Bedside Snapshot

Indications
  • Incident declared: patients exceed immediate resources
  • Many casualties at one scene, sorted before transport
  • Tags carry the category to each receiving facility
Contraindications / Abort
  • Unsafe scene: do not enter until hazards are controlled
  • Immediate patient: bleeding and airway first, not the full sort
  • Resources exceeded: escalate to incident command
Critical Steps
  • Global sort: walking last, obvious bleeding first
  • Adult START: RR >30/min, no radial pulse or CRT >2 s, or no simple commands = Immediate
  • JumpSTART (under 8 y): RR outside 15–45/min = Immediate
Confirm & Monitor
  • One tag per patient; colour counts match the headcount
  • Re-triage at every move and at the receiving site
  • Injured patients: destination per 2021 field triage

Key Numbers

Triage sorts many patients quickly so that the most treatable life threats are treated and moved first. Use these thresholds to decide the category, then follow your local protocol for every decision that changes care or destination.

ParameterValue
START: breathing
Respiratory rate above 30/min: Immediate (red)
START: not breathing
Reposition the airway once. Still not breathing: Deceased/Expectant (black). Breathing after repositioning: Immediate (red). Local protocols differ on how deceased and expectant are assigned
START: perfusion
No radial pulse, or capillary refill time over 2 s: Immediate (red)
START: mental status
Cannot follow simple commands: Immediate (red). Otherwise Delayed (yellow)
START: walking
Can walk away from the scene: Minor (green)
JumpSTART: age
Children younger than 8 years (pediatric algorithm)
JumpSTART: breathing
Respiratory rate below 15/min or above 45/min: Immediate (red)
JumpSTART: mental status
Alertness, or appropriate response to verbal or painful stimuli (not the adult simple-commands test)
SALT: categories
Immediate (red), Delayed (yellow), Minimal (green), Expectant (gray), Dead (black)
Injured patient: destination
Physiologic criteria include: motor GCS below 6 (unable to follow commands), respiratory rate <10 or >29/min, respiratory distress or need for respiratory support, room-air SpO2 below 90%; systolic BP <90 mm Hg (age 10–64 y), <110 mm Hg (65 y and older), <70 + 2 × age mm Hg (0–9 y); at age 10 y and older, heart rate above systolic BP (2021 field triage, for trauma center destination)
Re-triage interval
Per local protocol. No fixed interval in the sources reviewed
Most lethal error: Treating the tag as a diagnosis. The tag is a snapshot. A Delayed patient can become Immediate, so re-triage as the scene and the patient change.

Overview & Principles

When resources cannot treat everyone at once, triage gives each patient a priority category. That category sets the order of treatment and transport. It is a scene-level call. It is not a diagnosis, and it is not a plan for one patient.

How It Works

  • Global sort: Split walkers from non-walkers. Under SALT, walkers are assessed last. Obvious uncontrolled bleeding is assessed first.
  • Individual assessment: Check breathing, perfusion and mental status, always in the same short order. Simple Triage and Rapid Treatment (START) is the adult algorithm.
  • Lifesaving care: Control major bleeding and open the airway. Other lifesaving steps, such as decompressing a tension pneumothorax, happen as the protocol allows. SALT builds this step into the sequence.
  • Tag and move: attach a tag with the category, time and an identifier, then send the highest category first.
  • Re-triage: reassess at each move, at the transport point and at the receiving facility.

Where It Fits

START is the adult tool. JumpSTART is its pediatric version, for children younger than 8 years. SALT (Sort, Assess, Lifesaving Interventions, Treatment and/or Transport) is the 2008 proposed national guideline (Lerner et al.). It folds the older systems into one set of colour categories. This page covers SALT's categories and sequence only. The individual assessment questions sit in the 2008 flowchart, and this page does not reproduce them. Local systems differ, so your tag labels have to match your agency's protocol. Figure 1 shows the adult START sequence.

