22

DISASTER TRIAGE
Lou E. Romig and E. Brooke Lerner

LEARNING OBJECTIVES

When this chapter is completed, readers will be able to:

1. Define triage.
2. Describe the differences between daily hospital triage, multiple or mass casualty incident (MCI)/
disaster triage, and population-based triage.
3. Understand the situations in which each model of disaster triage is used.
4. Discuss how objective disaster triage tools are beneficial not only to the victims themselves but also
to those tasked with performing triage.
5. Explain the criteria for each of the five basic primary disaster triage levels.
6. Discuss the differences between primary, secondary, and tertiary disaster triage.
7. Discuss the special situations presented during population-based triage.
8. Differentiate disaster triage tools and identify the tool used in your community/agency.
9. Identify the five key elements of triage tools.
10. Discuss how the presence of contaminated patients affects triage in the field and at the hospital.

KEY MESSAGES

Accurate triage provides responders with the opportunity to do the greatest good for the greatest
number of casualties (with the least amount of harm), and is the cornerstone of good disaster
medical resource management.
Disaster triage is employed when the types and/or amounts of available medical resources are
inadequate to provide immediate comprehensive care to all victims.
Performing triage under disaster conditions requires a paradigm shift on the part of disaster
response nurses and other first responders: The focus turns from doing the best for each patient to
optimizing the outcome for all victims as a group, even if that means withholding resources from
the most critically ill or injured patients.
Disaster triage is a dynamic process, with opportunities to retriage patients with each assessment and
as additional resources become available.
Different models are available for disaster/mass casualty triage. Unfortunately, no primary disaster
triage tool has been empirically validated in a prospective manner. However, a set of minimum

381
382 IV  Disaster Response

core criteria that should be included in a triage system has been identified (Lerner, Cone, et al.,
2011), and the Federal Interagency Committee on Emergency Medical Services (FICEMS) has
started the implementation process for these criteria nationally (FICEMS, 2013). Nurses must be
aware of the disaster triage tools and systems used by their local EMS system and hospital, as well
as when it is appropriate to use them.
Primary triage is based on a rapid initial assessment and places patients into broad categories that
prioritize them for treatment and/or transport.
Special circumstances may require unique triage procedures, including incidents involving hazardous
materials (in which triage is severely limited until patients have been decontaminated) and
community-wide events (in which population-based triage must focus on preventing further spread
of the disease or risk of harm).

There is a good chance that at least some of the healthcare

CHAPTER OVERVIEW providers called upon to perform the critical function of disaster
triage will have never had the opportunity to perform the task
The United Nations defines a disaster as “a serious disrup- in anything but a drill setting. Often with very little notice,
tion of the functioning of a community or a society at any providers must decide which patients need care, where they
scale due to hazardous events interacting with conditions of should receive it, in what order they should receive care, and,
exposure, vulnerability and capacity, leading to one or more in situations of severely constrained resources, who should
of the following: human, material, economic and environ- receive only palliative care or no care at all. In addition, some
mental losses and impacts” (United Nations International events, such as industrial incidents and intentional attacks in-
Strategy for Disaster Reduction, 2017). The emphasis on volving chemical, biological, radiological, or nuclear agents,
the (in)ability to cope with an incident using only native may require an alteration in the triage process due to the need
resources applies to many aspects of disaster preparedness to mitigate further injury by decontaminating patients before
and response but is particularly pertinent to a community’s medical care can safely be provided.
ability to respond to the acute medical needs generated by
a disaster. When the ability to meet the demand for medical
care is compromised by a lack of personnel, equipment, and
supplies, special measures must be taken to ensure that the
available medical resources are used in the most efficient, BASIC PRINCIPLES OF DISASTER TRIAGE
effective, responsible, and ethical manner possible. This
process is called “triage,” a familiar term to most urgent and “Triage is a process which places the right patient in the right place
acute medical care providers; however, “disaster triage” is at the right time to receive the right level of care” (Rice & Abel,
different in practice and principle from the triage performed 1992). The word “triage” is derived from the French word trier,
on a daily basis. which means, “to sort out or choose.” The Baron ­Dominique Jean
Emergency triage, whether done in the field by EMS providers Larrey, Napoleon’s chief surgeon, is credited with organizing the
or in hospital emergency departments (EDs) and alternative first triage system (Robertson-Steele, 2006). The U.S. military
care centers, is a difficult and sometimes inconsistent process first used triage to describe a sorting station where injured soldiers
even on an average day. When disaster strikes and overwhelms were distributed from the battlefield to distant support hospitals.
the available medical resources, triage becomes, at the same Following World War II, triage came to mean the process used
time, more important and more difficult. Unlike everyday triage, to identify those most likely to return to the battle after medical
where the choices affect primarily time to care, disaster triage intervention. This process facilitated the provision of expeditious
is used to decide who will get the resources that are available medical care to soldiers who could fight again. During the Korean
and who will not. These choices are made to do the greatest and Vietnam conflicts, triage was further refined to resemble the
good for the greatest number of people. process that is still used today in both military and civilian arenas.
This chapter presents the fundamental concepts of disaster Triage is the process of prioritizing which patients are to be
triage. Triage is the first medical action in any response for treated first and is the cornerstone of good disaster management
multiple or massive numbers of casualties. Decisions made in terms of judicious use of medical resources (Auf der Heide,
during the triage process may have a significant impact not 2000). Accurate triage allows disaster nurses and other responders
only on the individual victims, but also on the health outcomes to do the greatest good for the greatest number of afflicted. Al-
of the entire affected population. Disaster triage is a difficult though the fundamentals of triage remain consistent wherever it
and intimidating task because it requires making rapid deci- is conducted, performing triage during a disaster presents unique
sions in an often chaotic environment using minimal data, and challenges. Its overall success may be highly dependent on the
places the job of making life-or-death decisions squarely on competence, experience, and composure of the nurse, working
the shoulders of those performing triage. in close concert with the rest of the emergency care team.
 22  Disaster Triage 383

Disaster triage will always be a difficult and daunting task. overwhelm a much smaller system, requiring resources to
Previous triage experience in an ED is excellent preparation for be given to those most likely to survive while those who are
disaster triage. Burkle (1984) identified a variety of personal abilities unlikely to survive might have to wait to receive resources
that are essential to be an effective triage officer during a disaster: because there are not enough for everyone.

■■ Clinically experienced In true disaster triage, there is a paradigm shift in fundamental

■■ Good judgment and leadership triage philosophy from “do the best for each patient, regardless
■■ Calm and cool under stress of what it takes” to “do the greatest good for the greatest num-
■■ Decisive ber” (Auf der Heide, 2000). Resource management becomes
■■ Knowledgeable of available resources the linchpin driving the provision of care. The goal of triage
■■ Sense of humor shifts to identifying and prioritizing injured or ill patients who
■■ Creative problem solver have a good chance of survival with immediate interventions
■■ Available that do not consume extraordinary resources (Auf der Heide,
■■ Experienced and knowledgeable regarding anticipated 2000). During a disaster, patients are usually sorted into one
casualties of the following categories (Lerner, Cone, et al., 2011):

