Simple triage and rapid treatment

Last updated
Simple triage and rapid treatment
Purposeclassify victims during a mass casualty incident

Simple triage and rapid treatment (START) is a triage method used by first responders 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 and Newport Beach Fire Department located in California, and is currently widely used in the United States. [1]

Contents

Classification

First responders using START evaluate victims and assign them to one of the following four categories:

[2]

The colors correspond to triage tags, 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. [3]

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:

All other patients are classified as delayed. [1] [2]

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. [2] More detailed secondary triage 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. [2] [3]

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. [4]

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 for capillary refill in classifying patients as immediate. [3] The Fire Department of New York uses a modified version of START with an orange or "urgent" classification intermediate in severity between immediate and delayed. [5]

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 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. [2]

Similar triage systems

Other triage systems that are variations of or similar to START include Triage Sieve, Pediatric Triage Tape, and CareFlite Triage. [2] 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. [2] Like many other triage systems, START suffers from implementation problems such as substantial amounts of overtriage. [6] 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. [7] [8]

See also

Notes

  1. 1 2 START Adult Triage Algorithm. Radiation Emergency Medical Management: REMM (US Department of Health and Human Services). https://remm.hhs.gov/startadult.htm
  2. 1 2 3 4 5 6 7 Lerner, E. Brooke; Schwartz, Richard B.; Coule, Phillip L.; Weinstein, Eric S.; Cone, David C.; Hunt, Richard C.; Sasser, Scott M.; Liu, J Marc; Nudell, Nikiah G.; Wedmore, Ian S.; Hammond, Jeffrey; Bulger, Eileen M.; Salomone, Jeffrey P.; Sanddal, Teri L.; Lord, Graydon C.; Markenson, David; O'Connor, Robert E. (September 2008). "Mass Casualty Triage: An Evaluation of the Data and Development of a Proposed National Guideline". Disaster Medicine and Public Health Preparedness. 2 (S1): S25–S34. doi:10.1097/DMP.0b013e318182194e. PMID   18769263.
  3. 1 2 3 Benson, Mark; Koenig, Kristi L.; Schultz, Carl H. (June 1996). "Disaster Triage: START, then SAVE—A New Method of Dynamic Triage for Victims of a Catastrophic Earthquake". Prehospital and Disaster Medicine. 11 (2): 117–124. doi:10.1017/S1049023X0004276X. PMID   10159733. S2CID   6001680.
  4. Navin, D. Michael; Sacco, William J.; Waddell, Robert (July 2010). "Operational Comparison of the Simple Triage and Rapid Treatment Method and the Sacco Triage Method in Mass Casualty Exercises". Journal of Trauma: Injury, Infection & Critical Care. 69 (1): 215–225. doi:10.1097/TA.0b013e3181d74ea4.
  5. "Triage Overview: modified S.T.A.R.T." (PDF). Journal CME Newsletter. 17 (11): 5–18. November 2011. Archived from the original (PDF) on 2013-10-29. Retrieved 21 May 2012.
  6. Frykberg, E. R. (December 2005). "Triage: Principles and Practice". Scandinavian Journal of Surgery. 94 (4): 272–278. doi:10.1177/145749690509400405. PMID   16425622.
  7. Lerner, E. Brooke; Cone, David C.; Weinstein, Eric S.; Schwartz, Richard B.; Coule, Phillip L.; Cronin, Michael; Wedmore, Ian S.; Bulger, Eileen M.; Mulligan, Deborah Ann; Swienton, Raymond E.; Sasser, Scott M.; Shah, Umair A.; Weireter, Leonard J.; Sanddal, Teri L.; Lairet, Julio; Markenson, David; Romig, Lou; Lord, Gregg; Salomone, Jeffrey; O'Connor, Robert; Hunt, Richard C. (June 2011). "Mass Casualty Triage: An Evaluation of the Science and Refinement of a National Guideline". Disaster Medicine and Public Health Preparedness. 5 (2): 129–137. doi:10.1001/dmp.2011.39. PMID   21685309. S2CID   205005377.
  8. Argon, Nilay Tanik; Ziya, Serhan; Winslow, James E. (2011). "Triage in the Aftermath of Mass-Casualty Incidents". Wiley Encyclopedia of Operations Research and Management Science. doi:10.1002/9780470400531.eorms0925. ISBN   978-0-470-40063-0.

