START (triage)

START (triage)
Name	START (triage)
Acronym	START
Purpose	Rapid patient categorization in mass casualty incidents
Developed	1983
Developers	Hoag Hospital, Sacramento County, California Department of Health Services
Use	Emergency medical services, disaster response

START (triage) is a rapid triage protocol designed for initial sorting of victims during mass casualty incidents, enabling first responders to prioritize care and transport. It was developed in Orange County, California and popularized through emergency medical services networks, influencing disaster preparedness frameworks used by organizations such as the American Red Cross, Federal Emergency Management Agency, and World Health Organization. The system emphasizes speed, simple physiologic criteria, and a four-category color-coded outcome to guide allocation of limited resources.

Overview

The START approach arose from collaborative efforts among practitioners in California and has been integrated into protocols promoted by National Association of Emergency Medical Technicians, International Committee of the Red Cross, and municipal emergency plans in cities including Los Angeles, New York City, and Chicago. It uses simple assessments—respiration, perfusion, and mental status—to classify patients rapidly, informing decisions by personnel from agencies such as Emergency Medical Services, Fire Department of New York, and regional trauma systems like King County Emergency Medical Services. START's adoption intersected with developments in disaster medicine from institutions including Johns Hopkins Hospital, Massachusetts General Hospital, and Mayo Clinic.

Triage Categories and Criteria

START assigns victims to four principal color-coded categories that parallel systems used by organizations such as American College of Surgeons, Centers for Disease Control and Prevention, and National Institutes of Health-affiliated trauma centers. The categories align with triage frameworks in events like the Northridge earthquake, Oklahoma City bombing, and Hurricane Katrina response, and reflect inputs from training curricula used by California Emergency Medical Services Authority and United Kingdom National Health Service emergency planners. Criteria hinge on observable signs consistent with physiologic scoring used in emergency settings at hospitals like Cedars-Sinai Medical Center and St. Mary’s Hospital.

Procedure and Implementation

The START procedure proceeds with a rapid approach used by teams from agencies such as California Highway Patrol, New York Police Department, and municipal fire services. First, responders command a simple "walking wounded" call similar to mass movement protocols seen in responses coordinated with Metropolitan Police Service and Transport for London during major incidents. Assessment uses: respiratory rate, capillary refill or radial pulse, and ability to follow simple commands, reflecting standards taught in courses by American Heart Association and National Association of Emergency Medical Technicians. Implementation often integrates incident command structures like the Incident Command System and coordination with dispatch centers modeled after Los Angeles County Fire Department communication systems.

Training and Use in Mass Casualty Incidents

Training for START is delivered through programs run by institutions such as Red Cross, St. John Ambulance, EMT-Basic and Paramedic academies, and regional disaster exercises hosted by Federal Emergency Management Agency and Department of Homeland Security partners. Simulated incidents used for drills draw on historical cases including the 9/11 attacks, London bombings (2005), and major sporting-event security plans for venues like Wembley Stadium and Madison Square Garden. Practical exercises emphasize concurrency with hospital surge plans at trauma centers like Royal London Hospital and University Hospital Birmingham and interoperability with military medical assets such as United States Army Medical Command in large-scale disasters.

Limitations and Criticisms

Critiques of START appear in analyses by academics at Harvard School of Public Health, Johns Hopkins Bloomberg School of Public Health, and within reports by National Academies of Sciences, Engineering, and Medicine. Limitations cited include oversimplification of physiologic complexity compared with systems like Revised Trauma Score or Triage Sieve, challenges during incidents described in reports on the Utøya attack and Mumbai attacks (2008), and difficulty accounting for special populations treated in centers like Great Ormond Street Hospital and Sheba Medical Center. Ethical debates reference frameworks from World Medical Association and legal reviews involving agencies such as Department of Justice and state health departments.

Variants and Related Triage Systems

Numerous adaptations and related systems coexist with START, including SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport), CareFlight triage model, Triage Sieve, and military protocols like the Simple Triage and Rapid Treatment (military) approaches used by United States Navy Hospital Corps. International triage variants are applied in systems overseen by World Health Organization, European Centre for Disease Prevention and Control, and national services such as Australian Red Cross and Health Service Executive in Ireland. Hospitals and agencies often combine START with in-hospital triage tools like the Manchester Triage System and scoring systems including Glasgow Coma Scale and National Early Warning Score to refine resource allocation.

Category:Triage