Triage Principles in Mass Casualty Incidents
START Triage Method
- The Simple Triage and Rapid Treatment (START) method categorizes victims into four color-coded priorities based on respiratory status, perfusion, and mental status. This systematic approach allows healthcare providers to quickly assess and sort large numbers of casualties to maximize survival.
- Assessment sequence includes: ability to walk, respiratory status, perfusion (capillary refill/pulse), and mental status (follows commands).
Key Points
- Green (Minor): Walking wounded, can wait for treatment
- Yellow (Delayed): Serious injuries but stable, can wait hours for treatment
- Red (Immediate): Critical injuries requiring immediate intervention
- Black (Deceased/Expectant): Dead or unlikely to survive given available resources
Clinical Scenario: A bus crash has resulted in 30 casualties arriving at your emergency department. As the triage nurse, you first identify all ambulatory patients and direct them to the green treatment area. A patient with respiratory rate of 32, delayed capillary refill, and confused mental status would be tagged as RED (immediate) priority.
JumpSTART Pediatric Triage
- JumpSTART is a pediatric-specific modification of START triage that accounts for developmental and physiological differences in children. The algorithm includes an additional "APNEIC" assessment step with rescue breathing attempts before declaring a child deceased/expectant.
- Pediatric patients have different vital sign parameters and may present with compensated shock, making standard adult triage criteria less reliable for children.
Key Points
- Respiratory rates <15 or >45 indicate immediate (red) status in children
- Palpable peripheral pulse is used instead of capillary refill in pediatric assessment
- AVPU scale (Alert, Verbal, Pain, Unresponsive) is used to assess mental status
- Apneic children with palpable pulse receive 5 rescue breaths before triage determination
Comparison: START vs. JumpSTART Triage
| Assessment |
START (Adults) |
JumpSTART (Pediatrics) |
| Respiratory Rate |
<10 or >30 = Red |
<15 or >45 = Red |
| Perfusion |
Capillary refill >2 seconds = Red |
Palpable peripheral pulse = Yellow/Green |
| Apneic Patient |
Position airway, if still apneic = Black |
Position airway, if pulse present give 5 rescue breaths |
| Mental Status |
Follows commands = Yellow/Green |
AVPU scale, appropriate response = Yellow/Green |
Reverse Triage
- Reverse triage involves identifying and discharging lower-acuity hospitalized patients to create surge capacity during mass casualty incidents. This process requires rapid assessment of inpatients to determine who can be safely discharged or transferred.
- The goal is to maximize hospital capacity for incoming casualties while ensuring currently hospitalized patients remain safe.
Key Points
- Patients are categorized by risk if care is discontinued (minimal, moderate, or major risk)
- Patients with minimal risk of adverse events if care is discontinued are prioritized for discharge
- Requires interdisciplinary coordination and modified documentation procedures
- Must consider transportation, medication, and follow-up needs for discharged patients
Memory Aid: START Triage Assessment
Remember "30-2-Can Do":
- 30: Respirations above 30 = Red
- 2: Capillary refill greater than 2 seconds = Red
- Can Do: Cannot follow commands = Red
Quick Check: Triage Categories
Match the correct color tag with the description:
- Walking wounded who can wait for care: Green
- Critical patients needing immediate intervention: Red
- Serious injuries but stable vital signs: Yellow
- Deceased or unlikely to survive: Black
Infectious Disease Outbreak Response
Personal Protective Equipment (PPE)
- PPE selection is based on the mode of transmission of the infectious agent and the type of patient interaction anticipated. Proper donning and doffing sequences are critical to prevent self-contamination and disease transmission.
- Healthcare facilities must maintain adequate PPE supplies and conduct regular training on proper use, especially for high-risk pathogens requiring enhanced precautions.
Key Points
- Standard PPE includes gloves, gown, mask, and eye protection
- N95 respirators (or higher) are required for airborne pathogens
- Doffing (removing) PPE is the highest-risk step for self-contamination
- PPE must be donned before patient contact and removed immediately after
Proper Sequence for Donning PPE:
- Perform hand hygiene
- Don isolation gown
- Apply mask or respirator
- Put on eye protection (goggles/face shield)
- Apply gloves, extending over gown cuffs
Proper Sequence for Doffing PPE:
- Remove gloves using glove-in-glove technique
- Perform hand hygiene
- Remove face shield/goggles by headband/earpieces
- Remove gown by untying and pulling away from body
- Remove mask/respirator by straps (don't touch front)
- Perform hand hygiene again
IMPORTANT ALERT: Never reuse disposable PPE between patients. Always check N95 respirator seal before entering patient room. Remove PPE immediately if damaged or heavily contaminated.
Isolation Precautions
- Isolation precautions are implemented based on the mode of transmission (contact, droplet, airborne) of the infectious agent. Standard precautions apply to all patients, while transmission-based precautions are added for specific pathogens.
- Proper signage, patient placement, and environmental controls are essential components of effective isolation practices during infectious disease outbreaks.
