Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach (2024)

START triage system

This system is the most commonly used triage system in the United States. This system is also used in Canada and parts of Australia and the Israeli-occupied territories. It was created by the Newport Beach Fire Department and Hoag Hospital in California in 1980 [1]. In this system, all injured adults older than 8 years are evaluated, based on the algorithm of the system in 60 seconds or less (preferably 30 seconds). In this system, the criteria including the ability to walk, respiratory rate, capillary filling, radial pulse and obeying the commands are used. By examining each criterion, the patient will be marked by one of the red, yellow, green and black tags (Figure 1) [7].

Since the capillary filling criterion in the dark and cold environments in emergencies and disasters is not an appropriate reflection of the circulatory system, this criterion has been omitted in the modified model of the triage system (MSTART) (Figure 2). The only therapeutic measures allowed in this method are opening the airway of the patient and controlling the bleeding by direct pressure on the site of the bleeding.

Reverse Triage

Reverse triage is a method that is commonly used during emergencies and disasters. In reverse triage, injured people with fewer damages and minor injuries are at the priority of receiving services. This is also used in cases, where the treatment team or soldiers, during the war, are injured.

Moreover, this kind of triage system is used in the disaster and emergencies, where medical resources are limited, with the aim of returning people as quickly as possible and helping other people [3]. Reverse triage is also a way to increase the capacity of the emergency unit of the hospital during disasters. Accordingly, those patients with mild injuries and those supposed to be without any medical complications for at least 96 hours after discharge are at the top of the discharge list [8].

Military Triage

The main goal of the military triage is to treat and return more injured soldiers to the battlefield. In this method, immediate and rapid classification of the injured people is based on the type and severity of the injury, the probability of survival, as well as the priority of treatment in order to provide the best health care services for the largest number of people [1], [9], [10]. Most military triage systems use T (Treatment) codes including T1, T2, T3, T4 and dead to classify the injured individuals, while others use P (Priority) codes including P1, P2, P3 and P-hold [11].

MASS triage (Move, Assess, Sort, Send)

This system is a disaster triage system used in the United States. Although this system is based on the START triage system, it does classify the injured people before individual examination [1]. This includes four stages of moving, evaluating, classifying and transferring. This system, whose algorithm is very similar to the SALT triage method, has four tags: red, yellow, green and black (Figure 3). Allowed therapeutic measures in this model include opening the airway, controlling bleeding, Antidote injections and chest decompression. After performing the actions for this red group, then the yellow and green groups are considered, respectively [1], [12].

Sieve Triage

Similar to the START method, this method, which is used in parts of Europe, Australia, and the United Kingdom, first uses the walking filter to examine the injured individual, and uses four tags encompassing red, yellow, green and black tags to classify the injured patients (Figure 4) [13], [14], [15].

CESIRA Protocol

This method was designed in 1990. In this method, the injured people fall into three red, yellow and green classes. The red class includes people, who are unconscious and in shock, have bleeding, and ineffective breathing. The yellow class involves patients with fractures of the bones and other injuries, and the green class includes injured people, who can walk [1], [4].

Homebush Triage

This method was designed in 1999 in Australia, which attempts to integrate the triage protocols in that country [16]. This method is based on START and SAVE triage systems [17] and includes 5 classes of triage (Table 1). Although the application of this system was documented in 2002, there are no data on its accuracy and its impact on specific consequences like other triage systems [18].

Triage in special circ*mstances of the CBRN (Chemical, Biological, Radiological, Nuclear)

Although up to now, damages are often caused by explosion, collision or collapse of buildings in most disasters, there are also other probable scenarios, where damages are caused by chemical, biological, radiation, nuclear, and hazardous materials, which have occurred so far all over the world. It is very difficult to design a comprehensive triage system, which is easy to use and scientifically valid for all hazards. In some resources, it is recommended that, under certain circ*mstances such as incidents of weapons of mass destruction or hazardous materials, in case of occurring mass casualty incidents, a START-based triage algorithm, with a consideration of a series of special measures based on the type of the incident, such as decontamination, use of personal protective equipment and some special clinical considerations should be used. The SALT triage system is proposed with the aim of establishing a comprehensive method for the triage of injured patients at all hazards, but there is little evidence of its effectiveness in CBRN conditions [19].

CareFlight Triage

This method is a tool for rapid triage in mass casualty incidents, in which such criteria as walking ability, obeying the commands, palpable radial pulses, and airway respiration are evaluated (Figure 5). The injured people are placed in four urgent (red), emergency (yellow), delayed (green) and non-salvageable (black) classes.

The noteworthy point is that in this method the criterion of obeying the commands is examined before the evaluation of breathing and pulse rate. This method is one of the fastest triage methods, which takes only 15 seconds to test each patient [3], [14].

SALT triage (Sort, Assess, lifesaving intervention, Treatment/Transport)

This is one of the latest triage systems, which was introduced and registered by the CDC in 2008 as a national standard for mass casualty incidents. This process begins by categorising the patients into three groups based on simple voice commands.

