15.2 Mass Casualty Triage (START/JumpSTART) & Incident Command System (ICS)

15.2 Mass Casualty Triage (START/JumpSTART) & Incident Command System (ICS)

Core Concept: In mass casualty disasters, triage shifts from providing maximal individual care to doing the greatest good for the greatest number of victims using standardized algorithms (START and JumpSTART) coordinated within the structured Incident Command System (ICS).

Principles of Disaster Triage vs. Emergency Department Triage

Disaster triage during a Mass Casualty Incident (MCI) differs fundamentally from daily Emergency Department (ED) triage (such as the Emergency Severity Index [ESI]). In routine ED triage, resources are tailored to treat the sickest patients first, regardless of resource consumption. In an MCI, local healthcare capabilities and supplies are acutely overwhelmed. Consequently, disaster triage prioritizes rapid assessment and resource allocation to maximize overall survival—allocating immediate interventions strictly to salvageable patients while withholding resource-intensive care from those with non-survivable injuries.

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The START Disaster Triage Algorithm (Adults)

The Simple Triage and Rapid Treatment (START) algorithm is the gold standard for adult mass casualty triage. Responders perform triage assessments in 60 seconds or less per patient using the RPM memory tool: Respirations, Perfusion, and Mental Status.

The Four START Triage Categories

Step-by-Step START Algorithm Execution

1. Initial Command: Call out, "If you can walk, move to designated green location." All who walk are tagged Green (Minor).
2. Respirations (R):
   • If breathing is absent, manually open the airway. If breathing remains absent, tag Black (Expectant). If breathing resumes, tag Red (Immediate).
   • If spontaneous respiration rate is > 30 breaths/min, tag Red (Immediate) immediately.
   • If respiration rate is <= 30 breaths/min, proceed to evaluate Perfusion.
3. Perfusion (P):
   • Assess radial pulse or capillary refill.
   • If radial pulse is absent or capillary refill is > 2 seconds, tag Red (Immediate) and control major external arterial bleeding.
   • If radial pulse is present and capillary refill is <= 2 seconds, proceed to evaluate Mental Status.
4. Mental Status (M):
   • Ask the patient to follow a simple command (e.g., "Open your eyes" or "Squeeze my hand").
   • If the patient cannot follow simple commands (unconscious or altered), tag Red (Immediate).
   • If the patient follows simple commands, tag Yellow (Delayed).

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JumpSTART Pediatric Disaster Triage Modification

Children possess different baseline physiological parameters and are prone to early primary respiratory arrest (unlike adults, who predominantly suffer primary circulatory collapse). The JumpSTART algorithm is specifically validated for pediatric victims (typically defined as under 8 years of age or appearing pediatric in size).

Critical Differences in JumpSTART vs. START

• Five Rescue Breaths Rule: If a pediatric victim is apneic, opening the airway is performed first. If apnea persists but a palpable peripheral pulse is present, the responder administers 5 artificial rescue breaths (mouth-to-mask or bag-valve-mask).
  • If breathing resumes after 5 breaths -> Tag Red (Immediate).
  • If breathing remains absent after 5 breaths -> Tag Black (Expectant).
• Respiratory Rate Thresholds: The normal pediatric respiratory rate range is defined as 15 to 45 breaths/min.
  • RR < 15 bpm or > 45 bpm -> Tag Red (Immediate).
  • RR between 15–45 bpm -> Proceed to Perfusion.
• Mental Status (AVPU Scale):
  • Alert, responds to Voice, or responds appropriately to Pain -> Tag Yellow (Delayed).
  • Inappropriate response to Pain, Posturing (decerebrate/decorticate), or Unresponsive -> Tag Red (Immediate).

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Incident Command System (ICS) Structure & Nursing Roles

The Incident Command System (ICS) is a standardized, all-hazard on-site emergency management structure established under the National Incident Management System (NIMS). ICS eliminates jurisdictional confusion by employing unified command terminology and clear lines of authority across hospital, prehospital, and emergency management agencies.

The Five Core ICS Functional Management Sections

1. Incident Commander (IC):
   • Holds ultimate operational responsibility for the incident response.
   • Directs command staff: Safety Officer (has authority to halt unsafe operations), Public Information Officer (PIO) (manages media relations), and Liaison Officer (coordinates external agencies).
2. Operations Section:
   • Executes tactical objectives to address the emergency directly.
   • In hospital and field settings, Operations oversees the Triage, Treatment, and Transport Branches, as well as nursing clinical teams.
3. Planning Section:
   • Collects, evaluates, and disseminates incident intelligence.
   • Formulates the formal Incident Action Plan (IAP), tracks resource status, and plans for demobilization.
4. Logistics Section:
   • Provides all support, facilities, equipment, communication infrastructure, medical supplies, pharmaceuticals, and personnel nutrition/hydration.
5. Finance / Administration Section:
   • Monitors incident-related costs, processes vendor contracts, tracks payroll/overtime, and manages worker's compensation claims.