What does a yellow triage tag mean?

Disaster triage nursing review for students about the color-coded tags and the START method!

The goal of this review is to help you understand each of the four tag colors that make up the triage tagging system and how to use the START method to assign tag colors in a disaster situation. For exams, you want to be familiar with the following:

• Meaning of the four tag colors (ex: the colors, who is seen first and so forth, what injury types are included)
• How to apply the START method in scenarios you will be given on an exam (ex: a wounded individual is presenting with the following….what color tag is the wounded assigned using the START method?)

Don’t forget to test your knowledge on this content by taking the disaster triage nursing quiz.

Disaster Triage Nursing Lecture

Disaster Triage Nursing

In this review, we will be concentrating on triage related to a disaster situation. This is where there are many wounded individuals, but the personnel and resources available to treat those wounded are limited. Therefore, personnel and resources should be used wisely, and this is where the disaster color-coded triaging tagging system and START method can be helpful.

Disaster Triage Color Tags

There are four colors and a wounded individual will be tagged one color based on their health status. The four colors include:

To help you keep the meaning of the tag colors red, yellow, and green separated, think of a traffic light and what you do at the traffic light when it turns certain colors. The reason I include this is because many students get confused about these three colors on exams. The black tag color is easy to remember because black is most commonly associated with death, which is the meaning of this tag color.

Red Tag: Immediate

What do you do at a traffic light when it turns red? You stop! Therefore, when a patient is tagged red, STOP and get them treatment because they have first priority in receiving care.

• Seen 1st
• Injuries are life-threatening but they could possibly survive if they are immediately treated.
• Severe alteration in breathing, circulation, and neuro/mental status
• Conditions that would cause a wounded individual to be tagged red (think of conditions or systems of the body that if severely damaged could majorly alter the breathing, circulation, and neuro system)
  • Spinal cord injuries: remember various areas of the spinal cord control breathing, brain and heart function…shock can occur like neurogenic, cardiogenic etc.
  • Severe bleeding (internal or external): if the patient is treated immediately so the bleeding could be stopped and transfused with blood products they may live
  • Major burns that affects a high percentage of the body: burns can affect the circulation and the respiratory system (depending on the burn type and where it’s located)
  • Some types of major respiratory trauma: pneumothorax etc.

Yellow Tag: Delayed

What do you do at a traffic light when it turns yellow? You slow down or delay because you’re about to stop. Therefore, when a patient is tagged yellow their treatment is delayed but for only about an hour or so because they could turn critical based on their presenting injuries.

• Seen 2nd (second priority)
• Significant injuries BUT at this point their breathing, circulation, and mental status is within normal range but this could change.
• Conditions:
  • Bone fractures: major fractures that require medical treatment
  • Integumentary damages: open wounds, deep lacerations etc.

Green Tag: Minor

What do you do at a traffic light when it turns green? You go! Many times these wounded individuals are termed the “walking wounded”. Therefore, these patients can get up and GO (move around). Their injuries are minimal.

• Treatment can be delayed for several hours and some can treat themselves.
• Breathing, circulation, mental status not expected to change

Black Tag: Expectant

• Wounded is dying or expired.
• Injuries are deadly to the point the individual will not survive.
• Absence of breathing, circulation, mental status.

START Method

This method can help determine what tag color a wounded victim is assigned. START stands for “Simple Triage And Rapid Treatment”. This particular method is for the adult. It’s very easy to use and quick.

First, you want to look at the wounded individual and ask yourself “what is the wounded victim doing?” Are they able to walk around? OR Are they unable to walk or move?

If the wounded individual can walk around and move, their breathing, circulation, and mental status are within normal range. Therefore, they are tagged GREEN.

Walking? GREEN TAG

Unable to move or walk? Check these three things in this order: Breathing, Circulation, and Mental Status/Neuro. The wounded individual that cannot walk will be tagged either RED, YELLOW, or BLACK.

Breathing?

