A nurse is triaging patients in the emergency department following a chemical spill incident. Using the START (Simple Triage and Rapid Treatment) system, which patient should receive the highest priority (RED tag)?
1A 45-year-old male who is ambulatory, has minor lacerations on his arms, and is asking for water
2A 30-year-old female who is unconscious, has no spontaneous respirations, and whose airway remains obstructed after manual opening
3A 25-year-old male who is conscious but unable to walk, has a suspected femur fracture, and has a rapid, weak radial pulse
4A 35-year-old female who is conscious, has difficulty breathing with a respiratory rate of 35/min, and a heart rate of 125/min✓ 정답
해설
Patient 4 is a RED tag per START: non-ambulatory, respiratory distress (RR 35/min), and tachycardia (125/min) indicate immediate life-saving intervention needed. Other patients are lower priority: ambulatory (green), deceased/unsalvageable (black), or delayed treatment (yellow).
Core Nursing Explanation
This question tests the application of the START (Simple Triage and Rapid Treatment) system, a standardized method used in mass casualty incidents (MCIs) to quickly categorize patients based on the severity of their injuries and the resources required. The core principle is to do the greatest good for the greatest number of patients. Triage decisions are based on a rapid assessment of three key parameters: ability to walk, respiratory status, and perfusion status (pulse/bleeding control).
Key Concept Analysis
The START system uses a color-coded tagging system:
RED (Immediate): Patients with life-threatening injuries who have a high chance of survival with immediate intervention.
YELLOW (Delayed): Patients with serious injuries that are not immediately life-threatening.
GREEN (Minimal): "Walking wounded" with minor injuries.
BLACK (Deceased/Expectant): Patients who are deceased or have injuries so severe that survival is unlikely given available resources.
The triage algorithm is sequential: First, direct all who can walk to a designated area (GREEN tag). For those who cannot walk, assess breathing. If not breathing, open the airway. If breathing resumes, tag RED. If not, tag BLACK. If breathing is present, assess perfusion (radial pulse or capillary refill). If absent, tag RED. If present, assess mental status (ability to follow commands). If unable to follow commands, tag RED. If able, tag YELLOW.
Answer RationaleKey Point! Patient 4 (conscious, respiratory rate 35/min, heart rate 125/min) is the correct RED tag priority. This patient is non-ambulatory (implied by being triaged in the non-walking group), has respiratory distress (RR > 30/min is a critical threshold in START), and has tachycardia indicating compromised perfusion or shock. This combination of findings signifies an immediate threat to life from airway, breathing, or circulation compromise that requires urgent intervention.
Distractor AnalysisWatch out for confusion!
Patient 1: Is ambulatory with minor injuries. According to the START algorithm, all ambulatory patients are initially tagged GREEN (Minimal). They are the lowest priority for immediate resource allocation.
Patient 2: Is unconscious with no spontaneous respirations after a simple airway maneuver. In a mass casualty setting, this patient is categorized as BLACK (Deceased/Expectant). Resources are not directed to patients who are unsalvageable with simple interventions, in order to save more lives.
Patient 3: Is conscious, non-ambulatory (due to femur fracture), but has a palpable radial pulse (even if rapid and weak). The presence of a radial pulse indicates perfusion is not immediately absent. This patient would be tagged YELLOW (Delayed). Their injury is serious but not an immediate threat to life compared to a patient in respiratory distress.
Related Concepts
Understanding START is foundational for disaster nursing. It differs from everyday emergency department triage (like ESI - Emergency Severity Index), which focuses on individual patient needs. START is a population-based, resource-constrained model. Nurses must be able to rapidly apply the algorithm without extensive diagnostic tools, relying on quick physical assessments.
Concept Summary
Triage Color
START Criteria
Priority
Example (from question)
RED (Immediate)
Non-ambulatory, with life-threatening compromise of Airway, Breathing, or Circulation (e.g., apnea after airway open, no radial pulse, RR > 30, altered mental status).
1st (Highest)
Conscious patient with respiratory distress (RR 35) and tachycardia.
YELLOW (Delayed)
Non-ambulatory, but with adequate breathing and perfusion (radial pulse present). Serious but stable injuries.
2nd
Conscious patient with femur fracture and a palpable radial pulse.
GREEN (Minimal)
Ambulatory ("walking wounded") with minor injuries.
3rd
Ambulatory patient with minor lacerations.
BLACK (Deceased/Expectant)
No spontaneous respirations after simple airway opening, or obviously fatal injuries.
4th (Lowest)
Unconscious patient with no respirations after airway maneuver.
Side-by-Side Comparison!
Triage System
Context
Key Principle
Priority Basis
START/JumpSTART (Pediatric)
Mass Casualty Incident (MCI), Disaster
Greatest good for the greatest number. Rapid sorting (< 60 sec/patient).
Color-coded tags (RED, YELLOW, GREEN, BLACK) based on walking, breathing, perfusion.
ESI (Emergency Severity Index)
Routine Emergency Department
Individual patient acuity and expected resource needs.
Level 1 (Resuscitation) to Level 5 (Least urgent).
Primary Survey (ABCDE)
Any Emergency/ Trauma Assessment
Identify and treat immediate life threats in order.
Physiology: The START assessment targets the ABCs (Airway, Breathing, Circulation). Respiratory rate >30/min indicates severe respiratory compromise, often due to pulmonary injury, shock, or anxiety. A rapid, weak radial pulse indicates poor peripheral perfusion, a late sign of shock.