To understand the subtle differences between the philoso- ■■ Minimal or minor (designated with the color green): These
phies of different types of acute medical triage, it is important are patients who are physiologically well compensated and
to know the most common terminology (Cone & MacMillan, likely to remain so for an extended period of time. These
2005; Hogan & Lairet, 2002): patients require only basic immediate care and can probably
wait for a considerable period of time for definitive care with
■■ Daily triage is performed by nurses on a routine basis in the minimal risk of deterioration. Examples of minimal casualties
ED, often utilizing a standardized approach, augmented by might be those with minor lacerations, burns, or other soft
clinical judgment. The goal is to identify the sickest patients tissue or orthopedic injuries without significant bleeding or
to assess and treat them first, before providing treatment to neurovascular compromise. Victims with mild to moderate
others who are less ill and whose outcome is unlikely to be psychological stress reactions related to the incident can also
affected by a longer wait. The highest intensity of care is often be triaged in the minimal category. In the event that
provided to the most seriously ill or injured patients, even hospital resources are overwhelmed, community emergency
if those patients have a low probability of survival. management plans might call for minimal-category patients
■■ Incident triage occurs when the ED is stressed by a large to be directed to predesignated alternate care sites such as
number of patients due to an acute incident or an ongoing community clinics and urgent care centers.
medical crisis such as pandemic influenza, but is still able ■■ Delayed (designated with the color yellow): These are patients
to provide care to all patients utilizing existing agency re- with compensated physiology but a significant potential for
sources. Additional resources (on-call staff, alternative care deterioration or morbidity if there are long delays before
areas) may be used, but disaster plans are not activated and definitive care can be provided. If sufficient resources are
treatment priorities are not changed. The highest intensity available, many of these patients can be temporarily treated
of care is still provided to the most critically ill patients. ED and stabilized in the field. Examples include physiologically
delays may be longer than usual, but eventually everyone stable patients with possible spine or head injuries without
who presents for care is attended to. acute neurological deficits, significant bleeding controlled
■■ Disaster triage is a general term employed when local EMS with pressure dressings or tourniquets, and orthopedic inju-
and hospital emergency services are overwhelmed to the ries with signs of neurovascular compromise that improve
point that immediate care cannot be provided to everyone after basic splinting.
who needs it because sufficient resources are not immediately ■■ Immediate (designated with the color red): These are pa-
available. The terms “multiple casualty/multicasualty” and tients with uncompensated physiology and injuries that are
“mass ­casualty” triage (both also known as “MCI triage”) life-threatening but probably amenable to rapid interventions
are often used ­interchangeably with “disaster triage.” The that do not require consumption of an inordinate amount
distinction between “multiple” and “mass” casualties is of resources. These patients may die or sustain significant
principally in the number of victims and the degree of morbidity unless they receive rapid care in both the field
restriction of resources. There is no standardized threshold and the hospital. Examples include patients with poorly
beyond which a multiple casualty incident becomes an MCI. controlled external bleeding, moderate burns, or penetrating
Similarly, there is little consistency in number of patients that trauma without other critical injuries, altered mental status,
demand changing from everyday triage to true MCI triage early shock, and respiratory distress (but not failure). These
because it is the capability of a system to respond that is are the patients who, in general, should be transported first
more important than absolute patient numbers. For example, from the scene.
a bus crash with 15 to 20 victims might be called an MCI in ■■ Deceased (designated with the color black): These patients
a large EMS/healthcare system and MCI triage tools might are those with no detectable vital signs, typically identified
be used, but all victims except those with injuries that are as victims not breathing on their own. In everyday practice
clearly incompatible with life will still be treated using all settings, we would attempt resuscitation if there are no
the normal resources of that system. The same crash might signs of obvious death, but in a disaster situation we simply
384 IV  Disaster Response

designate the victim as dead, since the resources required and decontaminate victims often adds significantly to delays in
to revive a person in cardiac arrest are not available or are triage and treatment. These delays may result in the d­ eterioration
available but would be put to more effective use to attempt of patients who might have been less seriously affected if more
to save a greater number of other patients who have better rapid care had been possible.
chances of survival. Patients in the deceased category include Population-based triage: The predominant disaster triage
those who are not breathing even after performing simple models taught in the United States are based on mass casualty
airway-opening maneuvers. scenarios that unfold in a single location at a single point in time.
■■ Expectant (designated with the color gray): These patients Emerging infectious diseases such as severe acute respiratory
are those who are still alive but due to their injuries and/or syndrome (SARS) and avian influenza, as well as the threat
medical condition are unlikely to survive given the available of bioterrorist events such as the deliberate dissemination of
resources. In everyday practice settings, providers would anthrax in 2001, serve to highlight the inadequacies of disaster
attempt to treat these patients even though their most triage systems for widespread, community-based events. SARS
likely outcome would ultimately be death. In a disaster, is a severe respiratory illness that is caused by a coronavirus
these patients would be assigned to wait for treatment and is transmitted especially by contact with infectious material
until sufficient resources were available. To do the greatest (e.g., respiratory droplets or body fluids) and is characterized
good for the greatest number of people, the resources that by fever, headache, body aches, a dry cough, hypoxia, and
would have been consumed by these patients are used to usually pneumonia. Other examples of events that might
treat other patients who have a better chance of survival. lead to large numbers of people who need assistance across a
Patients in the expectant category might include those with wide geographical area are natural disasters such as floods or
agonal respirations, massive head injuries, dismemberment, hurricanes. It is important to note that regardless of the cause
extensive burns, crush injuries, critical penetrating trauma, (man-made or natural), these events are managed medically
or multiple life-threatening injuries. In a mass radiation in a similar fashion. Everyone in the population requires some
exposure event, patients with vomiting/diarrhea soon after intervention, ranging from timely and accurate medical infor-
exposure may be classified as expectant, as early gastrointes- mation to vaccination and/or prophylaxis.
tinal (GI) symptoms and signs are signals of lethal radiation The main goal of population-based triage is to prevent
poisoning. In a mass exposure to organophosphates/nerve secondary illness or injury such as disease transmission from
agents, patients with seizures soon after exposure may infectious individuals or foodborne illness from contaminated
also be classified as expectant, as they are a sign of likely or poorly refrigerated supplies. The messages and directions
lethal exposure. Patients designated as expectant should be sent during population-based triage will depend on the type(s)
reevaluated regularly. Once there are sufficient resources, of illness or injury that is trying to be contained. Depending
these patients may be treated, provided with comfort care, on the severity, lethality, and/or transmissibility of the illness
or declared dead if there are no longer any signs of life. or injury being prevented, these events can be very serious and
have a huge impact on a community.
It will never be easy to withhold care from a disaster victim Infectious disease containment strategies, such as social
who still has signs of life. It goes against our instincts and distancing, sheltering-in-place, isolation, and quarantine, are
common practice. The need to recognize and accept futility the first line of management under state public health law. In
becomes even harder when faced with a victim who is a child this model, everyone in the population falls into one of five
or sparks an unusually strong compassionate urge in responders population-based triage categories (SEIRV classifications),
(e.g., a fellow responder). It is possible that having an objective each requiring both generic and disease-specific interventions:
triage tool that dictates that patients meeting certain criteria
be tagged as Deceased or Expectant may help protect triage ■■ Susceptible individuals—those individuals who are unex-
officers from some of the emotional trauma inherent in the posed but susceptible.
role because it is the tool that dictates the decision, not the ■■ Exposed individuals—susceptible individuals who have
responder himself or herself. been in contact with the disease and may be infected and
Special conditions during triage: Incidents involving incubating but still noncontagious.
chemical, biological, or radioactive agents may be intentional ■■ Infectious individuals—persons who are symptomatic and
or unintentional (e.g., a truck crash involving the release of contagious.
hazardous materials). These triage situations require personal ■■ Removed individuals—persons who no longer can pass the
protective equipment for all responders coming into contact disease to others because they have survived and developed
with potentially contaminated patients and decontamina- immunity or died from the illness.
tion capabilities both in the field and at receiving facilities ■■ Vaccinated or on prophylactic antibiotics—persons in this
(­Hogan & Lairet, 2002). During any disaster, triage personnel group are a critical resource for the essential workforce.
must ensure that they themselves do not become victims. One
enters the scene for field triage only when scene safety has In such a situation, many people are being triaged simul-
been assured (see Chapter 35 “Decontamination and Personal taneously at multiple sites—triage and information centers,
Protective Equipment,” Mass Casualty Decontamination, for vaccination and/or other clinics, EDs, and hospitals. Triage
further ­information). Triage during special conditions does not nurses have a vital role in this process (whether triage is per-
change the sorting process so much as the circumstances in formed face-to-face or over telephone or Internet “hotlines”),
which it must be performed. The need to protect responders classifying citizens and assigning them to levels and locations
 22  Disaster Triage 385

