The Simple Triage and Rapid Treatment (START) system is a standardized method used by first responders to quickly classify victims during a mass casualty incident (MCI). Developed in California in the 1980s, START provides a systematic way to sort patients based on injury severity. The primary goal is to rapidly assess a large number of victims to determine the urgency of their need for medical care. This initial classification maximizes the number of survivors by prioritizing resources effectively at the scene. The START system focuses solely on rapid categorization to guide subsequent rescue and transport efforts, not definitive medical treatment.
Why Rapid Triage is Necessary
A Mass Casualty Incident (MCI) is any event that results in more casualties than can be handled by the normal resources of a local emergency medical system. In these chaotic scenarios, focusing on the most severely injured person first would quickly deplete limited medical supplies and personnel. This requires shifting the philosophy from delivering the highest level of care to a single individual toward providing the greatest good for the greatest number of people.
The START system addresses this resource mismatch by creating a fast, objective framework for decision-making. The method ensures that patients with life-threatening but salvageable injuries are identified and prioritized immediately. It also quickly identifies those with minor injuries who can wait and those whose injuries are so severe that immediate resources would be ineffective. The initial assessment for each victim takes thirty seconds or less, allowing first responders to bring order to a scene quickly.
The Three Key Assessment Steps (RPM)
The START system relies on three physiological parameters, collectively known by the mnemonic RPM: Respiration, Perfusion, and Mental Status. This sequential assessment is applied to all non-ambulatory victims after the initial instruction for the “walking wounded” to move to a designated area. Failure at any step immediately results in an “Immediate” (Red) categorization, allowing the responder to move quickly to the next victim.
Respiration (R)
The first check is for Respiration (R), beginning with whether the victim is breathing. If a victim is not breathing, the responder performs a simple airway repositioning maneuver. If breathing does not resume, the victim is tagged Deceased (Black). If breathing starts, the victim is tagged Immediate (Red). If the victim is breathing spontaneously, the responder checks the respiratory rate. If the rate is greater than 30 breaths per minute, the victim is immediately tagged Immediate (Red).
Perfusion (P)
If the respiratory rate is 30 or less, the assessment moves to Perfusion (P), which evaluates circulatory status. This is assessed by checking the capillary refill time (CRT) by pressing on the nail bed. If the color returns in more than two seconds, or if a radial pulse is absent, the victim is tagged Immediate (Red). The two-second threshold indicates inadequate blood circulation, a sign of shock.
Mental Status (M)
Finally, if the victim passes both the respiration and perfusion checks, the responder assesses the Mental Status (M). This is determined by the victim’s ability to follow simple commands, which is often remembered as the “Can Do” portion. If the victim is unable to follow a simple command, they are tagged Immediate (Red). Only victims who pass all three physiological checks—respiration under 30, capillary refill under two seconds, and ability to follow commands—are designated as Delayed (Yellow).
Meaning of the Triage Color Codes
The START system uses four color codes to communicate the priority level for ongoing care and transport. These designations dictate the order in which victims will receive resources and be moved to a medical facility. The classification system is designed to provide a clear, visual indicator of the patient’s status for all arriving personnel.
Immediate (Red)
The Immediate (Red) tag signifies that the victim has life-threatening injuries but a high probability of survival if treated without delay. These patients failed at least one of the RPM checks, indicating a compromise in breathing, circulation, or neurological function. Red-tagged victims receive the highest priority for medical treatment and transport.
Delayed (Yellow)
The Delayed (Yellow) tag is assigned to victims whose condition is serious but stable. These individuals passed all the physiological thresholds and are not in immediate danger of death. Their treatment can be postponed until all Immediate (Red) victims have been addressed.
Minor (Green)
The Minor (Green) tag is given to the “walking wounded”—those who were able to follow the initial instruction to move to a safe area. They generally have minor injuries and will be the last priority for evacuation.
Deceased (Black)
The Deceased (Black) tag is reserved for victims who are unresponsive and not breathing, even after an attempt to open the airway. This designation indicates that the victim’s injuries are incompatible with life given the constraints of the mass casualty environment. These individuals are not transported until all other victims have been evacuated.