Triage is a process used at multiple patient incidents to:

The intent is to "do the most good for the greatest number." Triage should be initiated at those incidents where the number of patients and/or the severity of their injuries exceeds the capabilities of the on scene personnel to provide effective extrication, treatment and transportation. A single person, or a two-person "triage team" can perform triage.

The use of triage tags are dependent on resources available and at the discretion of the incident commander. Because of these factors, a definitive number of patients to initiate the system is difficult to determine. The decision to triage and to use the triage fanny pack carried on all EMS companies should be made as early as possible by the first arriving company officer.

Some incidents may require patients to be extricated from the scene to the treatment area before triage has been performed. This may be due to safety considerations, such as a building collapse or hazardous materials release, or due to the nature of the incident, such as a bus collision or train wreck. Under these circumstances, the triage team performs triage under the direction of the Triage Officer at the entrance to the treatment area.

Regardless of where it is conducted, triage will be performed using "S.T.A.R.T." or "Simple Triage and Rapid Treatment." This is a nationally approved triage technique to quickly categorize patients as IMMEDIATE, DELAYED, MINOR or DEAD/DYING. Using S.T.A.R.T., a triager can assess an average of one patient every 30 seconds. (Note:Pediatric patients should referred to as "Peds," not Minor patients.)

 

Figure 1--THE S.T.A.R.T. ALGORITHM*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


ACTION Tagged as...

Using S.T.A.R.T.

In a large incident, a triager first directs those victims who are able to get up and move to a specific holding area. This allows the "walking wounded" to remove themselves from the scene and quickly reduces scene congestion. These folks are later tagged "MINOR" by the Extrication Sector Officer.

Once the walking wounded have been directed from the scene, the triager begins assessment of the victims who cannot move. Approach any patient and begin triage.

Utilizing S.T.A.R.T., the triager evaluates a patient using "RPM" to assess the respirations, pulse and mental status of each patient (see Figure 1). If a patient is found with no respirations, the airway should be opened and cleared of debris. An oropharngeal airway (OPA) should be inserted. If breathing does not resume, the victim should be tagged DEAD/DYING. The triager moves to the next patient.

If patient begins to breathe once the airway is opened, the patient is categorized as "IMMEDIATE." The triager should use whatever material is at hand to secure the airway or instruct a non-injured bystander to immobilize the patient’s airway.

If a patient is conscious and breathing, then their Respirations are counted. If respirations are over 30 per minute, the patient is tagged "IMMEDIATE." No further assessment is done.

If the patient’s respiratory rate is less than 30 per minute, then the Pulse is checked. If there is no radial pulse, the systolic blood pressure of this person has dropped below 80. This patient is in shock and should be tagged "IMMEDIATE." If the triager finds any signs of external bleeding he/she should direct a bystander to apply direct pressure to control the bleeding. The patient can also be placed in a supine position with the legs elevated.

If a patient is conscious, their airway is open, their respirations are under 30, and they have a radial pulse, then the triager should check their Mental Status. Ask a few simple questions. If the patient appears confused or cannot answer simple commands, they may have a serious head injury. They are tagged "IMMEDIATE."

Any patient found with an intact "RPM" (respirations less than 30 times a minute, radial pulse present, mental status intact) should be tagged DELAYED. The DELAYED category doesn’t mean the patient is not injured. It means that their injuries are not immediately life threatening. These people need medical attention, but can wait until those patients with life-threatening injuries are treated and transported.

Using the S.T.A.R.T. criteria, the only treatment rendered to a patient by the triage team during the triage phase is to:

There are two additional considerations when triaging patients. First, once all IMMEDIATE patients have been treated and transported, DELAYED patients should be reassessed and upgraded, especially if their mechanism of injury warrants transport to a appropriate trauma center. For example, a patient found with a serious mechanism of injury, but whose "RPM" is intact, will initially be tagged DELAYED. As resources become available, these DELAYED patients can be upgraded to "IMMEDIATE-by-Mechanism" and transported to an operate trauma center.

Second, at incidents with fewer than ten patients, do not ask the walking wounded to self extricate themselves from the scene. Patients without apparent injuries can initially be tagged MINOR, but should not be asked to walk to a treatment area as this may aggravate any existing injuries.

The goal during triage is to find, treat and transport patients, beginning with those tagged as IMMEDIATE. Don’t get distracted by screaming victims or grotesque injuries. Stay focused and move quickly.

TRIAGE SYSTEM

The core of the Triage System consists of a triage fanny pack containing:

Using this system, the triager first evaluates a patient using the S.T.A.R.T. method. Then, he/she bends and tears off the bottom of the tag to expose the patient’s category (IMMEDIATE, DELAYED, MINOR or DEAD/DYING). Then the triager removes one of the tracking slips located on the side panel of the tag. This is placed in the front pocket of the triage fanny pack.

The triage tag is fastened to the patient’s wrist with a nylon zip tie. Be careful not to over tighten the zip tie as this will cut off circulation to the extremity. (If both arms are injured, attach the tag to the patient’s ankle.) If the patient is tagged "IMMEDIATE," an IMMEDIATE label is also placed on or near the patient to increase their visibility to arriving EMS crews. Finally, the tracking slips are given to the Triage Officer, who will then prepare a "Triage Report" to be radioed to Alarm

TRIAGE TAG DOCUMENTATION AND EMS INCIDENT REPORTING

At most multiple patient incidents involving less than 10 patients, completing a standard EMS incident report while on scene will cause unnecessary delays in the transport of IMMEDIATE and DELAYED patients. Under these circumstances, treatment teams can use the triage tag to initially record patient information; it is a good "mini" EMS form. Later, transport crews can relay the information from the tag on to a standard EMS incident report once they arrive at the hospital. (Note: There is usually enough time on scene to document MINOR and DEAD/DYING patients using a standard EMS form.)

Mass casualty incidents will over tax any EMS agency. In the setting of a large number of patients, it may be appropriate to use triage tags in lieu of standard EMS incident reporting. In this setting, the triage tag will be the only form of EMS documentation. This decision will be made my Command and communicated to all crews. Specifically specifically assigned “Documentation Teams” can conduct formal patient documentation after the incident at the hospitals. Patient triage tags can be used to collect data for proper documentation.

The most critical patient information is located on the front of the tag. This includes patient age, sex, major injuries, transport unit and hospital. (This is also the most essential information, along with an ETA, to relay to a trauma center when performing a Courtesy Notification.) Other information such as age, address, medical history, vital signs, physical findings and treatment rendered, can be completed on the back of the tag as time permits.

THE DYING PATIENT

There is a fine line between the obviously mortally injured (dying) patient and a seriously injured patient who may survive if ALS treatment is rendered. If the medical incident involved only a single patient who appears mortally injured, enough trained manpower and equipment is available to totally commit crews to that patient. However, as the number of IMMEDIATE patients increases, personnel and equipment become extremely limited.

Under these circumstances, mortally injured patients may need to be tagged DEAD/DYING, with no treatment administered, while available resources concentrate on treating viable IMMEDIATE patients. In any case, the blunt force trauma code patient should always be tagged DEAD/DYING. Research has shown their survivability is zero.