of care based on disease susceptibility, vulnerability, comorbid critical triage category) at any time in the ongoing assessment
conditions, symptoms, infectiousness, and/or exposure. For process. Likewise, a patient who becomes more stable during
example, in 2003, the Toronto Health System utilized their treatment in the field or hospital may be downgraded, although
1-800-telehealth hotline to disseminate pertinent information to some authors disagree, stating that a patient should never be
the public through both recordings and live phone triage. Phone down-triaged (Hogan & Lairet, 2002). It is also important to
triage nurses fielded over 28,000 calls during the SARS outbreak recognize that errors may be made in the triage process and
and served as a major triage element, making triage decisions that reassessment provides the opportunity to correct any errors.
prevented further mixing of patients and preventing unnecessary A second patient assessment (“secondary triage”) may be
secondary cases (Svoboda et al., 2004). In an epidemic, those performed on-scene if transport is delayed for any reason or
who are susceptible may be triaged to a vaccination area; those at the hospital itself. In secondary triage, additional informa-
who are ill may be triaged to an acute care facility, an alternate tion about each patient is obtained through a more thorough
care facility, or to remain at home. Those who are ill may also physical assessment and history (when available). This is
be triaged to isolation, whereas those who are exposed but not similar to the traditional trauma secondary survey, in which
yet ill may need to be triaged to quarantine. physiology is reassessed and obvious injuries are identified.
Population-based triage is in the early stages of develop- When secondary triage is done in the field, one of the goals
ment; there are currently no nationally accepted schemes. It is is to determine which patients have conditions that can be
a concept that has only recently begun to be described and it is temporarily but effectively treated on-scene using available
possible that, because there is such a wide spectrum of commu- personnel and resources (e.g., initial IV fluid resuscitation)
nicability, virulence, and available treatment for diseases that and identify those whose immediate needs can be met only in
could rise to epidemic proportions, no single triage algorithm a hospital setting (e.g., uncontrollable bleeding or other need
can be developed. However, it is essential that the triage nurse for immediate surgical intervention). In this way, patients
be prepared to utilize an event-specific triage algorithm when within the same triage category can be prioritized for transport
triaging during a population-based event. If such a situation when limited transport resources are available. For example,
were to occur, the algorithm to be used will likely be issued delayed patients requiring timely hospital-based interventions
by state or territorial Departments of Health in concert with will be transported before other delayed patients who can be
the U.S. Centers for Disease Control and Prevention (CDC). temporarily treated in the field. There is no uniformly adopted
tool used in the United States for secondary triage. Some
EMS agencies use their local trauma triage protocols or no
PHASES OF DISASTER TRIAGE: FROM THE standardized system at all. Other agencies use the Secondary
FIELD TO THE HOSPITAL Assessment of Victim Endpoint (SAVE) tool developed for
use after earthquakes in California. SAVE combines standard
Prehospital care providers are trained and well practiced trauma assessment techniques and a dynamic assessment of
in triaging individual injured or ill patients to appropriate available resources to prioritize patients during prolonged
hospitals based on their needs for specialized care. Most delays to definitive care caused by severe resource constraints
EMS personnel have also been trained in disaster/MCI triage, (Benson, Koenig, & Schultz, 1996).
although relatively few have ever had to perform true disaster Although it would make sense to transport the most critically
triage in a large incident. They may employ MCI triage tools ill patients from a disaster scene first, effective use of ground
not only in MCIs that overtax local and regional EMS and and air transport resources often requires that several patients
hospital resources but also in smaller multicasualty incidents be placed in each transport unit. In these cases, an Immediate
that primarily overwhelm the local field response resources. patient may be transported with a Delayed or Minimal patient
Field disaster triage protocols, aimed at maximizing the or patients to the same hospital instead of with another Imme-
outcome for the greatest possible number of victims, are diate patient. In this way, multiple patients can be evacuated
usually utilized only for the initial gross sorting of patients from the scene without overwhelming the capacity of the EMS
in the field. This phase is called “primary triage.” The goal personnel working in the transporting air or ground ambulances.
of primary triage is usually to sort patients into five triage Ideally, identified family members should also be transported
categories: Immediate, Delayed, Minimal, Expectant, and to the same facility. This is especially true when there are
Dead. Although there are many triage tools currently on the ­injured children. Both injured and noninjured parents and other
market and there are efforts to standardize the categories, guardians may refuse to be separated from their children. This
it is important to be familiar with the tools that are used in may result in the need to make difficult transport decisions,
and around your community since they may include slightly especially if an injured child requires specialty pediatric care
different categories and/or labels. available only at a distant facility. Parents have also been
The primary triage phase is similar to the trauma primary known to deny being injured or refuse care to remain with their
survey, in which physiology is the focus rather than identification child, only to request care once the child has been treated. In
of specific injuries. The MCI triage tools used most commonly general, families should be transported to a facility capable of
in the United States and around the world were developed to providing appropriate care for all family members; however,
facilitate primary triage, not to act as the only point of patient arranging to do so should not significantly delay the transport
assessment. Indeed, triage is a dynamic process. Each time a of the most critically injured patient.
provider assesses a patient is an opportunity to reevaluate their Patients arriving at the hospital from an incident scene via
triage prioritization. A victim may be upgraded (assigned a more EMS are then usually triaged again at the ED and sorted based
386 IV  Disaster Response

on patient needs and the available resources at the hospital.

Unless the hospital is or is likely to be overwhelmed by p­ atients BOX 22.1  Typical Data Elements Gathered at ED
presenting for emergent care, the hospital staff may use their Triage During Normal Operations
typical daily triage philosophy of doing the best for each
­patient. However, this is where communication between the Name
scene and the area hospitals is very important, since a hospital Age
may commit their resources to the patients at their facility only Gender
to find that many more patients may be arriving. Chief complaint (CC)
“Tertiary triage” may then become necessary if the hospitals’ History of present illness (HPI)
resources become overwhelmed. In this step, hospital personnel Mechanism of injury (MOI)
determine if the facility can provide appropriate care or if the Past medical or surgical history (PM/SHx.)
patient will require stabilization and transfer to a facility capable Allergies to food or medication (Allergies)
of a higher level of care. In an MCI, hospitals may be required Current medications (Meds)
to accept patients they usually would not receive from EMS or Date of last tetanus immunization
would ordinarily have to transfer out for definitive care. This Last menstrual period (for females between the ages
may occur because of the hospital’s proximity to the incident or of 11 and 60) (LMP)
because the specialty facilities are also overwhelmed with disaster Vital signs: temperature, pulse, blood pressure, re-
victims. The most common types of patients who might have spiratory rate, oxygen saturation (VS)
to be stabilized and later transferred are children and those with Level of consciousness (LOC)
multisystem trauma, burns, or spinal cord injuries. Freestanding Skin vital signs (Skin vitals): temperature, color,
pediatric hospitals might have to initially stabilize and then transfer moisture
adult patients, including parents who denied injuries or refused Visual inspection for obvious injuries
care until they were satisfied that their child was being cared for. Height and weight (pediatric patients) (Ht./Wt.)
It is important to understand that it is possible that not all Mode of arrival (MOA)
patients coming to a hospital from a disaster scene will be Private medical provider (PMD)
transported by EMS, especially if the hospital is close to the Other
incident. In very large incidents, significant numbers of patients
may be transported by private vehicle or even walk to the closest ED, emergency department.
hospital. Children are portable; well-intentioned lay rescuers or
family members may feel that children will receive care more
quickly if they can get to a hospital without waiting for EMS treatment tend to collect more information at the point of triage.
to evaluate them. Most patients arriving at the hospital on their Some may use the information gathered at triage to implement
own have not yet been triaged at all. Every hospital must be protocols allowing nursing staff to initiate testing and treatment
prepared to perform the same primary triage sorting that is’ before a physician or advanced practice provider (APP) sees
done in the field, sometimes using the same tools. In these cases, the patient. Low-volume EDs rarely experience large volumes
the same flow of primary, secondary, and tertiary triage may be of patients or delays in detailed assessment and treatment, and
conducted at the hospital itself. Often while EMS is bringing tend to collect fewer data elements at triage, as other nursing
patients in from the incident, other patients not associated with and physician/APP staff see the patients rapidly. Detailed
the disaster are also presenting for care in the ED as well as those information is collected during initiation of treatment rather
who come from the incident by private vehicle. Hospital disaster than in triage. During a disaster, in which a large number of
triage policies and procedures sometimes fail to recognize and patients arrive at the ED within a short time, the number of data
plan for the fact that regular ED patients will also present for elements collected during the initial triage encounter may need
care during a disaster. A hospital’s obligations to these patients to be significantly reduced. Box 22.2 shows an abbreviated list
are not diminished by the fact that they are overwhelmed with of data elements commonly obtained when an ED is operating
disaster victims. This process of accommodating both disaster in disaster triage mode. This list represents elements that are
and nondisaster patients is often not addressed adequately, or essential to identify emergent cases. Depending on the nature
at all, in hospital disaster plans and drills. and extent of the disaster as well as the volume of nondisaster
patients, triage staff may have the time and resources to do a
more complete assessment during the triage process and include
BASIC DIFFERENCES BETWEEN DAILY TRIAGE additional elements from Box 22.1.
AND DISASTER TRIAGE AT THE HOSPITAL
Daily Triage in the Hospital Setting
Usual hospital triage is what is done every day during ordi-
nary circumstances. Basic information is obtained that allows If EDs were able to handle each case as it arrived to the hospital,
the triage nurse to make a judgment regarding the actual or there would be no need for triage. Each patient would be treated
potential severity of the problem and the degree of urgency immediately upon arrival to the ED. In 2013, there were over
for further evaluation and treatment. Box 22.1 lists the typical 130 million ED visits in the United States (CDC, 2013). The
types of data that are gathered during hospital triage evalua- number of ED visits in the United States continues to grow each
tion. High-volume EDs that frequently have longer delays for year. The demand for services frequently exceeds the capacity
 22  Disaster Triage 387

