walk relocate to a certain area, thereby identifying the ambulatory, or walking wounded, patients. Non-ambulatory patients are then assessed. The only medical intervention used prior to declaring a patient deceased is an attempt to open the airway. Any patient who is not breathing after this attempt is classified as deceased and given a black tag. No further interventions or therapies are attempted on deceased patients until all other patients have been treated. Patients who are breathing and have any of the following conditions are classified as immediate: * Respiratory rate greater than 30 per minute; * Radial pulse is absent, or

capillary refill Capillary refill time (CRT) is defined as the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. It can be measured by holding a hand higher than heart-level and pressing the soft pad of a f ...

is over 2 seconds; * Unable to follow simple commands All other patients are classified as delayed.

Treatment and evacuation

After all patients have been evaluated, responders use the START classifications to determine priorities for treatment or evacuation to a hospital. The most basic way to use the START classifications is to transport victims in a fixed priority manner: immediate victims, followed by delayed victims, followed by the walking wounded. More detailed secondary

systems such as SAVE may also be used: in this case, the START classifications are used to determine the order in which victims should undergo secondary triage. START is not a system for determining resource allocation. The classification algorithm used in START does not depend on the number of victims or on the number of resources available to treat them, nor does using START alone provide any prioritization of patients within any of the four triage classes. Therefore, significant differences in implementation of treatment and evacuation may exist across different agencies using START.Navin M, Sacco W, and Waddell R. ''Operational Comparison of the Simple Triage and Rapid Treatment Method and the Sacco Triage Method in Mass Casualty Exercises''. Journal of Trauma Vol. 69 No. 1 July 2010 pp.215-225. http://journals.lww.com/jtrauma/pages/default.aspx

Modifications to START and similar triage systems

Numerous agencies have developed modifications to START or new triage systems similar to START. One early proposed modification substituted the presence of a radial

pulse In medicine, a pulse represents the tactile arterial palpation of the cardiac cycle (heartbeat) by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed near the surface of the body, such as at the nec ...

for capillary refill in classifying patients as immediate. The

Fire Department of New York The New York City Fire Department, officially the Fire Department of the City of New York (FDNY), is an American department of the government of New York City that provides fire protection services, technical rescue/special operations services, ...

uses a modified version of START with an orange or "urgent" classification intermediate in severity between immediate and delayed.

Modification for pediatric patients

START has also been modified to provide better treatment for children. One such modification is known as JumpSTART. There are several simple modifications to the adult version. The primary modification for use with pediatric patients is to change the "normal" respiratory rate: since children breathe faster than adults, JumpSTART assigns the immediate classification on the basis of respiratory rate only if the child's respiration is under 15 or over 45 per minute. Another change is in the

apneic Apnea, BrE: apnoea, is the temporal cessation of breathing. During apnea, there is no movement of the muscles of inhalation, and the volume of the lungs initially remains unchanged. Depending on how blocked the airways are ( patency), there may ...

pediatric patient with a pulse the patient is given 5 breaths. If they resume breathing on their own, they are tagged as "immediate". If they do not resume breathing on their own, they are tagged as "deceased". Another needed bit of information is to decide who qualifies as a pediatric patient and who qualifies as an adult. This can quickly be decided by a rapid check for underarm hair development on boys, and breast bud or breast development on girls. If the age is known, the age cut off for child versus adult is 8 years old.

Similar triage systems

Other triage systems that are variations of or similar to START include Triage Sieve, Pediatric Triage Tape, and CareFlite Triage. Each of these systems uses four or five triage classes with the red, yellow, green, and black colors.

Limitations

There is no accepted measure to judge the appropriateness of any given system in mass casualty triage. Like many other triage systems, START suffers from implementation problems such as substantial amounts of overtriage. Frykberg ER. "Triage: Principles and Practice." ''Scandinavian Journal of Surgery'' 94, 2005, pp 272-278 One of the major strengths of START, its simplicity, is also a major limitation. Since START was developed, consensus has emerged that triage should be more sophisticated, by incorporating resource limitations and capacity in determining how to prioritize patients.Lerner EB, Cone DC, Weinstein ES. "Mass Casualty Triage: An Evaluation of the Science and Refinement of a National Guideline." ''Disaster Medicine and Public Health Preparedness'' 5, 2011, pp 129-137.Argon NT, Ziya S, Winslow JE. "Triage in the Aftermath of Mass-Casualty Incidents." ''Wiley Encyclopedia of Operations Research and Management Science.'' John Wiley & Sons, 2011 doi:10.1002/9780470400531.eorms0925

Notes

External links

* (Newport Beach Fire Department) * * * (PDF - 197 KB) (Adult, SC-EMS.com) * * Maryland Institute for Emergency Medical Service Systems {{cite web, url=http://www.miemss.org/home/TriageTagTraining/tabid/152/Default.aspx, title=Simple Triage and Rapid Treatment training, archive-url=https://web.archive.org/web/20130903224414/http://www.miemss.org/home/TriageTagTraining/tabid/152/Default.aspx, archive-date=2013-09-03 Triage