Adult START sequence: walking is Minor; RR above 30, no radial pulse or CRT over 2 s, or no simple commands is Immediate
Figure 1: Adult START decision sequence (red, yellow and green categories). Source: E3 Learning

Indications & Contraindications

Indications

  • An incident declared under your local system, where the number of patients exceeds the immediate resources available
  • Multiple casualties at one scene, where a fast category decides which patients are moved and treated first
  • Hand-off of many patients to several receiving facilities, where the tag carries the category forward

Absolute Contraindications

None once an incident is declared. A single patient with a clear, time-critical problem goes through the individual protocol, not a tag.

Relative Contraindications & Cautions

  • Unsafe scene: do not enter until hazards such as traffic, fire, violence or hazardous materials are controlled, per agency policy.
  • Hazardous material or infectious exposure: Decontamination and PPE come first, per protocol. The sort happens afterward, inside the decontaminated zone.
  • Resources already exceeded: The sort is no substitute for escalation. Request more resources early.

Abort / Stop Criteria

  • Scene hazards persist: stop entry, request resources and wait for safe access.
  • Patient in extremis at the scene: control bleeding and open the airway first, then continue the sort.
Life over sequence: An Immediate patient gets bleeding control and an open airway before you finish sorting everyone else.

Scope & Team Roles

Provider LevelTypical RoleNotes
EMT
Performs
Sort and tag with START or SALT; scope varies by state and agency
AEMT
Performs
Sort, tag and monitor Immediate patients per protocol
Paramedic
Performs
Lead triage and lifesaving care per protocol; often the triage officer
RN (ED/ICU)
Performs
Triage or re-triage at the facility, per the hospital disaster plan
Critical Care Transport (CFRN / CTRN / FP-C / CCP-C)
Monitors & maintains
Monitors Immediate patients in transport; re-triages per protocol
Physician / APP
Assists
Medical command: decides expectant categories and resource allocation

Team Roles During the Procedure

  • Triage officer: runs the sort, assigns categories and calls the next patient.
  • Treatment lead: directs lifesaving care for the Immediate group.
  • Recorder: keeps the count by colour, the times and the tag numbers.
  • Transport officer: matches categories to destinations and vehicles.
Note: Scope varies by state, agency and facility. Follow your local protocols and medical direction.

Equipment & Preparation

Equipment

  • Triage tags: colour-coded, numbered and tear-off, with fields for category, time and identifier
  • Marking pen and clipboard: to write on tags and the recorder's sheet
  • Watch or timer: to time each assessment and each re-triage
  • Bleeding control: tourniquets and hemostatic dressings, per protocol
  • Airway and decompression: suction, an airway adjunct and a tension pneumothorax kit, per protocol
  • Pediatric sizing: a length-based tape or sizing system for children, per protocol (see Broselow)

Sizing

Triage uses vital signs and observation, not sizing. Use the pediatric vital signs reference to judge what is normal for a child's age. Adult START and pediatric JumpSTART use different breathing ranges. See Key Numbers.

Japanese triage tags in black 0, red I, yellow II and green III categories, with fields for name, time and transport
Figure 2: Triage tags from the Tokyo Fire Department. Category numbers and colours differ from START and SALT labels. Source: Wikimedia Commons, Genppy, public domain

Pre-Procedure Checklist

  • Incident declared and command post identified
  • Scene safety confirmed; entry point and exit route chosen
  • Triage officer, recorder, treatment lead and transport officer assigned
  • Tags in all four categories, plus extras, staged and visible
  • Count sheet ready for colours and times
  • Lifesaving equipment within reach of the treatment lead
  • Communication with receiving facilities and transport confirmed
  • Pediatric triage reference and sizing available

Step-by-Step Procedure

Phase 1: Prepare

  1. Confirm the incident and scene safety: declare the incident per the local system. Do not enter an unsafe scene.
  2. Assign roles: one triage officer, one recorder, one treatment lead and one transport officer.
  3. Stage the tags: set out the colour-coded tags and a pen where the triage officer can reach them.