Examples include cardiac arrest, airway obstruction, respiratory

BOX 22.2  Basic Data Elements Gathered at ED distress, uncontrolled acute bleeding, poor perfusion, acutely
Triage in the Disaster Setting altered mental status, and acute pain. The Urgent category is
assigned to patients with serious illness or injury that must
Name or other temporary identifier be attended to as soon as possible, but for whom a wait of up
Basic mechanism of injury (MOI) or history of present to 2 hours would probably not add to morbidity or mortality.
illness (HPI) Examples include deformed long bone fractures, bleeding
Airway, breathing, circulation (primary survey) controlled with a pressure dressing, acute psychiatric problems
Skin vitals (color, moisture, temperature) (where the patient is in a safe environment), mild to moderate
V/S: pulse, respirations acute abdominal pain, and complicated open wounds. Nonurgent
Level of consciousness status is used for any patient who can wait more than 2 hours
Visual inspection for obvious injuries to be seen without the likelihood of deterioration. This includes
Signs of or history suggesting contamination or a problems or conditions such as simple fractures, minor lacer-
contagious illness ations, ear or throat pain, rash, or medication refill requests.
In a four-tier system, the Emergent category is usually sub-
ED, emergency department. categorized to identify those conditions that must be treated
immediately (STAT or 1A) versus rapidly (within a few minutes,
1B). STAT conditions would include cardiac arrest, respiratory
of the system at any given moment; therefore, a triage system failure/arrest, airway obstruction, shock, and seizure. Conditions
has evolved in which the sickest patients are given priority. classified as 1B would include moderate to severe respiratory
In the event of a multicasualty incident, additional staff and distress, cardiac dysrhythmia with adequate blood pressure, or
resources are sent to the ED and other acute care areas of the heavy bleeding without hypotension or tachycardia.
hospital but standard ED triage, often in an abbreviated form, In a five-tier system, the Nonurgent category is also sub-
is often still used. If a hospital’s capacity is likely to be over- categorized. Conditions that are nonacute, but require the
whelmed, patients being transported by EMS may be diverted technology of the ED to diagnose or treat, are categorized as
to other institutions. It is only when the number and severity nonurgent ED (Class 3). This would include conditions such as
of casualties is greater than the hospital or available system minor lacerations requiring sutures, or minor musculoskeletal
can handle that true disaster triage is initiated in a hospital. trauma requiring x-rays for diagnosis. These types of condi-
The main purpose of daily in-hospital triage is to identify tions are frequently treated in an ED because there is a lack of
those patients who have the highest degree of compromise for access to these services on an emergency basis in the primary
the purpose of providing rapid care to the sickest patients first. care setting. Nonurgent Ambulatory Care (Class 4) is used to
Patients with airway, breathing, circulation, or ­neurological classify those conditions that are nonurgent in nature and can
emergencies are assigned the highest degree of urgency and routinely be provided in the ambulatory care setting. Examples
receive care first. Individuals in extremis, even if they are of problems in this group are requests for medication refills,
­expected to die or require an extraordinary amount of resources suture or staple removals, or chronic conditions that are stable
for their care, are provided with immediate treatment. such as preexisting skin rashes.
EDs that routinely experience significant overcrowding
In-Hospital Triage Systems for Daily Operations problems and long treatment delays often utilize a five-tier
Most hospitals utilize a triage system that has three to five system, whereas those that rarely have delays tend to use a
categories. The three main categories are emergent (Class 1), three-tier system. It has been suggested that EDs that usually
urgent (Class 2), and nonurgent (Class 3; Lanros & Barber, use a three-tier system should be able to switch to a more
1997). Where four or five levels are used, subcategories are detailed system (e.g., the five-tier system) during times of
added to either end of the spectrum. Table 22.1 illustrates the higher patient volumes to distinguish between sicker and less
typical categories in three-, four-, and five-tier systems. sick patients within the urgent and nonurgent groups. This is
In a three-tier system, Emergent signifies a condition that an adaptation that might be required in disasters and should
requires treatment immediately or within 15 to 30 minutes. be addressed in ongoing staff education and disaster drills.

TABLE 22.1  Hospital Triage Categories for a Three-, Four-, or Five-Tier System

Three-tier system Emergent Urgent Nonurgent

Class 1 Class 2 Class 3

Four-tier system Emergent Emergent Urgent Nonurgent

Class 1A Class 1B Class 2 Class 3

Five-tier system Emergent Emergent Urgent Nonurgent Nonurgent

Class 1A Class 1B Class 2 ED Care Ambulatory Care
Class 3 Class 4
388 IV  Disaster Response

Disaster Triage in the Hospital Setting

BOX 22.3  Contents of Typical Disaster STAT Pack
True MCIs are uncommon in the United States. It is, therefore, Chart System
very uncommon for hospitals in the United States to have to
make decisions to withhold treatment from mortally injured Preassigned STAT medical record number and STAT
disaster victims. Exceptions may include large disasters in rural number or pseudonym
areas with limited hospital and subspecialty (e.g., pediatric Prestamped:
and burn care) capabilities and incidents such as Hurricane ED medical record
Katrina and the spring 2011 tornadoes in the midwestern and Triage slip
southern United States, in which hospitals were themselves Laboratory slips
compromised and sometimes rendered nearly inoperable but X-ray requisitions
still faced with triaging and caring for both affected inpatients Labels for blood tubes
and incoming casualties. Patient identification band
Similar to EMS systems, what is deemed a disaster for Log form that contains preentered STAT medical
one hospital may be seen as routine operations for another. record number and STAT number/name that can be
For example, a large ED with an annual volume of more than used to track patients through the system
100,000 patients per year and full trauma care capabilities may
not commence disaster operations for the arrival of even 10
trauma victims. Conversely, such a number of casualties may As EMS patients present to the ED, triage team staff should
be overwhelming and require disaster resources in a smaller be stationed at the ambulance bay. Table 22.2 lists the staff
facility. Regardless of the size of the facility, each hospital required for a typical disaster triage team and their roles in the
must have in place a system to recognize when the available triage process. If there are a large number of casualties arriving
resources are likely to be inadequate and be able to implement simultaneously, two or more triage teams may be utilized. A
disaster triage and operations at a moment’s notice. triage team may need to be located at the ED walk-in entrance
During a community-wide disaster, hospitals and their to assess patients arriving by personal vehicles and other forms
EDs usually activate their resources and prepare to receive an of transportation that are not part of the EMS system. It is worth
unusual influx of patients. Available non-ED staff report to a repeating that it is possible that not all disaster victims will
personnel pool for assignment, additional staff may be called arrive at the hospital having already been triaged, treated, or
in, and patients may be moved or procedures suspended to decontaminated prior to their arrival. The more patients present-
prepare for incoming casualties and their needs. ing to the hospital, the more likely it is that ED staff will have
During normal operations, noncritical treatment and ­diag- to do disaster-style primary triage. More conventional triage
nostic interventions in the ED are sometimes delayed until the may then be used as a form of secondary triage after patients
registration process is complete and medical record and account are initially grossly sorted using field triage tools.
numbers are retrieved or generated. To eliminate this delay in As the patient arrives, the triage team does a rapid triage
disasters, previously made disaster or “STAT charts” should be evaluation, while a clerk applies a STAT record identification
prepared ahead of time, so that, as each patient enters the ED, a band, hands the corresponding triage slip to the triage officer,
medical record number is immediately assigned. Using the STAT places the STAT chart on the gurney with the patient, and logs
pack patient ID system, diagnostic testing can be performed with- the STAT medical record number, STAT number/pseudonym,
out waiting for an actual registration in the hospital information and, if possible, the patient name, as well as the ED area
system. Similar systems are used frequently in trauma centers, ­assignment. Ambulatory or wheelchair-bound patients may be
and they work well. These STAT charts contain a sequential asked to carry their own charts to their assigned treatment area.
STAT number or pseudonym (“Disaster 1” or “Disaster Orange”) As a patient is stabilized and leaves the ED, the disposition is
in the patient name section of the chart along with a predes- entered on the tracking log. If the patient name is not available
ignated medical record number. Preassembled STAT packets at the time of triage, evaluation and treatment is initiated using
contain the STAT chart, a prestamped triage slip, identification the STAT medical record number and name.
band, and lab and x-ray requisition slips. Box 22.3 illustrates a After rapid assessment, the patient is triaged to a treatment
typical STAT chart packet. As patients arrive at the ED disaster location and team in the ED (or other designated area in the
triage area(s), they are issued a STAT pack and the STAT chart facility), where a more thorough evaluation and treatment
numbers and/or pseudonyms are entered onto a disaster patient will take place. It is also important to remember that during a
tracking log. The tracking log should also record the triage tag disaster situation, nondisaster patients will continue to arrive
numbers of patients transported by EMS, as EMS officials often at the ED. Provisions need to be made for these patients as
track patients by their tag numbers rather than patient name. well, as there is a risk of this group being ignored in the fray.
Linking the triage tag number with other hospital-acquired Note that many MCIs produce more Minor patients than any
patient identifiers can help in reuniting family members with other triage category. It is not unusual that these patients are
their loved ones and help provide response partners with patient placed on a bus or other nonmedical transport vehicle(s) at the
linkages for follow-up information important for after-action scene and transported in groups to one or more local hospitals
documentation and analyses. When time and resources permit, for further evaluation. These Minor patients may present to
real names and other essential medical record information the hospital early in the incident if the more seriously injured
should be appended to the STAT chart record. patients require extrication or experience other delays at the
 22  Disaster Triage 389

status. These patients often benefit from being placed in an area

TABLE 22.2  Staff Complement of a Typical Disaster away from the noise and traffic of the main ED, attended not only
Triage Team by medical personnel but also by mental health professionals,
social workers, or members of the clergy. It is also helpful to
Staff Functional Role in Triage make these types of staff members available in areas where
family members of the victims are coming to inquire about a
Emergency physician* Triage officer loved one or are waiting while their relative receives treatment.
Emergency nurse (1) Evaluates patient and reports One of many lessons that was shared from the 2016 Orlando
findings to officer, supervises nightclub shooting is the need to address the large numbers of
clerk, nursing aid, and friends, family members, and the media who will come to the
transporters hospital after an event looking for information (Heightman, 2017).
The need to deal with the psychological trauma of a disas-
Emergency nurse (2) Records all assessments
ter in the hospital-based acute care setting has only recently
Nurse’s aide/clerk Applies prenumbered started to receive more attention. The concept of “Continuous
identification band Integrated Triage,” proposed by Dr. Maurice Ramirez follow-
ing his experience as a federal Disaster Medical Assistance
Transporter Moves patient from triage area to
assigned area in the ED
Team member working with casualties at the Louis Armstrong
International Airport in New Orleans after Hurricane Katrina,
emphasizes the dynamic nature of disaster triage from the
ED, emergency department.
scene to the h­ ospital and introduces the need to place an equal
Note: Depending on the size and nature of the disaster, and available staff,
emphasis on the potential psychological impact of the disaster
several triage teams may be assembled or different levels of staff may be used
to perform these functional roles. on victims, their loved ones, and field- and hospital-based
* responders (­Shultz et al., 2007).
In some facilities, a senior level ED registered nurse may be designated as
the triage officer. A final issue related to ED triage of disaster victims is the
complexity of the real-time determination of a given ED’s status
scene. It is important not to allow Minor patients to take up and capacity at the time of an acute disaster. Many EDs work
space and resources that may be needed for sicker patients at or above capacity through much of the year. When a disaster
just because they arrive first. It is sometimes useful to separate occurs, EDs must often find ways to stretch their capacity even
the minimal treatment area from the main part of the ED. For further to receive casualties. At the onset of a disaster, the local
example, onsite clinics or urgent care areas may be used. These EMS system will often poll local hospitals to determine how
areas are then staffed with a mix of ED and other hospital per- many victims they can handle and of what level of acuity; a very
sonnel, and stocked with equipment and supplies for the care quick assessment of the hospitals’ status is often required. The
of minor wounds and musculoskeletal trauma. It is imperative determination is usually made by the ED nurse manager/charge
to remember that an initial Minimal triage designation does not nurse and ED attending physician(s), often in concert with the
guarantee that a patient does not have a potentially dangerous house nursing supervisor. Although it is the ED’s capacity that
injury. All Minor patients require a high index of suspicion and is the foremost factor in the determination, the availability of
careful evaluation during secondary triage at the ED. operating rooms, intensive care unit beds, and onsite availability
Several other complicating factors may affect triage and of clinicians and support staff is also important. The number,
initial treatment operations at the hospital. Similar to what status, and acuity of ED patients already undergoing treatment
may occur in the field, injured adult caregivers accompanying as well as those waiting to be seen must be considered, along
injured children can interrupt patient flow if they refuse to be with the availability of treatment area beds for critical and less
separated from their children. When this occurs, it is often best critical patients once the existing patients who can be moved
to triage each individual but then send the whole family to the to an alternate treatment area are physically relocated. Even
treatment area designated for the triage category of the sickest the number of available stretchers can play a role, as patients
individual. This may result in a child identified as being in the transported on backboards with spinal motion restriction
minimal category being sent to an area designated for those with measures in place must be placed on the floor if stretchers are
delayed or immediate needs with their caregiver, who has been not available. What may seem like a simple request, to declare
identified as needing more urgent care, or vice versa, but keeping how many Immediate, Delayed, and Minimal patients an ED
them together may save time and effort later. Unaccompanied can receive, is in fact a complicated question that requires the
minors may require additional staff to stay with them, even if consideration of many factors. Some hospitals use formulas to
they do not require constant bedside nursing care. Nonclinical help make this determination but there is no easy way to give
hospital staff can perform this function if they were recruited anything other than an estimate. In a prolonged or large-scale
and trained as part of the disaster plan. Having a staff member incident, hospitals may be repolled to determine their available
with unaccompanied minors is a critical function that not only capacity. Hospitals themselves should contact the coordinating
helps to ensure patient safety but also provides very important center to change their status if they have more capacity than
psychological support for the children. they originally estimated or if they have reached or exceeded
Patients with acute emotional/psychological decompensation their capacity. It is important to note that EMS agencies are
but otherwise minor injuries require not only medical care for not bound by the hospital capacity estimates. The need to jug-
their physical injuries but also assessment of their psychological gle numbers and types of patients to clear the disaster scene
390 IV  Disaster Response

