The World Health Organization defines mass casualty incidents as disasters and major incidents characterized by quantity, severity, and diversity of patients that can rapidly overwhelm the ability of local medical resources to deliver comprehensive and definitive medical care. They have been occurring more frequently in recent decades and affect countries of all socioeconomic backgrounds. Preparedness and planning are vital, as these events can happen in any community at any given time. Defined pre-hospital triage systems are essential in saving lives and optimizing initiation of resource allocation when these disasters strike.
Mass casualty incidents triage systems are implemented to offer the greatest good to the greatest amount of people as healthcare resources are limited or strained due to the number of injured individuals. Treatment during triage is minimal, and this is counterintuitive to normal pre-hospital protocols. The goal is to move patients away from the incident and toward resources that offer more comprehensive care.
Most mass casualty incident triaging systems use tags or colored designations for categorizing injured persons. It is important to designate areas where to tagged and/or labeled individuals can relocate. These areas will dually serve as treatment and loading zones for arriving ambulance crews. Triaging during a mass casualty incident is a dynamic and fluid process which requires a certain degree of pre-incident training. Patients may initially be triaged to one category but may be switched to another due to changes in their clinical status. Many of the triage tags have fold over tabs that are designed to switch patients between categories easily. However, emphasis should be placed on rapid assessment and quick movement of patients.
Primary triage systems are not built for determining resource allocation. There may be various implementation strategies for treatment and evacuation once patients have been triaged depending on the system or agency using the system. They do not rely on the number of victims present or resources available, and some have argued the need for a more sophisticated system allowing for consideration of these factors. Triaging algorithms are simple, straightforward, and easy to use; however, they can allow for over or under triaging depending on the situation. There are many available systems, and it is important to choose one and have it in place as an important part of any disaster preparedness plan which can ultimately help save lives.
Multiple triage systems are currently being implemented around the world. Some of the more well-known algorithms include START (simple triage and rapid treatment), SALT (sort, assess, lifesaving interventions, treatment/triage), STM (Sacco triage method), Care Flight Triage, and SAVE (Secondary assessment of victim endpoint). There is limited data available to support one system over another. However, it is important to choose one and adhere to its algorithm to maintain an ordered approach.
Simple triage and rapid treatment (START) is currently the most widely used triage system in the United States for mass casualty incidents. It was developed in 1983 by staff at Hoag Hospital and Newport Beach Fire Department in California for rescuers with basic first-aid skills. First responders delegate the movement of injured victims to a designated collection point as directed by using four main categories based on injury severity:
The triage colors may be assigned by giving triage tags to patients or simply by physically sorting patients into different designated areas. (see the algorithm below) "Green" patients are assigned by asking all victims who can walk to a designated area. All non-ambulatory patients are then assessed. Black tags are assigned to victims who are not breathing even after attempts are made to open airway. Red tags are assigned to any victim with the following:
Yellow tags are then assigned to all others. The mnemonic “RPM:30-2-can do” is an easy way to remember these decision points.
The sort, assess, life-saving interventions, and triage/treatment approach is similar to the START system; however, it is more comprehensive and adds simple life-saving techniques to be done during the triage phase.
JumpSTART is a modification to the START system and takes into account the difference in “normal” respiratory rates for children. This tool acts to assess pediatric patients better. The age cutoff for use is eight years old. If the child’s age is unknown, the rescuer can assess for underarm hair in males or breast development in females as an indicator of adult age and exclusion from this cohort.
The differences in this algorithm include: