Triage is the process of rapidly sorting and prioritizing victims in a mass casualty incident (MCI) or a high-volume emergency environment. The core purpose is to ensure that limited resources, such as medical personnel, supplies, and transport vehicles, are used in a way that provides the greatest good for the greatest number of people. This systematic approach is applied when the severity and quantity of patients rapidly overwhelm the ability of a local medical system to provide comprehensive and immediate care to everyone. Triage is not about providing extensive treatment but rather a quick assessment to assign a priority for treatment and transport. The initial assessment is a dynamic process where a patient’s priority can be changed if their condition improves or deteriorates.
Standardized Triage Systems
Effective triage relies on standardized, rapid systems that ensure consistency and speed across different first responders. These systems provide a framework for objective decision-making in a chaotic environment. The most widely used method for adults in the United States is the Simple Triage and Rapid Treatment (START) system, which was developed in 1983.
The primary goal of the START system is to assess each patient in under 60 seconds, which forces responders to quickly identify those with life-threatening conditions. This rapid assessment is typically performed at the initial scene of the incident to sort patients before they are moved to a designated collection point. The system uses three objective physiological observations—Respiration, Perfusion, and Mental Status—to determine the patient’s priority.
To ensure that children are assessed accurately, a modified system called JumpSTART exists for pediatric patients. Because children have different normal physiological ranges than adults, the criteria for JumpSTART are adjusted to reflect these differences, particularly in respiratory rate. Standardized systems like START and JumpSTART establish a uniform language and process, which is necessary for coordinating a multi-agency response.
The Step-by-Step Assessment Sequence
The core of the START system is the assessment sequence, often remembered by the acronym RPM, which stands for Respiration, Perfusion, and Mental Status. Before initiating the assessment, the first step is to instruct all victims who can walk to move to a designated safe area. These ambulatory patients are immediately categorized as having minor injuries, allowing the responder to focus on those unable to move.
Respiration (R)
The assessment begins with checking if the patient is breathing. If a patient is not breathing, the rescuer must quickly attempt to open the airway using a simple head-tilt or jaw-thrust maneuver. If breathing is restored, the patient is immediately tagged for immediate care, but if they remain apneic, they are classified as deceased.
If the patient is breathing spontaneously, the next check is the respiratory rate, looking for a rate greater than 30 breaths per minute. A rate exceeding this threshold is a sign of shock or respiratory distress and is an automatic indicator for immediate priority. If the respiratory rate is 30 or less, the assessment proceeds to the circulation check.
Perfusion (P)
Perfusion assesses the adequacy of circulation. This is done by checking the capillary refill time or the presence of a radial pulse. Capillary refill is measured by pressing on a nail bed until it blanches and timing how long it takes for the color to return.
If the capillary refill time is greater than two seconds, or if the radial pulse is absent, the patient is classified as needing immediate care. An absent radial pulse suggests inadequate blood pressure, while a prolonged capillary refill indicates poor tissue perfusion. If perfusion appears adequate, the rescuer moves to the final step.
Mental Status (M)
Mental Status determines the patient’s neurological function. This is done by asking the patient to follow a simple command, such as “Squeeze my hand” or “Open your eyes.” A patient who is unresponsive or unable to follow these basic directions is classified as immediate priority. If the patient successfully follows the command, they have passed all three RPM criteria.
Assigning Priority Categories
The outcome of the rapid RPM assessment determines which color-coded priority category the patient is assigned. This color designation dictates the order in which patients will receive medical attention and be transported for definitive care. The categories are designed to quickly communicate the urgency of the patient’s condition to other arriving responders.
The four priority categories are:
- Red (Immediate): Assigned to patients who fail any of the RPM criteria. Their injuries are life-threatening but treatable with quick intervention. These patients require immediate transport and are the first priority because they have a high chance of survival if treated without delay. Conditions that warrant a Red tag include a respiratory rate over 30, absent radial pulse, or an inability to follow simple commands.
- Yellow (Delayed): Assigned to patients who cannot walk but pass all three RPM criteria. These patients have serious injuries but are stable enough that treatment and transport can be delayed until all Red-tagged patients have been addressed. Their condition is not immediately life-threatening, but they still require hospital care.
- Green (Minor): Reserved for the walking wounded who were able to follow the initial instruction to move to a safe area. These patients have non-life-threatening injuries and are the lowest priority for transport from the scene. They are typically directed to a separate area to await further assessment and treatment.
- Black (Deceased/Expectant): Assigned to patients who are deceased or have injuries so severe that survival is unlikely given the limited resources available. This category includes patients who are not breathing even after the airway is opened. The decision to assign a Black tag is made to ensure that limited resources are focused on those with a higher probability of survival.