efficiently sometimes results in a patient distribution that does be incorporated into all primary MCI triage tools in the United
not match declared capacities. Hospitals must remain as flex- States. The guidelines are called the Model Uniform Core Cri-
ible as possible and expect to be challenged, but it is equally teria (Lerner, Cone, et al., 2011). A significant number of the
important that they be honest and report to EMS when there are pertinent professional associations in the United States endorsed
patient safety issues and they can no longer take any or certain these guidelines (Model uniform core criteria for mass casualty
kinds of patients. This is possible only in systems with multiple triage, 2011). An implementation plan for these guidelines was
hospitals. Once all hospitals have reached capacity, patients may issued in 2013 by the FICEMS and these efforts are continuing
need to be transported to more distant resources and/or the local to evolve (FICEMS, 2013). Research into population-based
hospitals may need to implement “real” disaster triage strategies triage as well as secondary and tertiary triage is nonexistent and
and ration resources. The available resources in a community there are a limited number of papers written by topic experts in
and the circumstances of the event will dictate when this point the field describing these practices. Additional research into the
is reached; it will likely be sooner in more isolated areas. effectiveness of triage modalities and on triage as it relates to
surge capacity is needed (Rothman, Hsu, Kahn, & Kelen, 2006).
Although the existing triage tools lack validation, a prevailing
PREHOSPITAL DISASTER TRIAGE opinion is that it is better to use even a nonvalidated tool than no
tool at all. Objective tools can help to bring some organization
Although the military has been performing field triage for and standardization to a difficult process in a chaotic environ-
many years, specific prehospital MCI/disaster triage tools have ment. Clinicians of different levels of training and experience
been available in the United States only since the release of the can theoretically perform in a similar fashion by adhering to
Simple Triage and Rapid Treatment (START) tool in 1983. The standardized guidelines and using tools to assist them in making
majority of the tools used around the world for primary disaster a rapid triage decision for each patient. Perhaps as important
triage are physiology-based and rely on a rapid assessment of as the effect of the triage process on the patients themselves is
respirations, perfusion, mental status and, often, the ability of the effect on the providers performing triage. Primary triage
victims to walk. See Box 22.4 for a list of the most commonly may go against all the natural instincts of rescuers accustomed
used prehospital MCI primary triage tools. to trying to save each patient. Being responsible for making
It is important to note that, although many tools are avail- the call to withhold care and prioritize access to resources can
able, no primary MCI triage tool has been clinically validated be a heavy emotional burden that may adversely affect a pro-
prospectively (Kilner et al., 2011). Most of these tools were vider both professionally and personally. By offering objective
developed by clinicians based on clinical experience and, in guidelines, the triage tool itself absorbs at least some of the
some cases, utilizing components of trauma scores and tools responsibility of making those critical decisions.
that are used for everyday triage of trauma patients. A single It is important that ED-based clinicians know and understand
tool, the Sacco Triage Method, was developed using a math- the MCI triage tools and systems utilized by their local EMS
ematical model-based analysis of retrospective outcome data agencies to be able to interpret their triage decisions and a­ nticipate
from a statewide registry of trauma patients (Sacco et al., 2005). the resources needed by those patients based on their initial triage
The body of literature on MCI triage tools consists primarily of categorizations. Because SALT, START, and JumpSTART are
analyses of drills, effectiveness of training, skills retention, and commonly used primary triage tools in the United States, we will
reproducibility (Deluhery, Lerner, Pirrallo, & Schwartz, 2011; present them in some detail. Detailed information about other
Lerner, Schwartz, Coule, & Pirrallo, 2010; Navin & Waddell, triage systems is widely available via Internet searches. Local
2004; Risavi, Salen, & Heller, 2001; Sanddal, Loyacano, & EMS agencies may also be able to provide information about, and
Sanddal, 2004; Sapp, Brice, Meyers, & Hinchey, 2010). There training for, hospital staff on the tools used in their jurisdictions.
are limited reports of sensitivity and specificity of given tools in There are several key aspects that are common to most triage
real incidents or nondisaster (ED/clinic) settings (Kahn, Schultz, systems. Death is usually defined by apnea. A pulse check is not
Miller, & Anderson, 2009; Wallis & Carley, 2006). Clinical performed because it is assumed that all nonobstructive adult
validation efforts are handicapped by the difficulty inherent in apnea is accompanied by myocardial anoxia and pulselessness.
recording and collecting data in the chaos of disasters and the Even if the victim were to have a pulse, it is unlikely it would
lack of standards by which to judge the clinical appropriateness continue long enough for sufficient additional resources to
of the triage decisions for individual victims. A recent publication arrive to initiate resuscitation. If a victim is actively bleeding
has proposed a criterion standard definition for evaluating the or unable to maintain an open airway, the responder perform-
accuracy of triage based on the diagnosis and the care that is ing triage may quickly attempt to control the bleeding and/or
ultimately provided that is likely to allow for more research to open the upper airway. However, the provider(s) assigned to
be conducted in the near future (Lerner, McKee, et al., 2015). conduct triage cannot stay with the victim. Most triage sys-
In 2008, a multidisciplinary committee funded by the CDC tems will allow the responder to apply a pressure dressing or
studied the existing MCI triage tools. Noting the lack of consis- tourniquet to control bleeding or open the airway with a jaw
tency and validation, the committee developed a primary triage thrust maneuver and/or insertion of an oropharyngeal airway.
tool, SALT Triage (see the next section), drawing from existing If further interventions are needed, the provider may try to
evidence and experience (Lerner, Schwartz, Coule, Weinstein, quickly obtain assistance from a bystander, minimally injured
et al., 2008). Recognizing that designing a tool left little room victim, or other first responder who will stay with the patient,
for innovation, the committee was expanded and produced a set but the responder(s) assigned to triage victims cannot stay to
of evidence-based guidelines for common elements that should provide further treatment and must move to the next victim.
 22  Disaster Triage 391

The first step of SALT triage is global sorting. This step

BOX 22.4  Prehospital MCI Triage Tools prioritizes patients for individual assessment using two voice
commands. The first command directs patients to walk to a
All Ages designated area, “If you can hear my voice and need help, please
The Sacco Triage Method move to __________.” Those who walk are the last priority for
SALT Triage individual assessment; however, it is important to emphasize
Adults Only that these patients are not automatically triaged to the Minimal
Simple Triage and Rapid Treatment (START) category; they need an individual assessment. These patients
Pediatrics Only will be the last to be individually assessed, because they are
JumpSTART Pediatric MCI Triage the least likely to have a life-threatening condition (i.e., their
The Pediatric Triage Tape brain and muscles are getting sufficient oxygen to process
Age Not Specified information and to move). The second command directs those
Careflight Triage who remain to wave, “If you can hear my voice and need help,
Triage Sieve please wave your arm or leg.” The patients who do not move
at all or those with obvious life threats (e.g., major bleeding)
MCI, mass casualty incident; SALT, Sort-Assess-Lifesaving are prioritized first for individual assessment. Those who wave
interventions-Treatment/transport. are the second group for individual assessment, and those who
walked to the designated area are prioritized last for individual
assessment. While the global sorting process will not be perfect,
SALT Triage it will create some order to the scene. It is an initial attempt
As described previously, a CDC-sponsored expert panel to organize numerous casualties into three groups, but every
developed SALT Triage. It is nonproprietary and meets the casualty still needs to be individually assessed.
model uniform core criteria for mass casualty triage. SALT The second step in SALT Triage is the individual assess-
stands for Sort-Assess-Lifesaving interventions-Treatment/ ment of each casualty. The individual assessment should begin
transport, which describes the steps followed when performing with considering if the victim needs lifesaving interventions.
SALT triage (Lerner, Schwartz, Coule, Weinstein, et al., 2008; These interventions include: (a) controlling major hemorrhage;
­Figure 22.1). It uses an all-hazards approach that is intended (b) opening the airway with a basic airway maneuver (Two rescue
to be used for any age patient in any type of event. breaths may also be delivered if a child is apneic after upper airway

Walk
assess third

Step 1–sort: Wave/purposeful movement

Global sorting assess second

Still/obvious life threat

assess first

Step 2–assess:
Individual assessment

LSI:
Obeys commands or makes
Control major hemorrhage
purposeful movements? Minor
Open airway (if child, Yes All Yes
consider 2 rescue breaths) Breathing Has peripheral pulse? injuries Minimal
Not in respiratory distress? Yes only?
Chest decompression
Auto injector antidotes Major hemorrhage is controlled?
No No
Dead Any No Delayed

Likely to survive given Yes

Immediate
current resources

No

Expectant

FIGURE 22.1  SALT Triage.

392 IV  Disaster Response

positioning; these breaths are given in an effort to help open the all vital physiological functions must be adequate to coordinate
mid to lower airways.); (c) performing needle decompression for and power the sophisticated task of hearing, interpreting, and
a possible tension pneumothorax; and (d) providing autoinjector obeying the command to walk. It is very important that a clini-
antidotes. Each of these procedures should be provided quickly cian assess all Minor patients as soon as possible in secondary
if the equipment is available and is within the provider’s scope of triage or as part of any reassessment of primary triage. These
practice. These specific interventions were selected because they victims might have deteriorated over time or have injuries
can be done quickly and, with the exception of the lower airway or comorbid conditions that make them potentially unstable.
opening ventilations, are known to improve the likelihood of survival. All of the victims who are unable to get up and walk are then
Once any lifesaving interventions are performed, the assessed individually. Responders generally work from victim to
­responders should evaluate the patient and prioritize him or victim in a grid pattern rather than trying to go to the obviously
her for treatment and/or transport. sickest patients first. For each victim the responder determines
if he or she is breathing spontaneously. If an upper airway
■■ Dead: those who are not breathing even after lifesaving opening maneuver does not stimulate spontaneous respirations,
interventions have been attempted. the patient is triaged as Expectant without further assessment.
■■ Immediate: those with difficulty breathing, uncontrolled If the patient is breathing spontaneously on initial approach,
hemorrhage, absence of peripheral pulses, and/or inability the responder quickly estimates the respiratory rate. If the rate
to follow commands; who are likely to survive given the is faster than 30 breaths per minute, the patient is triaged as
available resources. Emergent and the responder moves on to the next patient. If the
■■ Expectant: those with difficulty breathing, uncontrolled patient is breathing at a rate of 30 breaths per minute or less,
hemorrhage, absence of peripheral pulses, and/or inability the responder assesses circulation by checking capillary refill
to follow commands; who are unlikely to survive given the or palpating for a pulse. In cool/cold weather, pulse palpation
available resources. may be more accurate than capillary refill and is also easier
■■ Delayed: those who are alert and follow commands, have to perform in poor lighting. Rescuers wearing multiple layers
palpable peripheral pulses, no signs of respiratory distress, of gloves may find capillary refill to be easier than feeling a
and all bleeding is controlled, with injuries or an illness that pulse. If the capillary refill (central or in the least-injured limb)
in the opinion of the rescuer is more than minor. is greater than 2 seconds or if there is no palpable pulse, the
■■ Minimal: those who are alert and follow commands, have patient is triaged as Emergent. Remember that this patient is
palpable peripheral pulses, no signs of respiratory distress, breathing, so the lack of a pulse is an indicator of shock but
and all bleeding is controlled, with injuries/condition that not cardiac arrest.
in the opinion of the rescuer are minor. If the perfusion is adequate, as determined by capillary
refill or pulse, the responder assesses mental status by asking
To learn more about using the SALT Triage method, there the patient to follow a simple command such as “squeeze my
is an educational lecture available at www.Salttriage.org hand.” If the patient can presumably hear and interpret the simple
command but cannot comply, he or she is tagged Emergent. If
the patient can obey the command, he or she is tagged Urgent.
To be triaged Urgent, a patient must be nonambulatory but have
Simple Triage and Rapid Treatment adequate respirations and circulation and, presumably, sufficient
The START triage tool is a commonly used adult MCI primary mental status to be able to guard his or her own airway.
triage tool developed by the Newport Beach Fire and Marine
Department and Hoag Hospital in California, first published in
1983 and revised in 1994 (Benson, Koenig, & Schultz, 1996).
It was devised for use only for adults, with an arbitrary lower TABLE 22.3  Using RPM to Classify Patients Using START
application limit of a patient weight of 100 pounds. The five
basic parameters assessed with START are: (a) the ability to
Category (Color) RPM Indicators
walk, (b) the presence or absence of spontaneous respirations,
(c) the respiratory rate, (d) an ­assessment of perfusion, and Emergent (Red) R = Respiratory rate > 30
(e) the ability to obey commands. These parameters are often P = Capillary refill > 2 sec or absent
referred to as respirations, ­perfusion, and mental status (RPM). peripheral pulse
The parameters are assessed in a sequential fashion for each M = Does not obey commands
patient, with the assessment being terminated immediately
Urgent (Yellow) R < 30
upon the identification of a critical threshold criterion. P < 2 sec
The first action upon entering the scene (after identifying M = Obeys commands
and starting mitigation of ongoing hazards) is to make an
­announcement stating:” Anyone who can hear my voice should Expectant: Dead R = Not breathing after jaw thrust
get up and walk to a designated point, where they will be met or dying (Black)
by a rescuer at the first possible opportunity.” All victims able Minor (Green) Able to walk
to walk alone or with minimal assistance are designated as
Minor. These patients are presumed to have well-compensated RPM, respirations, p­ erfusion, and mental status; START, Simple Triage and
physiology, regardless of the nature of their injuries, because Rapid Treatment.
 22  Disaster Triage 393