Phase 2: Sort and Assess

  1. Global sort: direct walking patients to a Minor area and assess them last. Assess patients with obvious uncontrolled bleeding first.
  2. Check breathing: count the respiratory rate of each patient who cannot walk. In adult START, a rate above 30/min is Immediate. A patient who is not breathing has the airway repositioned once: still not breathing is Deceased/Expectant (black); breathing after repositioning is Immediate (red). Local plans differ on how deceased and expectant are assigned.
  3. Check perfusion: feel for a radial pulse and check capillary refill time (CRT). No pulse or CRT over 2 s is Immediate.
  4. Check mental status: ask the patient to follow a simple command (adult START; JumpSTART uses alertness or appropriate response to verbal or painful stimuli). Failure is Immediate. A patient who passes all checks is Delayed.
  5. Apply lifesaving care: control major bleeding and open the airway as your protocol allows. Decompression and other interventions are protocol-dependent; then move on.
Move on after the first Immediate criterion: One failed check makes the patient Immediate. Tag them and move to the next patient. The remaining checks wait.
SALT sequence: global sort, lifesaving interventions, assess and tag, treat or move; colours red, yellow, green, gray and black
Figure 3: SALT sequence and colour categories as set out in the 2008 proposed national guideline. Source: E3 Learning

Phase 3: Tag and Move

  1. Tag each patient: record the category, time and identifier, and attach the tag to the patient.
  2. Move the Immediate group first: send Immediate patients to the treatment lead, then to transport in category order.
  3. Keep a count: record the total for each colour and report it to incident command.
  4. Re-triage: reassess tagged patients as they move and at intervals set by protocol.

Confirmation & Monitoring

Primary Confirmation

Each patient has one tag with a category, time and identifier. The colour counts add up to the headcount.

Secondary Confirmation

  • The Immediate group is being treated and moved first.
  • Walking patients are separated from patients who cannot walk.
  • The receiving facility has the count and the tag details.
FindingSuccessFailure / Re-tag
Tag on each patient
One tag per patient, matched identifier
Missing or duplicate tag: tag now and log it
Immediate group
Treated and moved first
Immediate patient still waiting: escalate to the treatment lead
Walking patients
Minor, separated from the rest
Walking patient now cannot walk: re-triage as Immediate
Count
Colour totals match the headcount
Mismatch: recount and report to incident command

Ongoing Monitoring

  • Re-triage at every move, at the transport point and at the receiving facility
  • Reassess the Immediate group's airway, breathing, bleeding and mental status at the protocol interval
  • Update the count after every transport and every change in category
False reassurance: A Delayed or Minor tag records one moment. The patient who looked stable at the start of the scene can still get worse. Re-triage. Don't trust the first tag.

Troubleshooting

ProblemLikely CauseFix
Too many Immediate tags
Single criterion used as the whole decision, or overtriage
Recheck each criterion; follow the protocol and escalate to medical command
Patient cannot follow a command
Language or hearing barrier, intoxication, head injury, confusion or distress
Use a nonverbal command per protocol; treat as Immediate until reassessed
No radial pulse
Shock, cold extremity or the wrong arm
Check the other arm and capillary refill; treat as Immediate per the criterion
Walking patient collapses
Initial Minor tag was wrong, or the injury is delayed
Re-triage at once and move the patient to the Immediate group
Not breathing after airway opening
Airway obstruction or a fatal injury
Reposition the airway once: still not breathing = Deceased/Expectant (black); breathing after repositioning = Immediate (red). Follow local protocol and medical command
Tag separated from patient
Tag not attached, or torn off in transport
Retag from the recorder's sheet, match the identifier and log it

If the Sort Cannot Keep Up

  1. Call for resources: ask incident command for more units, staff and receiving capacity.
  2. Move the Immediate group: send transports in category order and report the count.
  3. Escalate expectant decisions: these belong to medical command under the local plan, not to the first responder.

