Triage is Broken

“Triage is broken,” said Dr. P.K. Carlton, former USAF Surgeon General, at the 2004 Medical Readiness Conference to an audience that included U.S. Surgeon General Richard Carmona.

“Triage is broken,” said Dr. P.K. Carlton, former USAF Surgeon General, at the 2004 Medical Readiness Conference to an audience that included U.S. Surgeon General Richard Carmona. ‘There is no scientific basis for the current system. It is not scalable, not reproducible, and does not lend itself to computer applications!” Data from the Madrid bombing of March, 2004, supported his contention. Of 312 patients that were “red tagged” for designation as immediate (i.e. those expected to die without immediate medical intervention), only 89 required hospitalization for more than 24 hours. Did all of the other 223 patients truly require the extraordinary resources needed to provide immediate care? While this may have wasted money, it may have also cost lives. Patients arrived at treatment facilities over a three-hour span. How many of the 14 in-hospital deaths received delayed care due to the mistriaging of others?

On January 26, 2005, two commuter trains with 241 passengers derailed in Glendale California. One hundred twenty-nine injured were transported by 24 ambulances and 3 helicopters to 13 area hospitals. How does one at the scene determine the order to send patients, make the best use of helicopter and ambulances, and maximize the savings of lives? How does a harried triage officer ensure that he is not moving the disaster from the scene to the hospital, as happened in 75% of US mass casualty incidents (Auf de Heide et al) where a majority of patients were sent to a single hospital? This is a complicated problem, but this is triage. Was the triage strategy in Glendale effective? There is no way to know. The patients’ outcome of current triage strategies is not measured and it cannot be measured under current protocols. This is probably why the American College of Surgeons suggests that a minimum 50% over-triage rate is desirable so as to not miss critically injured patients!

A recent study further indicates problems with current triage protocols. A mass casualty tabletop exercise conducted across six EMS regions in Pennsylvania in 2003 and 2004 indicated extraordinary inconsistency in triage within regions and across the state. The inconsistency was evident in the ”tagging” of victims and in setting priorities for treatment and transport. The results of this study are the subject of this paper.


Triage is based on a method called Simple Triage and Rapid Treatment (START). The system was developed in the 1980s as a way to manage the chaos of a multiple casualty scene. Most versions of START begin by separating ambulatory or walking wounded patients simply by instructing those able to move to another area to do so. These patients are identified with green tags. Often they receive little or no further assessment until medical resources are abundant. For those remaining, START uses a series of three physiological screens — respirations, pulse or perfusion, and mental status — to classify victims as s immediates and delayeds. As shown on Figure 1, if a victim has a respiratory rate that satisfies a prescribed criteria (e.g. respiratory rate exceeding 30 breaths per minute), they are classified as immediate and

The triage strategy is to send red-tagged victims for treatment first, followed by the yellows. While there are not objective criteria for differentiating patients within the groupings, worst-patient-first is the suggested and typically practiced protocol. There is no adjustment to this process for the number of casualties, the abundance/scarcity of resources or blunt/penetrating trauma.

The Study

In 2003, the Pennsylvania Department of Health’s EMS Office initiated a demonstration program involving six of the state’s EMS regions, representing 29 counties and 279 emergency personnel, including first responders, EMT-Basics, paramedics, RNs, emergency physicians and a few regional- and state-level EMS policy makers. All used color-coded tagging to set triage priorities on hypothetical patients, though their protocols varied slightly. Regions A, B and C all used START. Region D did not know it by name but used a START-like protocol based on respiratory rate, pulse and mental status. Region E extended START, using physiological screens and subjectively adjusting for observable injury and severity. Region F is rural and had no mass-casualty triage protocol at the time.

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