Related Research Articles

<span class="mw-page-title-main">Community emergency response team</span>

In the United States, community emergency response team (CERT) can refer to

<span class="mw-page-title-main">First aid</span> Emergency first response medical treatment

First aid is the first and immediate assistance given to any person with either a minor or serious illness or injury, with care provided to preserve life, prevent the condition from worsening, or to promote recovery until medical services arrive. First aid is generally performed by someone with basic medical training. Mental health first aid is an extension of the concept of first aid to cover mental health, while psychological first aid is used as early treatment of people who are at risk for developing PTSD. Conflict first aid, focused on preservation and recovery of an individual's social or relationship well-being, is being piloted in Canada.

<span class="mw-page-title-main">Triage</span> Process of determining the priority of patients treatments based on the severity of their condition

In medicine, triage is a process by which care providers such as medical professionals and those with first aid knowledge determine the order of priority for providing treatment to injured individuals and/or inform the rationing of limited supplies so that they go to those who can most benefit from it. Triage is usually relied upon when there are more injured individuals than available care providers, or when there are more injured individuals than supplies to treat them.

A medical emergency is an acute injury or illness that poses an immediate risk to a person's life or long-term health, sometimes referred to as a situation risking "life or limb". These emergencies may require assistance from another, qualified person, as some of these emergencies, such as cardiovascular (heart), respiratory, and gastrointestinal cannot be dealt with by the victim themselves. Dependent on the severity of the emergency, and the quality of any treatment given, it may require the involvement of multiple levels of care, from first aiders through emergency medical technicians, paramedics, emergency physicians and anesthesiologists.

<span class="mw-page-title-main">Emergency department</span> Medical treatment facility specializing in emergency medicine

An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care center.

Human decontamination is the process of removing hazardous materials from the human body, including chemicals, radioactive substances, and infectious material.

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 the necessary immediate care for the victims until more help arrives. Triage tags were first introduced by Baron Dominique Jean Larrey, a French surgeon in Napoleon's army.

<span class="mw-page-title-main">ABC (medicine)</span> Initialism mnemonics

ABC and its variations are initialism mnemonics for essential steps used by both medical professionals and lay persons when dealing with a patient. In its original form it stands for Airway, Breathing, and Circulation. The protocol was originally developed as a memory aid for rescuers performing cardiopulmonary resuscitation, and the most widely known use of the initialism is in the care of the unconscious or unresponsive patient, although it is also used as a reminder of the priorities for assessment and treatment of patients in many acute medical and trauma situations, from first-aid to hospital medical treatment. Airway, breathing, and circulation are all vital for life, and each is required, in that order, for the next to be effective. Since its development, the mnemonic has been extended and modified to fit the different areas in which it is used, with different versions changing the meaning of letters or adding other letters.

In first aid and triage, the walking wounded are injured persons who are of a relatively low priority. These patients are conscious and breathing and will often have only relatively minor injuries; thus they are capable of walking. Depending on the resources available, and the abilities of the injured persons, walking wounded may sometimes be called upon to assist treatment of more seriously injured patients or assist with other tasks.

Hospital emergency codes are coded messages often announced over a public address system of a hospital to alert staff to various classes of on-site emergencies. The use of codes is intended to convey essential information quickly and with minimal misunderstanding to staff while preventing stress and panic among visitors to the hospital. Such codes are sometimes posted on placards throughout the hospital or are printed on employee identification badges for ready reference.