*Evaluate infants first in

Able to YES Secondary secondary triage using
MINOR
walk? Triage* the entire JumpSTART
algorithm

NO

NO Position BREATHING
Breathing? IMMEDIATE
upper airway

APNEIC

Palpable NO
DECEASED
pulse?

YES

YES 5 rescue APNEIC

DECEASED
breaths
BREATHING

IMMEDIATE

<15 OR >45
Respiratory IMMEDIATE
Rate

15–45

Palpable NO
IMMEDIATE
pulse?

YES

“P” (Inappropriate)
Posturing or “U”
AVPU IMMEDIATE

“A,” “ V, ” or “P”
(Appropriate)
DELAYED

FIGURE 22.2  JumpSTART triage algorithm.

AVPU, alert, voice, pain, unresponsive; START, Simple Triage and Rapid Treatment.

Table 22.3 summarizes the critical decision thresholds Dr. Romig recognized that there were several decision thresholds
utilized by START. The thresholds for Emergent and Urgent for START that were not appropriate for pediatric physiology.
can be easily remembered by the mnemonic: JumpSTART addresses the unique physiology of children while
paralleling the structure and procedures of START (Romig,
R (Respirations) P (Pulse) M (Mobility) 2002, 2007, 2011).
30 2 “Can do” Figure 22.2 shows the JumpSTART algorithm. JumpSTART
differs in several key ways from START:
JumpSTART 1. JumpSTART should be used for “all victims who appear
The JumpSTART Pediatric MCI Triage Tool was the first to be children” and START for “all victims who appear to
objective tool developed specifically for the primary triage of be young adults or older.” This means that START should
children in the multicasualty/disaster setting. JumpSTART was be used for “tweens and teens” who have adult respiratory
developed in 1995 and modified in 2001 by Dr. Lou Romig, a mechanics but may weigh less than START’s stated lower
pediatric emergency medicine physician with a background in limit of 100 pounds. A general guide for identifying those
both EMS and pediatric disaster preparedness and response. who “appear to be children” is the absence of secondary
394 IV  Disaster Response

sex characteristics such as breast development and growth assessed and triaged at the first possible opportunity. When the
of facial hair. triaging responder finds an apneic child, he or she performs
2. START’s criterion for being tagged Minor is the ability a jaw thrust. If the child starts to breathe, the child is triaged
to walk, but this may be inaccurate when triaging very Emergent, just as in the START algorithm. If the child does
young children and those with developmental or motor not start to breathe, the responder checks for the pulse with
disabilities that prevent unassisted ambulation. All children which he or she is most comfortable assessing on a child.
who probably are not able to walk unassisted under normal Note that this is different from START, and aims to detect
circumstances should be assessed using JumpSTART. Any children who may be in the “window of salvageability.” It
patient meeting an Emergent criterion is triaged as Emergent. also acknowledges the innate imperative most clinicians feel
For those patients who complete the algorithm and under to “go the extra mile” for a child. If no pulse is detectable,
JumpSTART would be considered Urgent, the responder the child is presumed to be in full cardiopulmonary arrest
performs a quick scan for external signs of significant and triaged as Dead. If a pulse is palpable, the responder
injury (e.g., penetrating injuries, significant burns, tissue quickly administers five breaths via a mouth-to-barrier device,
avulsions, amputations, crush injuries, abdominal distension, attempting to open the lower airways and trigger spontaneous
or vigorous active bleeding). If present, the patient remains breathing. This is called the “ventilatory trial” and is the
Urgent and, if absent, the patient is triaged as Minor, even “jump start” that gives JumpSTART its name. Some agencies
though they cannot walk. skip the pulse check and go directly to the ventilatory trial
3. Any child who is carried to the designated location when after upper airway opening fails to trigger respirations. If
the walk command is given should be individually assessed the child remains apneic after the five ventilations, he or she
first when sufficient personnel become available to attend is triaged Expectant, regardless of the presence of a pulse,
to the patients in that area. because there are insufficient resources to conduct a full
4. Because children primarily sustain respiratory failure/ resuscitation. If the child starts to breathe spontaneously, he
arrest before their hearts stop, there may be a short time or she is tagged Emergent.
period where a child may be apneic but still have detectable JumpSTART’s respiratory rate thresholds for spontaneously
circulation. This is more likely to occur in a child because breathing children are 15 and 45 breaths per minute. Rates
the heart does not stop functioning until it becomes anoxic greater than 45 or less than 15 are triaged Emergent. When
and sustains significant damage. In adults, apnea more often combined, the pediatric and adult critical respiratory rates then
follows cardiac arrest, while in children cardiac arrest more become easier to remember, as they are multiples of 15 (i.e., 15,
often follows hypoxia/apnea. It is theoretically possible that 30, and 45). As with START, either capillary refill or pulse
an apneic child who still has a perfusing rhythm may be palpation is used to assess perfusion. The Emergent criteria
salvageable if spontaneous ventilation can be reestablished of capillary refill greater than 2 seconds or failure to detect a
(i.e., “window of salvageability”). Therefore, five rescue pulse are the same as for START. Care should be taken not to
breaths should be provided to apneic children who have a spend more than 15 to 20 seconds trying to feel a pulse. The
detectable pulse. overall goal is to take a minute or less to triage each patient.
5. Because a slow respiratory rate has more dire implications If a pulse is that hard to find, err on the side of up-triaging,
than tachypnea in a child, JumpSTART adds a low respiratory especially if the capillary refill is also prolonged.
rate as a critical threshold. The final assessment is that of mental status. Because obey-
6. Young children may be unable or unwilling to obey ing commands is dependent on both cognition and behavior,
simple commands because they are not developmentally it is not a universally appropriate gauge of pediatric mental
or behaviorally capable or are just scared. Therefore, the status. Pediatric patients are rated using AVPU instead (Jevon,
AVPU (alert, voice, pain, unresponsive) scale is used as an Humphreys, & Ewens, 2008). If the patient is alert, responsive
indicator of mental status rather than simply the ability to to voice, or localizes a painful stimulus, he or she is triaged
obey commands. Urgent. If the patient has only a generalized response to pain,
exhibits posturing, or is truly unresponsive to all stimuli, he or
Although it is not unusual to find multicasualty scenes at she is triaged Emergent. As with START, an Urgent patient is
which there are only adult patients, it is virtually guaranteed one who presumably cannot walk due to the trauma but who
that when children are involved in an incident there will be has adequate respirations and circulation and sufficient mental
adults to triage as well. The parallel structures of START and status to protect his or her own airway.
JumpSTART make it easier to switch back and forth between
the algorithms depending on the apparent age of the victim
being assessed. Figure 22.3 shows how START and Jump- TRIAGE TAGS
START can be integrated.
When triaging a scene at which there are both adult and For the triage process to be effective, the findings from the
pediatric victims, the primary triage approach is the same triage process need to be communicated. This is typically done
as when dealing only with adults. The responder makes through triage tags that are attached to the patient. Triage tags
the announcement for ambulatory patients to proceed to a can be a commercial product or as simple as using a marker
designated point and stay there. Any infant or child who is to write the triage category directly on the patient or tying
carried to the designated Minor area must be individually appropriately colored contractor’s ribbon to the patient.
 22  Disaster Triage 395