Complications

ComplicationRecognitionPreventionManagement
Immediate: undertriage
Patient tagged Delayed or Minor deteriorates on transport or at the hospital
Use all checks; re-triage at each move
Retag now, move the patient, and notify the receiving team
Immediate: overtriage
Many Immediate tags with few life threats found on reassessment
Follow the criteria in order; avoid tagging on a single finding
Retag downward only after reassessment; report the count
Delayed: resources exhausted
Delayed patients wait too long and deteriorate
Reassess the Delayed group at set intervals
Escalate to incident command for more resources
Rescuer injury
Hazard not recognized on entry
Scene safety first; use PPE per protocol
Withdraw from the hazard and request support
Wrong patient or tag
Identifier does not match the patient
Attach the tag at the point of assessment; match the identifier
Reidentify the patient and log the correction

One 2003 train-crash evaluation found that START overtriaged 79 of 148 patients and undertriaged 3. Overtriage drains resources. Undertriage delays life-saving care.

Special Populations

Pediatrics

  • Use the pediatric algorithm: JumpSTART is for children younger than 8 years. Adult START thresholds don't fit young children.
  • Breathing: In JumpSTART, a respiratory rate outside 15 to 45/min is Immediate. The adult cutoff of 30/min does not apply here.
  • Perfusion: JumpSTART's perfusion check is simple. Is there a palpable pulse, yes or no?
  • Mental status: JumpSTART asks about alertness, or whether the child responds to voice or pain. It skips the adult simple-commands test.
  • Not breathing: reposition the airway. If the child is still apneic, check for a palpable pulse. No pulse: Expectant (black). Pulse present: give 5 rescue breaths. Breathing resumes: go to the respiratory-rate check. Still apneic: Expectant (black).
  • Late hypotension: Children compensate with tachycardia and vasoconstriction. Their blood pressure drops late, so watch perfusion, capillary refill and mental status. Use the Pediatric Assessment Triangle to organize the look.
  • Age cutoff: Your local protocol sets the line between JumpSTART and adult START. The CHEMM description used here gives only the under-8 limit.
Note: Age-based vital sign ranges live on the pediatric vital signs page. Use them to judge what is normal for a child's age. They are not a triage threshold.

Older Adults

  • In the 2021 field triage guideline, a systolic BP below 110 mm Hg at age 65 y or older is high-risk. It may already mean shock.
  • A low-level fall with significant head impact, in an adult 65 y or older, is an EMS judgment factor.

Pregnancy

  • In the 2021 field triage guideline, pregnancy over 20 weeks is an EMS judgment factor for trauma-center destination.
  • Tag by the same physiologic criteria. Notify the receiving obstetric service per local protocol.

Language and Communication Barriers

  • Language, hearing or a cognitive barrier can stop a patient from following a verbal command. The perfusion and breathing checks still apply.
  • Use a nonverbal command or a gesture per protocol, and record that method on the tag.

Post-Procedure Care & Transport

Immediate Aftercare

  • Move the Immediate group first and keep the tag with the patient through every move.
  • Treat and transport by category; do not hold an Immediate patient to finish the count.

Ongoing Maintenance

  • Reassess tagged patients at each move and at protocol intervals.
  • Keep the count by colour current for incident command.

Transport Considerations

  • Vehicle load: load by category and destination, and record the tag numbers on each vehicle.
  • Reassessment en route: monitor Immediate patients and re-triage on any change in breathing, perfusion or mental status.
  • Destination: injured patients meeting field-triage criteria go to the destination named in the 2021 guideline (see Key Numbers); the MCI tag does not replace that decision.

Document & Hand Off

  • Tag number, category, time and identifier for each patient
  • Category count by colour and the vehicle or destination for each group
  • Any change in category since triage, with time and reason
  • Interventions done (bleeding control, airway, decompression) and response
  • Hand-off to the receiving team by category, not by the first tag alone

Clinical Pearls & Pitfalls

Pearls

  • Sort first, treat second: The sequence is what puts each patient in a category. Treatment comes after, and it follows that category.
  • Walking patients are reassessed: START tags them Minor, and SALT assesses them last. Either way, a walker who deteriorates gets reassessed.
  • Colours differ by system: A Japanese tag runs 0 to III, with colours. SALT uses named categories. Confirm which system is in use on the scene.
  • Start with bleeding: SALT assesses obvious uncontrolled bleeding first. A bleeding patient is not sorted last.

