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START is not the best triage stategy
  1. L Wallis
  1. Dunstone Farm Barns, Shaugh Prior, Plymouth P17 5EH; lee.wallis{at}

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    I read with interest the article of Delaney and Drummond1 in the April issue, and found it both useful and informative. However, I must disagree that in mass casualty situations “Most experts agree that START (simple triage and rapid treatment) … is the best strategy”.

    This recommendation should only be made if the system is the easiest to use for the people undertaking the triage process, or is the most accurate at triaging patients.

    Three triage systems are currently in common use in the developed world: START, Careflight, and the Triage Sieve and Sort.

    START was devised in the mid 1990s in the United States, and has since been modified. It bases triage around walking, breathing, presence or absence of a radial pulse, and the ability to follow commands, and categorises patients for immediate or delayed care, or as unsalvageable.

    Careflight is used in many parts of Australia, and also uses walking as the first discriminator. It then relies on the ability to follow commands, presence of a radial pulse, and presence of breathing to assign an appropriate category. Patients are immediate, urgent, delayed, or dead.

    The UK system, Triage Sieve and Sort, uses the same four triage categories. The Sieve is used for primary triage, at the scene, and patients are retriaged using the Sort at the casualty clearing station.

    The Sieve first uses a walking filter, and then presence of breathing, respiration rate, and capillary refill time or heart rate to categorise patients. The Sort uses the triage revised trauma score, to which may be added anatomical information.

    In terms of ease of use, the algorithm chosen must fulfil two criteria. The first is that it is simple to use: all three algorithms fulfil this requirement. The second is that users should be familiar with it. The triage Sort will be familiar to most UK pre-hospital personnel, as it is the system used by most UK ambulance services on a day to day basis. The Sieve will be familiar to all those who have attended the Major Incident Medical Management and Support (MIMMS) course2 or the shorter one day version.

    As increasing numbers of doctors, nurses, ambulance personnel, and other emergency services are now attending MIMMS courses, the Triage Sieve and Sort will become more familiar. The course is now taught in Sweden, Holland, Australia, Cyprus, and has recently been accepted by NATO. It is being considered in South Africa.

    With regard to the accuracy of the algorithm, a recent article in the Annals of Emergency Medicine3 retrospectively compared START, Careflight, and the Triage Sieve. The authors found that START had the same sensitivity and a lower specificity than Careflight for identifying critically ill patients. The use of Triage Sieve alone rather than Sieve and Sort makes interpretation of their results with regard to that system unreliable.

    Many mass casualty situations involve children, and a triage algorithm that relies on walking or adult physiological values will over-triage many children. The Triage Sieve offers an alternative in the Paediatric Triage Tape, which is currently being prospectively validated in South Africa.

    This combination of factors—familiarity to UK pre-hospital providers, accuracy, and accommodating injured children—should lead to the recommendation that, for mass casualty situations in the United Kingdom, the Triage Sieve and Sort should be the triage algorithm of choice.

    Furthermore, all those providing medical care at mass gatherings such as sporting events should have attended a MIMMS course, which provides an excellent system in the unlikely event of a mass casualty situation.