<span class="mw-page-title-main">Disaster medicine</span> Area of medical specialization

Disaster medicine is the area of medical specialization serving the dual areas of providing health care to disaster survivors and providing medically related disaster preparation, disaster planning, disaster response and disaster recovery leadership throughout the disaster life cycle. Disaster medicine specialists provide insight, guidance and expertise on the principles and practice of medicine both in the disaster impact area and healthcare evacuation receiving facilities to emergency management professionals, hospitals, healthcare facilities, communities and governments. The disaster medicine specialist is the liaison between and partner to the medical contingency planner, the emergency management professional, the incident command system, government and policy makers.

<span class="mw-page-title-main">Medical Priority Dispatch System</span>

The Medical Priority Dispatch System (MPDS), sometimes referred to as the Advanced Medical Priority Dispatch System (AMPDS) is a unified system used to dispatch appropriate aid to medical emergencies including systematized caller interrogation and pre-arrival instructions. Priority Dispatch Corporation is licensed to design and publish MPDS and its various products, with research supported by the International Academy of Emergency Medical Dispatch (IAEMD). Priority Dispatch Corporation, in conjunction with the International Academies of Emergency Dispatch, have also produced similar systems for Police and Fire

Pulmonary hygiene, also referred to as pulmonary toilet, is a set of methods used to clear mucus and secretions from the airways. The word pulmonary refers to the lungs. The word toilet, related to the French toilette, refers to body care and hygiene; this root is used in words such as toiletry that also relate to cleansing.

<span class="mw-page-title-main">Mass casualty incident</span> Incident which results in medical care systems becoming overwhelmed

A mass casualty incident describes an incident in which emergency medical services resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties. For example, an incident where a two-person crew is responding to a motor vehicle collision with three severely injured people could be considered a mass casualty incident. The general public more commonly recognizes events such as building collapses, train and bus collisions, plane crashes, earthquakes and other large-scale emergencies as mass casualty incidents. Events such as the Oklahoma City bombing in 1995, the September 11 attacks in 2001, and the Boston Marathon bombing in 2013 are well-publicized examples of mass casualty incidents. The most common types of MCIs are generally caused by terrorism, mass-transportation accidents, fires or natural disasters. A multiple casualty incident is one in which there are multiple casualties. The key difference from a mass casualty incident is that in a multiple casualty incident the resources available are sufficient to manage the needs of the victims. The issue of resource availability is therefore critical to the understanding of these concepts. One crosses over from a multiple to a mass casualty incident when resources are exceeded and the systems are overwhelmed.

<span class="mw-page-title-main">Emergency Language Systems</span>

Emergency Language Systems is a Maryland S-Corporation in the business of publishing Emergency Medical Services (EMS) language translation field guides. Emergency Language Systems maintains copyrights and trademarks for a series of books called EMSpañol. The company's founders are Jeff Dean, NREMT-Paramedic and Miguel Castañares, NREMT-Basic.

<span class="mw-page-title-main">Trauma in children</span> Medical condition

Trauma in children, also known as pediatric trauma, refers to a traumatic injury that happens to an infant, child or adolescent. Because of anatomical and physiological differences between children and adults the care and management of this population differs.

A wilderness medical emergency is a medical emergency that takes place in a wilderness or remote setting affinitive care. Such an emergency can require specialized skills, treatment techniques, and knowledge in order to manage the patient for an extended period of time before and during evacuation.

Prehospital ultrasound is the specialized application of ultrasound by physicians and other emergency medical services (EMS) to guide immediate care and treatment procedures. Like conventional ultrasound, it is a device that produces cyclic sound pressure to penetrate a medium and reveal details about the inner structure of the medium.

RPM-30-2-Can Do is a mnemonic device for the criteria used in the START triage system, which is used to sort patients into categories at a mass casualty incident. The mnemonic is pronounced "R, P, M, thirty, two, can do."

The JumpSTART pediatric triage MCI triage tool is a variation of the simple triage and rapid treatment (START) triage system. Both systems are used to sort patients into categories at mass casualty incidents (MCIs). However, JumpSTART was designed specifically for triaging children in disaster settings. Though JumpSTART was developed for use in children from infancy to age 8, where age is not immediately obvious, it is used in any patient who appears to be a child.