*Using the JumpSTART

Able to YES algorithm, evaluate first
MINOR Secondary Triage*
walk? all children who did not
walk under their own
power.
NO

NO BREATHING
Breathing? Position upper airway IMMEDIATE

APNEIC
PEDI ADULT

+PULSE NO PULSE

YES
APNEIC
5 Rescue Breaths DECEASED

BREATHING

IMMEDIATE

>30 ADULT
Respiratory IMMEDIATE
Rate <15 or >45 PEDI

<30 ADULT
15–45 PEDI

CR>2 sec (ADULT)

Perfusion IMMEDIATE
No palpable pulse (PEDI)

YES “P” (Inappropriate) Posturing or “U”

(PEDIATRIC)
Mental Doesn’t obey commands
IMMEDIATE
Status (ADULT)

Obeys Commands (ADULT)

DELAYED
“A”, “V”, OR “P” (Appropriate) (PEDIATRIC)

FIGURE 22.3  Combined START/JumpSTART triage algorithm.

RPM, respirations, ­perfusion, and mental status; START, Simple Triage and Rapid Treatment.
Source: Additional information about JumpSTART, including downloadable graphic files, drill materials, and educational presentations, is available at
www.jumpstarttriage.com.

In some states or regions, common triage tags may be the field or in triage at the hospital, and allergy and medication
used to reduce costs and increase interoperability between history. It is also extremely useful to add guardians’ names
agencies. Regardless of the type of tag used, there are some and/or the guardian’s own triage tag number to the tag of an
recommended features. Figures 22.4 and 22.5 show some injured child. In incidents in which EMS response is robust
typical features of triage tags. Patient tracking is very import- and patients are transported quickly, it may be impossible to
ant, and using tags that include a unique identifier number add much information to the triage tag.
can improve this process. Some tags may include bar-coded It is important for ED personnel to be familiar with the
stickers or other features to simplify or automate the process tags used by responders in their area, as well as with any tags
for adding/communicating the unique identifying number to that are used internally for casualties or in case of facility
various patient-tracking logs and medical care records. Doing evacuation.
this can facilitate family reunification and other interagency
information sharing. Another consideration is using triage tags
that are waterproof and capable of being quickly and easily THE JOB OF THE TRIAGE OFFICER
affixed directly to the patient—not to the patient’s clothing.
Tags should contain as much information as is available and The primary responsibility of the triage officer is to ensure
should be easy to write on. Information to consider documenting that every victim has been found and triaged. Triage officers
on a triage tag includes the patient’s name (when available), (meaning the person[s] in charge of triage, not implying a
presenting injury or complaint, any interventions performed in rank) and those responders assigned to perform triage do not
396 IV  Disaster Response

FIGURE 22.4  A typical disaster triage tag.

Source: Courtesy of Disaster Management Systems.

Front of tag Back of tag

The tag is tied to
0246 0246 0246 the victim’s arm 0246 0246 0246
or leg

Name: Time:
Address: B/P:
Hospital: Pulse:
Treatment: Resp. Rate:
Meds:
Perforated
colored tab

0 BLACK 0246 0 BLACK 0246

1 RED 0246 1 RED 0246
2 YELLOW 0246 2 YELLOW 0246
3 GREEN 0246 3 GREEN 0246

FIGURE 22.5  Example of a typical color-coded triage tag with perforated color bars.
 22  Disaster Triage 397

provide immediate treatment other than to provide lifesaving

interventions such as opening airways and trying to control the allocation of scarce resources that defines a disaster.
active bleeding. In cases involving some chemical exposures, Successful use of a disaster-style triage system is a critical
triage personnel may also administer medications via an au- component of any hospital’s acute surge capacity. Triage
toinjector. In traditional MCI triage, the triage officer carries is the cornerstone of good disaster medical resource
only supplies for performing lifesaving interventions and management in both the field and the hospital. Nurses
triage tags. The role of the triage officer is critical, as he/she should be aware of the different types of triage and triage
is not only responsible for assuring that all victims have been systems used in and around their communities and when
identified and triaged but also for communicating the num- it is appropriate, use them as dictated by hospital policy.
bers of victims and the nature of their needs to the incident Disaster triage requires a significant paradigm shift for the
command supervisors so that appropriate resources can be nurse, and may be an emotionally distressing experience.
requested and dispatched. The difficulty of being responsible However, the performance of accurate triage provides
for making possible life-and-death decisions based on mini- nurses with the opportunity to do the greatest good for
mal information cannot be emphasized enough, especially in the greatest number of casualties.
the face of large numbers of casualties, pediatric victims, or
victims who are fellow first responders. This is most true for
responders in the field but may also be true for ED personnel
who take on that role. Personnel who have functioned in a STUDY QUESTIONS
disaster triage role should be monitored for immediate and
delayed stress reactions and offered assistance when needed.
1. How are the philosophies of daily hospital triage different
from disaster triage?

DISASTER TRIAGE FOR HAZARDOUS 2. Describe how numbers of patients and available resources
are related with regard to determining whether or not
MATERIAL DISASTERS disaster triage must be used.
Field trauma triage systems currently used by emergency re- 3. What are the basic daily hospital triage system categories?
sponders at MCIs and disasters do not adequately account for the Explain each.
possibility of contamination of patients with chemical, biological, 4. Why is there a need for disaster triage in the hospital setting?
radiological, or nuclear material (Cone & Koenig, 2005). Addi-
tionally, chemical or hazardous material disasters pose unique 5. Describe the basic elements of a disaster triage system.
challenges in that hospital-based staff members have the poten- What do the triage categories of Immediate, Delayed,
tial to become victims themselves from exposure to the toxins Minor, Dead, and Expectant mean? List types of problems
or the physiological effects of working while wearing personal for each category.
protective gear. Victims who are chemically contaminated must 6. Discuss the differences between primary, secondary, and
be decontaminated before being brought into the clean treatment tertiary disaster triage.
area on scene or at the hospital (see Chapter 35 “Decontamination
7. During triage for mass casualty hazardous materials
and Personal Protective Equipment,” Mass Casualty Decontam-
incidents, what are the differences in the triage activities
ination, for further information). Failure to do so may result in
in the hot, warm, and cold zones?
contamination of the staff, other patients, and the environment,
and can potentially require evacuation and closure of the entire 8. What are the five major cohort triage classifications
ED. Because some prehospital services may transport chemically during epidemic triage? To which area would each of
exposed victims to the hospital prior to decontamination, and these cohorts likely be triaged and what levels of care
because other victims may leave the scene before being triaged would they likely receive?
and decontaminated, each hospital must have a system in place to 9. What is the purpose of triage tags and why are they
employ special conditions triage and decontaminate these arrivals. important?
10. Compare and contrast triage for adults versus children.
SUMMARY

REFERENCES
Events may occur in which rapid assessment of large
numbers of patients is required. The ability to correctly
sort those patients may impact the health outcomes not Auf der Heide, E. (2000). Disaster response: Principles of preparation and
only of individuals, but also of the community as a whole. coordination. St. Louis, MO: CV Mosby. Retrieved from http://library
.ndmctsgh.edu.tw/milmed/avitation/file-med/DisasterResponse.pdf
Although empirical evidence to support the use of existing
Benson, M., Koenig, K. L., & Schultz, C. H. (1996). Disaster triage: START
triage systems is lacking, it is generally agreed that the then SAVE—A new method of dynamic triage for victims of a catastrophic
use of an objective triage system should help optimize earthquake. Prehospital and Disaster Medicine, 11(2), 117–124.
doi:10.1017/S1049023X0004276X