The first includes the group of the injured people, who can walk to the area requested by the person performing the triage. The second group is the injured people, who only can shake their hands or feet, and the third group consists of the injured patients, who have no movement or show life-threatening conditions. This third group will be the first group of individual evaluations. The actions recommended in this kind of triage include airway opening, external bleeding control, Antidote injections for some poisonings, and needle thoracostomy for pneumothorax (Figure 6) [4], [7].

STM (Sacco Triage Method)

This method, which is designed based on a mathematical model and is a numerical triage method, considers the resources, based on time and facilities, in addition to the triage of the injured people. In this method, based on the physiological criteria including respiration, pulse and motor response, the injured people are scored, and by the acquired score, the probability of the survival of the injured person or his death is calculated. The first group of the injured people, with a score of 0-4, is tagged with a black label. The injured people of the second group, who have a score ranging from 5 to 8 are likely to survive through interventions. And the patients of the third group with a score of 9 to 12, have a survival probability rate of more than 90 per cent. After rating the injured people, their situation is announced to the incident command centre and subsequently, hospital resources are considered for the treatment (Figure 7) [3], [20], [21].

Burn Triage

In this method, which is used to prioritise injured persons in burn events, the classification of the injured people is based on the severity and level of the burn (Table 2) [22], [23].

META Triage

This method has 4 steps, in which the first and second steps are called Stabilization Triage, and the third and fourth steps are named Evacuation Triage.

In each step, certain actions must be performed according to the algorithm. In the first step, the injured people are placed on the red, yellow, and green classes according to the A, B, C, D and E criteria, and at the next step, the injured individuals are classified based on the evaluation of the surgery and injuries (Figure 8, and ​and9)9) [24].

MASS Gathering Triage

This method is a proposed triage tool for the Australian context in mass casualty incidents that can be used for first responders (Table 3) [25].

SWiFT Triage (Senior, Without, Families, Team)

This method is a triage tool for disadvantaged older adults during disasters designed to quickly identify the needs of this specific group [26]. This method is designed at three levels and at each level specific actions are taken as shown in Figure 10.

Medical Triage Protocol

In this protocol, the walking ability criterion is initially controlled, and those who can walk are classified in the green group. Then, other criteria such as the level of consciousness, arterial bleeding, shock, breathlessness, fractures and injuries of the head and spine, and ultimately pathologies such as myocardial infarction, poisoning, burns, hypothermia, and chest pain are checked and the patient is tagged as red or yellow according to the following algorithm (Figure 11) [27].

TEWS triage (Triage Early Warning Score)

This method of triage is a numerical 5- level method, which was designed according to the experts’ opinion for the injured people over 12 years of age and above the height of 150 centimetres (Figure 12).

The injured person is placed in one of the five classes of red, orange, yellow, green and blue by the final score (Table 4) [28], [29].

MPTT Triage (Modified Physiological Triage Tool)

The method has four tags including red, yellow, green and black, and the injured patients are assessed based on the ability to walk, respiration, pulse and GCS criteria (Figure 13) [2].

ASAV triage system

Smart Triage System

This method of triage is similar to the START triage system. In this system, it is highlighted that if it is not possible to examine the capillary filling criterion, the radial pulse should be controlled. The injured people are also classified into four categories: red, yellow, green, and black according to the algorithm that sown in Figure 15 [31].

Tactical Triage

In this method of triage, the injured individuals are placed into four classes of green, red, yellow and black (Figure 16). The green group consists of patients, who can walk or have mild damages. The delayed or yellow group includes those patients, who may need surgery, but their general condition allows them to receive any medical or surgical operation with delay and without threatening their life. The immediate or red group includes people, who need immediate medical intervention, including rescue and surgical procedures. The key to the success of the triage is the rapid identification of people with a red tag [32].

Children’s triage systems

The Jump START triage system

This technique was designed by Dr Romig in 1995 as a tool for the triage of the children under the age of 8, and in 2001, some modifications were made to it, based on the principles of the START triage system [33]. These changes were based on three main differences between adults and children, namely the higher probability of the respiratory failure in children than adults, the number of different breath rates in children, and the inability of the young children to follow verbal commands. In this system, the AVPU was used to assess the level of the children’s consciousness, instead of the obeying the commands criterion used in the START triage system (Figure 17) [21].

PTT triage system (Pediatric Triage Tape)

There are three guidelines for this method, based on the height and weight of the infants and children. The first instruction is for the babies with a height of 50 to 80 cm (weighing 3 to 10 kg) (Figure 18). If the child cries and moves his body purposefully, he will be placed in the third priority (delayed). It is necessary to open the baby’s airway, in case he does not cry, move and breathe, and if respiration starts after this action, he will be placed at the priority (emergency). Otherwise he would be placed at the last priority (dead). In this guideline, the normal ranges of breathing and pulse are between 20-50 and 90-180 times per minute, respectively. By examining these criteria, the baby is placed in either red, yellow, green or black classes.