• Yes, rate is greater than 30: RED TAG
• Yes, rate is less than 30: check circulation
• No, reposition airway:
  • Still not breathing: BLACK TAG
  • Yes: RED TAG

Circulation? (radial pulse present or less than 2 seconds capillary refill)

• Yes: check mental status
• No: RED TAG

Mental Status? (can they obey your commands?)

• Yes: YELLOW TAG
• No: RED TAG

References:

START Adult Triage. (2019). [Ebook] (p. 1). Retrieved from https://chemm.nlm.nih.gov/StartAdultTriageAlgorithm.pdf

The World Health Organization defines mass casualty incidents as disasters and major incidents characterized by quantity, severity, and diversity of patients that can rapidly overwhelm the ability of local medical resources to deliver comprehensive and definitive medical care. They have been occurring more frequently in recent decades and affect countries of all socioeconomic backgrounds. Preparedness and planning are vital, as these events can happen in any community at any given time. Defined pre-hospital triage systems are essential in saving lives and optimizing the initiation of resource allocation when these disasters strike.[1][2][3][4][5]

Mass casualty incidents triage systems are implemented to offer the greatest good to the greatest amount of people as healthcare resources are limited or strained due to the number of injured individuals. Treatment during triage is minimal, and this is counterintuitive to normal pre-hospital protocols. The goal is to move patients away from the incident and toward resources that offer more comprehensive care.

Most mass casualty incident triaging systems use tags or colored designations for categorizing injured persons. It is important to designate areas where to tagged and/or labeled individuals can relocate. These areas will dually serve as treatment and loading zones for arriving ambulance crews. Triaging during a mass casualty incident is a dynamic and fluid process that requires a certain degree of pre-incident training. Patients may initially be triaged to one category but may be switched to another due to changes in their clinical status. Many of the triage tags have fold-over tabs that are designed to switch patients between categories easily. However, emphasis should be placed on rapid assessment and quick movement of patients.

Primary triage systems are not built for determining resource allocation. There may be various implementation strategies for treatment and evacuation once patients have been triaged, depending on the system or agency using the system. They do not rely on the number of victims present or resources available, and some have argued the need for a more sophisticated system allowing for consideration of these factors. Triaging algorithms are simple, straightforward, and easy to use; however, they can allow for over or under triaging depending on the situation. There are many available systems, and it is important to choose one and have it in place as an important part of any disaster preparedness plan, which can ultimately help save lives.

Multiple triage systems are currently being implemented around the world. Some of the more well-known algorithms include START (simple triage and rapid treatment), SALT (sort, assess, life-saving interventions, treatment/triage), STM (Sacco triage method), Care Flight Triage, and SAVE (Secondary assessment of victim endpoint). There is limited data available to support one system over another. However, it is important to choose one and adhere to its algorithm to maintain an ordered approach.[6][7][8][9][10]

START Triage

Simple triage and rapid treatment (START) is currently the most widely used triage system in the United States for mass casualty incidents. It was developed in 1983 by staff at Hoag Hospital and Newport Beach Fire Department in California for rescuers with basic first-aid skills.  First responders delegate the movement of injured victims to a designated collection point as directed by using four main categories based on injury severity:

• BLACK: (Deceased/expectant) injuries incompatible with life or without spontaneous respiration; should not be moved forward to the collection point

• RED: (Immediate) severe injuries but high potential for survival with treatment; taken to collection point first

• YELLOW: (Delayed) serious injuries but not immediately life-threatening

• GREEN: (Walking wounded) minor injuries

The triage colors may be assigned by giving triage tags to patients or simply by physically sorting patients into different designated areas. (see the algorithm below) "Green" patients are assigned by asking all victims who can walk to a designated area. All non-ambulatory patients are then assessed. Black tags are assigned to victims who are not breathing even after attempts to open the airway. Red tags are assigned to any victim with the following:

• Respiratory rate greater than 30

• Absent radial pulse or cap refill greater than 2 sec

• Unable to follow simple commands

Yellow tags are then assigned to all others. The mnemonic “RPM:30-2-can do” is an easy way to remember these decision points.

SALT Triage

The sort, assess, life-saving interventions, and triage/treatment approach is similar to the START system; however, it is more comprehensive and adds simple life-saving techniques during the triage phase.