Pharmacology: In the RED tag area, life-saving medications (e.g., epinephrine for anaphylaxis, analgesics, antibiotics) may be administered, but the focus is on stabilizing interventions like airway management, bleeding control, and chest decompression first.
Memory Tips
Mnemonic for START order:Walk? (GREEN) → Breathe? (No → BLACK; Yes → Next) → Perfuse? (No radial pulse → RED; Yes → Next) → Mental status? (Can't follow commands → RED; Can → YELLOW). Think: "Walk, Breathe, Pulse, Mind."
RED Tag Triggers: Remember "RAPID" – Respiratory distress, Apnea (after airway open), Perfusion absent (no radial pulse), Immediate threat, Disabled mental status.
High-Frequency NCLEX Topics
Disaster triage, specifically the START system, is a High Yield topic. The NCLEX-RN often tests:
Identifying the correct triage color for a given patient scenario.
Understanding the ethical principle of utilitarianism ("greatest good") underlying disaster triage.
Differentiating MCI triage (START) from daily ED triage.
Knowing the Key Point! that ambulatory patients are always GREEN tag first.
Watch Out for Question Variations!
Shift from "identify color" to "select first action": "The nurse is first assigned to the triage area of an MCI. What is the nurse's initial action?" (Answer: Direct all ambulatory patients to a specific area to clear the scene and identify GREEN tags).
Pediatric variation: Using the JumpSTART algorithm for children (differences in respiratory rate thresholds, pulse check, and apneic but pulseless patients).
Adding complexity: Including a patient with uncontrolled hemorrhage. Remember, major bleeding is controlled immediately during the circulation step, and the patient is then tagged RED.
Nursing Clinical Practice GuideClinical Scenario: You are the charge nurse in the ED when multiple ambulances arrive following a bus collision. Dozens of patients are on scene. You grab a triage tag pack and begin the START process.
Nursing Intervention Strategy:
Scene Safety & Initial Command: Ensure your own safety first (PPE for potential blood/body fluid exposure). Loudly instruct, "If you can hear me and can walk, please move to the area marked by the green flag!" This instantly identifies GREEN tag patients.
Systematic Assessment (60 seconds or less per non-ambulatory patient):
Approach the first non-walking patient. Assess Breathing: Look, listen, feel. If not breathing, perform a simple jaw-thrust to open the airway. If breathing resumes, tag RED. If no breathing, tag BLACK and move on.
If breathing is present, Assess Perfusion: Check for a radial pulse OR capillary refill >2 seconds. If absent (no pulse), tag RED for immediate hemorrhage control/shock management.
If perfusion is adequate, Assess Mental Status: Give a simple command: "Squeeze my hand." If the patient cannot follow commands (unresponsive, confused), tag RED. If they can follow commands, tag YELLOW.
Tagging & Documentation: Clearly attach the correct color tag. If possible, note a brief injury (e.g., "chest injury," "leg fracture") on the tag. Report findings to the incident commander.
Patient Safety and Precautions
Contraindications: Do not spend time on extensive assessments, taking full vital signs, or starting IVs during the initial triage sweep. This delays the sorting of other patients.
Re-triage: Triage status is not static. Patients in the YELLOW and GREEN areas must be reassessed periodically, as their conditions can deteriorate.
Psychological First Aid: While being efficient, use a calm, directive tone. For GREEN tag patients who are anxious, simple instructions like "Please wait here, help is coming" can prevent panic.
Nursing Procedure & Medication Flow
In the RED tag treatment area, care is focused on stabilizing ABCs:
Breathing: Administer high-flow oxygen, assess for and decompress tension pneumothorax, manage open chest wounds.
Circulation: Control external hemorrhage with direct pressure or tourniquets. Establish two large-bore IV lines and begin isotonic crystalloid (e.g., Normal Saline (NS)) bolus for hypovolemic shock. Key Point! Medication administration (e.g., analgesics, antibiotics) follows after these immediate life threats are addressed.
A Word from Your Senior Nurse
"Disaster triage feels counterintuitive because we're trained to help everyone immediately. In an MCI, your most critical nursing skill is rapid decision-making under pressure. Tagging that breathing, tachycardic patient RED and moving past the unresponsive apneic one is incredibly difficult, but it's the right decision to save the most lives. Practice the START algorithm until it's muscle memory. On the NCLEX and in a real crisis, that clarity will guide you. Remember, you are not deciding who lives or dies; you are prioritizing who gets care first to maximize survival for the entire community. That's the profound responsibility and skill of disaster nursing."
START Triage — Simple Triage and Rapid Treatment; A mass casualty incident (MCI) triage system that rapidly categorizes patients into four color-coded groups (RED/Immediate, YELLOW/Delayed, GREEN/Minimal, BLACK/Deceased) based on ability to walk, respiratory status, perfusion, and mental status.
Mass Casualty Incident — An event that generates more patients than available local resources can manage using routine procedures, requiring the implementation of disaster protocols and triage systems like START.
Utilitarianism — The ethical principle of "the greatest good for the greatest number" that underpins disaster triage decisions, prioritizing resource allocation to those who can benefit most.
JumpSTART Triage — A pediatric-specific modification of the START triage system for children (infants to age 8), with adjusted criteria for respiratory rates, pulse check, and a special assessment for apneic pediatric patients with a pulse (ventilate 5 times, then reassess).
Triage Tag — A color-coded tag (usually made of durable paper or plastic) attached to a patient during an MCI to visually communicate their triage priority (Red, Yellow, Green, Black) and often includes space for brief notes and tracking.