The second guideline of the PTT triage in a baby with a height of 80 to 100 centimetres and a weight of 11 to 18 kilograms is similar to the first instruction. At this stage, the normal range of respiration and heart rate of the child is 15 to 40 and 80 to 160 times per minute, respectively. In the third instruction, the triage of the child with 100 to 140 cm height (19 to 32 kg weight) is similar to the previous steps. At this stage, the normal number of respiration and pulse rate is 10 to 30 and 70 to 140 times per minute, respectively. In these two stages, it is also necessary to press the child’s forehead with a finger to control the capillary filling status [4], [11], [34].

Secondary triage systems

In cases, where the number of the injured people is high, and it is not possible to transfer all the patients to medical centres or hospitals or because of the large extent of the incident and lack of resources in the pre-hospital, the process of transferring all patients from the scene would be prolonged, it is probable that a group of the injured people remains at the disaster scene for a long time. Secondary triage systems are used in these cases as well as at the arrival of the injured patients to the emergency unit of the hospital. The two methods of secondary triage include the SAVE and the Sort triage systems [1].

SAVE Triage

The SAVE method (Secondary Assessment Victim Endpoint) is used to diagnose the patients, who take the most out of the existing care services.

To determine the survival chances and patient classifications, predictive tools of the patient clinical conditions such as limb rescue score, Glasgow Coma Scale (GCS), and survival rate data after burns are used (Table 5, and ​and6).6). The injured people, who cannot survive and cannot be treated at the disaster scene, but can be saved if they reach the hospital, will be tagged with a red label. Those patients, who take the most from the available therapeutic interventions, are marked with a yellow tag. Those injured individuals, who can survive even without medical intervention, are tagged with green labels, and finally, the deceased people are labelled with black colour [1].

Sort Triage

This method, which is a kind of secondary triage, has four stages and a numerical system (Figure 19). In this method of triage, patients are tagged according to the score obtained. If the number is 10 or less, the injured individual is placed at the red class, and if the number is equal to 11, he will be placed in the yellow class. A patient with 12 scores will be categorised in the green class [15].

Hospital Triage

The aim of the hospital triage in the emergency department is to place patients in a suitable clinical setting at the right time to receive the appropriate level of health care. There are two, three, four, and five level systems for hospital triage proposed in the world, among which five-level systems including Manchester Triage System (MTS), Canadian Triage and Acuity Scale (CTAS), Australia Triage System (ATS), and and Emergency Severity Index (ESI) have currently shown more validity and reliability scores according to the findings of the previous research [35]. All hospitals should design and develop a program for hospital triage in disaster situations and mass casualty incidents as part of the hospital emergency plan [36].

CRAMS Triage

Circulation, Respiration, Abdominal and Thorax Exam, Motor Response, Speech

This numerical method of triage, as a part of the hospital triage models, is used in some European and American countries (Figure 20). In this method, each criterion is scored from 0 to 2 points. Then, based on the score obtained, the patient with a score of less than 6 will be placed at the immediate class. An injured patient with a score of 7 is placed in the emergency class, and with a score of 8 to 10, he would be categorised in the delayed class [37].

Emergency Severity Index (ESI) Triage

The system was designed in late 1990 in the United States by two emergency medical experts named Richard Weurz and David Eitel [38], [39]. This system, not only determines which patient should be checked first but also indicates which levels of facilities and resources are needed to meet the patient’s needs (Figure 21).

The fourth version of the Emergency Severity Index had some modifications and was adopted by the Ministry of Health of Iran as the standard and acceptable method of triage in the emergency department [35]. This system is a useful tool, that can be used in all urban and rural emergency units and general and academic hospitals [38], [39], [40].

Components and approaches of Triage models

According to the results, there are two main numerical and algorithmic approaches for triage in the world. In the algorithmic approach, the injured person is placed in a particular class through examining and controlling each criterion and, if that criterion is normal, the next criterion will be evaluated. But in the numerical approach, the person performing the triage must first control and evaluate all the criteria in the model. Then, based on the score of each criterion, the final score of the injured person condition, which is based on the total score of all the criteria in the model, is specified. According to the final score, the injured individual is placed in one of the triage classes, which are marked with a specific tag. As indicated in this study, each model of triage consists of several criteria and components. Various ranges are considered for similar criteria of different models of triage. Nevertheless the variety of these criteria is also quite obvious, and even in some of these triage models, the same criteria have different prioritisation. For example, although there are similar criteria in the START and CareFlight models, in the former, unlike START, the criterion of the ability to obey the commands is evaluated before the controlling of the airway and respiratory tract. The following table shows the comparative characteristics of the triage systems in terms of the relevant criteria, their priority and the general approach of the model (Table 7).

Funding: This research did not receive any financial support

Competing Interests: The authors have declared that no competing interests exist

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