Common Pitfalls

  • Pitfall: one tag treated as final. Fix: re-triage at each move and at receiving facilities.
  • Pitfall: mixing adult and pediatric thresholds. Fix: use JumpSTART for children younger than 8 years and adult START for older patients.
  • Pitfall: using the trauma destination thresholds as the MCI tag. Fix: the 2021 field triage thresholds (respiratory rate below 10 or above 29/min; age-specific systolic BP) decide destination for injured patients; the MCI sequence decides order.
  • Pitfall: finishing every assessment before treatment. Fix: stop the sort for the Immediate patient who needs bleeding control or an airway.
  • Pitfall: treating every not-breathing patient the same. Fix: reposition the airway once; the result sets the tag, and local protocol and medical command govern expectant decisions.
Accuracy is limited: Simulation studies in 2025 put triage accuracy at about 70–76%, even after training. Build re-triage in. Don't trust the first pass alone.

Education & Skill Maintenance

Skill Maintenance

  • Run a timed sort drill at least once per shift or per quarter, with a debrief of each miscategory.
  • Practice the three checks (breathing, perfusion, mental status) on partners before a drill.
  • Rehearse the count and hand-off with the receiving facility.
  • Use virtual reality or low-fidelity simulation to rehearse the scene where live drills are limited.
Triage team leader in protective gear assessing volunteers with simulated wounds during an exercise
Figure 4: Triage exercise (FEMA Hospital Emergency Response Training). Source: Wikimedia Commons, FEMA (Shannon Arledge), public domain

References

  1. Lerner EB, Schwartz RB, Coule PL, Weinstein ES, Cone DC, Hunt RC, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(Suppl 1):S25-S34. https://doi.org/10.1097/DMP.0b013e318182194e
  2. Kahn CA, Schultz CH, Miller KT, Anderson CL. Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med. 2009;54(3):424-430. https://doi.org/10.1016/j.annemergmed.2008.12.035
  3. Jenkins JL, McCarthy ML, Sauer LM, Green GB, Stuart S, Thomas TL, Hsu EB. Mass-casualty triage: time for an evidence-based approach. Prehosp Disaster Med. 2008;23(1):3-8. https://doi.org/10.1017/s1049023x00005471
  4. Stéfani GM, de Melo ME, Zardeto HN, Costa VSLP, Lima FS, Cola M. JumpSTART triage protocol in disaster pediatric patients: a systematic literature review. Prehosp Disaster Med. 2022;37(2):240-246. https://doi.org/10.1017/S1049023X22000127
  5. Kman N, Way D, Panchal AR, Patterson J, McGrath J, Danforth D, Mani A, Babbitt D, Hyde J, Pippin B, de Visser E, McVay J. Virtual reality simulation for assessment of hemorrhage control and SALT triage performance: a comparison of prehospital to in-hospital emergency responders. Prehosp Disaster Med. 2025;40(4):191-198. https://doi.org/10.1017/S1049023X25101349
  6. de Visser E, Way DP, Danforth D, McGrath J, Hyde J, Choy K, Audick J, Pippin B, Panchal AR, McVay J, Kman N. Field triage errors: a cross-sectional study of emergency responders in a virtual reality mass casualty simulation. Disaster Med Public Health Prep. 2025;20:e4. https://doi.org/10.1017/dmp.2025.10288
  7. Newgard CD, Fischer PE, Gestring M, et al. National guideline for the field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2021. J Trauma Acute Care Surg. 2022;93(2):e49-e60. https://doi.org/10.1097/TA.0000000000003627
  8. Office of the Assistant Secretary for Preparedness and Response (ASPR), Chemical Hazards Emergency Medical Management (CHEMM). JumpSTART Triage (incident primer, triage section). 2026; accessed October 2026. https://chemm.hhs.gov/incident-primer/triage/jumpstart-triage

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  • For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
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