Key Points
- Standard Precautions: Apply to all patients regardless of infection status
- Contact Precautions: For pathogens spread by direct/indirect contact (e.g., MRSA, C. difficile)
- Droplet Precautions: For pathogens in respiratory droplets traveling ~3-6 feet (e.g., influenza, pertussis)
- Airborne Precautions: For pathogens in small particles remaining suspended in air (e.g., TB, measles, varicella)
Comparison: Isolation Precaution Requirements
| Precaution Type |
Room Requirement |
PPE Required |
Example Pathogens |
| Standard |
Regular room |
Gloves for potential contact with body fluids |
All patients |
| Contact |
Private room preferred |
Gloves and gown |
MRSA, VRE, C. difficile, norovirus |
| Droplet |
Private room preferred |
Surgical mask, eye protection |
Influenza, pertussis, mumps, rubella |
| Airborne |
Negative pressure room with 6-12 air changes/hour |
N95 respirator or PAPR |
TB, measles, varicella, SARS |
Cohorting Strategies
- Cohorting involves grouping patients with the same confirmed infection in designated areas with dedicated staff. This strategy optimizes resource utilization during outbreaks when single-patient rooms are limited.
- Effective cohorting requires clear physical separation between cohorts, dedicated equipment, and staff assignment strategies to prevent cross-contamination.
Key Points
- Patients should be laboratory-confirmed with the same pathogen before cohorting
- Suspected cases should be isolated individually until diagnosis is confirmed
- Staff should be dedicated to specific cohorts when possible
- Equipment should not be shared between cohorted and non-cohorted areas
IMPORTANT ALERT: When caring for multiple cohorted patients, always move from less ill to more ill patients within the cohort. Change PPE between patients even within the same cohort. Never cohort patients with different infectious agents together.
Memory Aid: Transmission-Based Precautions
Remember "CAD" for the three types of transmission-based precautions:
- Contact: Touching (gloves + gown)
- Airborne: Floating (N95 mask + negative pressure)
- Droplet: Spraying (surgical mask)
Common Pitfalls: Isolation Precautions
- Removing N95 respirator while still in an airborne isolation room
- Touching the front of mask/respirator during removal
- Failing to perform hand hygiene between doffing steps
- Using droplet precautions for airborne pathogens
- Removing isolation precautions too early before required negative tests
Surge Capacity Planning
Surge Capacity Components
- Surge capacity refers to a healthcare facility's ability to rapidly expand beyond normal services to meet increased demand during disasters or public health emergencies. The four essential components include staff, stuff (supplies/equipment), space, and systems.
- Effective surge capacity planning requires regular drills, multidisciplinary coordination, and scalable response levels based on the nature and magnitude of the incident.
Key Points
- Staff: Includes staff recall systems, cross-training, altered staffing ratios, and emergency credentialing
- Stuff: Involves stockpiling critical supplies, equipment, medications, and establishing resource allocation protocols
- Space: Requires identifying convertible spaces, alternate care sites, and capacity for patient cohorting
- Systems: Encompasses command structures, communication protocols, and documentation modifications
Clinical Scenario: During a severe influenza pandemic, your hospital activates its surge capacity plan. The cafeteria is converted to a low-acuity treatment area, nurses are reassigned to 1:8 ratios with support staff, medication administration protocols are simplified, and non-essential services are suspended. This demonstrates the integration of all four surge capacity components: space (cafeteria conversion), staff (altered ratios), stuff (simplified medication protocols), and systems (service prioritization).
Crisis Standards of Care
- Crisis Standards of Care (CSC) are substantial changes in healthcare operations and the level of care delivered during extreme public health emergencies when resources are severely limited. CSC requires formal declaration by appropriate authorities and involves systematic, evidence-based approaches to resource allocation.
- Implementing CSC involves ethical considerations including fairness, duty to care, duty to steward resources, transparency, consistency, proportionality, and accountability.
Key Points
- CSC implementation occurs in a stepwise fashion after conventional and contingency measures are exhausted
- Resource allocation decisions should be made by triage teams, not bedside providers when possible
- Documentation requirements are modified to focus on essential elements
- Regular reassessment of resource availability and allocation decisions is required
IMPORTANT ALERT: Crisis Standards of Care should only be implemented when all resource conservation and substitution strategies have been exhausted. Facilities must return to conventional standards as soon as resources become available. All CSC decisions must be documented with rationale.
Resource Allocation
- Resource allocation during mass casualty events requires objective, transparent, and ethically sound decision-making frameworks. Allocation decisions should be based on likelihood of benefit, conservation of resources, and minimizing harm.
- Triage officers or committees, rather than treating clinicians, should make allocation decisions to reduce moral distress and maintain the therapeutic relationship between providers and patients.
Key Points
- Sequential Organ Failure Assessment (SOFA) scores are commonly used to guide ventilator allocation
- Essential workers may receive priority for scarce resources based on instrumental value
- Age should not be the sole criterion for allocation decisions
- Regular reassessment of patients receiving scarce resources is necessary
Memory Aid: Surge Capacity Planning
Remember the 4 S's of Surge Capacity:
- Staff: Human resources
- Stuff: Supplies and equipment
- Space: Physical treatment areas
- Systems: Protocols and procedures
Quick Check: Surge Capacity Components
Match the surge component with the appropriate intervention:
- Converting a conference room to patient care area: Space
- Implementing emergency credentialing for volunteer providers: Staff
- Activating Incident Command System: Systems
- Distributing stockpiled ventilators: Stuff