• SORT: sort the walking, waving, and still. This can be achieved by asking everyone at the scene to walk to a designated casualty collection point similar to the START method; however, this is followed by asking to wave an arm or leg if they need help. Those who cannot move or follow commands should be assessed first.

• ASSESSMENT: assessment and life-saving interventions go hand in hand. When you assess a victim and find life-threatening injuries, you should intervene.

• LIFE-SAVING INTERVENTIONS: simple techniques such as controlling major hemorrhage, opening airways, needle decompression, and auto-injector antidotes should be performed as long as it is not time intensive. Once performed, the provider should assign a color-coded tag similar to the START system and move onto the next patient to ensure the forward flow of patients.

• TREATMENT AND TRANSPORT: Once tagged, patients will be moved to the designated casualty collection point for transport by emergency management services to receiving facilities.

JumpSTART

JumpSTART is a modification to the START system and takes into account the difference in “normal” respiratory rates for children. This tool acts to assess pediatric patients better. The age cutoff for use is eight years old. If the child’s age is unknown, the rescuer can assess for underarm hair in males or breast development in females as an indicator of adult age and exclusion from this cohort.

The differences in this algorithm include:

• Five rescue breaths are to be given to apneic children with a pulse; then, they are given a black tag.

• Normal RR are more than 15 or less than 45

• Neurological assessment is done using the mnemonic AVPU (alert, responds to verbal stimuli, responds to painful stimuli, and unresponsive). Any patient who has abnormal posturing to painful stimuli or is unresponsive gets a red tag designation.

Review Questions

1.

Lincoln EW, Freeman CL, Strecker-McGraw MK. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 22, 2021. EMS Incident Command. [PubMed: 30521221]

Heffernan RW, Lerner EB, McKee CH, Browne LR, Colella MR, Liu JM, Schwartz RB. Comparing the Accuracy of Mass Casualty Triage Systems in a Pediatric Population. Prehosp Emerg Care. 2019 May-Jun;23(3):304-308. [PubMed: 30196737]

Hart A, Nammour E, Mangolds V, Broach J. Intuitive versus Algorithmic Triage. Prehosp Disaster Med. 2018 Aug;33(4):355-361. [PubMed: 30129913]

Jain T, Sibley A, Stryhn H, Hubloue I. Comparison of Unmanned Aerial Vehicle Technology-Assisted Triage versus Standard Practice in Triaging Casualties by Paramedic Students in a Mass-Casualty Incident Scenario. Prehosp Disaster Med. 2018 Aug;33(4):375-380. [PubMed: 30001765]

Dittmar MS, Wolf P, Bigalke M, Graf BM, Birkholz T. Primary mass casualty incident triage: evidence for the benefit of yearly brief re-training from a simulation study. Scand J Trauma Resusc Emerg Med. 2018 Apr 27;26(1):35. [PMC free article: PMC5923025] [PubMed: 29703219]

Justice J, Walker, III JR. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 11, 2021. EMS Reverse Triage. [PubMed: 29489264]

Yu W, Lv Y, Hu C, Liu X, Chen H, Xue C, Zhang L. Research of an emergency medical system for mass casualty incidents in Shanghai, China: a system dynamics model. Patient Prefer Adherence. 2018;12:207-222. [PMC free article: PMC5798575] [PubMed: 29440876]

Ryan K, George D, Liu J, Mitchell P, Nelson K, Kue R. The Use of Field Triage in Disaster and Mass Casualty Incidents: A Survey of Current Practices by EMS Personnel. Prehosp Emerg Care. 2018 Jul-Aug;22(4):520-526. [PubMed: 29425472]

Hoff JJ, Carroll G, Hong R. Presence of undertriage and overtriage in simple triage and rapid treatment. Am J Disaster Med. 2017 Summer;12(3):147-154. [PubMed: 29270957]

Shartar SE, Moore BL, Wood LM. Developing a Mass Casualty Surge Capacity Protocol for Emergency Medical Services to Use for Patient Distribution. South Med J. 2017 Dec;110(12):792-795. [PubMed: 29197316]