START Triage Algorithm: The 60-Second Victim Assessment

A mass-casualty incident changes everything in an instant. Dozens of victims. Limited personnel. No time to deliberate. The first responder who arrives on scene needs a system that works under that pressure, one that’s easy to learn, easy to remember, and easy to use when the stakes are highest.

The START triage algorithm was built for exactly that moment. Developed in 1983 and refined through decades of real-world deployment, START (Simple Triage and Rapid Treatment) gives responders a structured path through the chaos, letting them assess each victim in 60 seconds or less. It doesn’t require advanced medical training. It requires discipline, practice, and a system you trust.

For departments building or refreshing their mass-casualty protocols, the START triage system remains one of the most widely adopted frameworks in U.S. emergency response. This post walks through how the algorithm works, what it assesses, and how to apply it correctly when every second counts.

What Is the START Triage Algorithm?

START triage is a field-based assessment system that allows first responders to quickly categorize victims in a mass-casualty incident (MCI) by severity of injury. Using three physiological indicators, respirations (R), perfusion (P), and mental status (M), responders assign each patient to one of four color-coded priority categories: immediate (red), delayed (yellow), minor (green), or deceased/expectant (black). The entire assessment takes 60 seconds or less per patient.

The system was developed at Hoag Memorial Hospital Presbyterian and the Newport Beach Fire Department in California in 1983, then updated in 1994. Its track record spans major incidents including the 1993 World Trade Center bombing and the 1995 Oklahoma City bombing, where responders used it under conditions that tested every aspect of the design. That history isn’t a footnote. It’s what makes START credible in the field.

What Is a Triage Algorithm?

A triage algorithm is a step-by-step decision framework that guides a responder through a standardized assessment sequence, producing a priority classification for each patient. Rather than relying on individual clinical judgment under high-stress conditions, the algorithm reduces decision fatigue by making each step predictable. You follow the path. The path tells you what to do next.

In mass-casualty response, speed matters more than perfection. Research indexed through the National Institutes of Health confirms that delayed triage in MCIs directly correlates with increased preventable mortality. An algorithm like START ensures that even a responder who completed only basic first aid training can make consistent, defensible decisions in the field.

How Does the 60-Second Assessment Work?

The START algorithm follows the RPM pneumonic in a fixed sequence. Here is what each step looks like in practice:

1. Walk and wave. Call out for anyone who can walk and wave to move to a designated area. These are your minor (green) patients. Clearing them first lets you focus immediately on those who can’t self-rescue.
2. Respirations. Check if the patient is breathing. If not, reposition the airway. If they resume breathing within roughly five seconds, classify as immediate (red). If they don’t breathe after repositioning, classify as deceased/expectant (black).
3. Perfusion. Check the radial pulse or capillary refill. If capillary refill exceeds two seconds, or there’s no radial pulse, classify as immediate (red).
4. Mental status. Give a simple command: “squeeze my hand” or “open your eyes.” If the patient can’t follow it, classify as immediate (red).
5. Tag and move. Assign the color tag, mark the patient, and move immediately to the next victim.

That five-second window during the breathing check is sometimes called “the 5-second rule” in field training. It’s brief enough to keep the assessment moving but long enough to give the airway a real chance to open. Andres Price has emphasized in training contexts that this pause is where new responders most often hesitate, which is exactly why drilling the sequence to automaticity matters so much before a real incident.

What Scenarios Does START Apply To?

START is designed for adult victims across the full range of mass-casualty incidents. Situations where responders regularly deploy the algorithm include:

• Multi-vehicle collisions with five or more victims
• Structure fires with trapped or unconscious occupants
• Industrial and workplace disasters
• Active shooter events and terrorist incidents
• Natural disasters: earthquakes, tornadoes, building collapses
• School and public venue emergencies
• Transportation incidents involving buses, trains, or aircraft

The algorithm is intentionally broad. That’s not a weakness. It means a single training standard applies across the full spectrum of emergencies a department might face. Detailed START training materials, including instructor manuals, lesson plans, and drill guides, are available to help departments build proficiency across all of these situations.

“Effective triage in mass-casualty incidents requires a systematic, repeatable approach that can be applied rapidly under high-stress conditions by responders at all training levels.”

— National Center for Biotechnology Information, StatPearls: Mass Casualty Management

What About Children? JumpSTART Triage

JumpSTART is a pediatric adaptation of the START algorithm developed in 1995 by Dr. Lou Romig. It modifies the respiratory and perfusion thresholds to account for physiological differences between children and adults. JumpSTART also adds a check for a brachial pulse, since children are more likely to maintain perfusion at lower heart rates than adults are.

If your department handles incidents where pediatric victims are likely, including schools, parks, and sporting events, training your crew on JumpSTART alongside START is worth building into your curriculum. The core sequence is the same. The cutoffs are different. Knowing both keeps responders from misclassifying a child as expectant when they’re actually salvageable with immediate intervention.

How Does START Compare to SALT Triage?

SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) is another widely used MCI triage system that adds a brief lifesaving-intervention step before assigning priority tags. That makes it slightly more interventional than START at the triage phase. Things like controlling major hemorrhage or opening an airway happen before, not after, the classification decision.

Neither system is universally superior. START is faster and demands less clinical decision-making from the initial responder. SALT offers a more flexible framework that accounts for simple interventions during the triage pass itself. The CDC supports SALT as a candidate for a unified national standard, but many jurisdictions, particularly across California, have trained on START for decades and apply it effectively under real-world conditions. What matters most is that your team trains on one system consistently and executes it without hesitation when the incident unfolds.

“No single triage system has been shown to be clearly superior to another; the best system is the one that responders know and can apply reliably under pressure.”

— Prehospital Emergency Care, Mass Casualty Triage: An Evaluation of the Data and Development of a Decision Aid

What to Expect From START in the Field

After initial training, responders can triage each victim in 60 seconds or less. That’s a verified performance benchmark confirmed by departments that have used the system across California. In a 50-victim incident, a three-person triage team working the START algorithm correctly can complete initial sorting in under 20 minutes.

Expect the first few live drills to run slower. That’s normal, and it’s not a problem as long as the drills happen regularly. The algorithm is simple, but applying it under simulated stress takes repetition before the sequence becomes automatic. The START training video walks through scenario-based exercises that replicate the time pressure and sensory load of a real incident, which closes the gap between classroom training and field performance. Most programs recommend quarterly exercises with scenario variation to maintain proficiency year over year.

Practical Tips for Building START Proficiency

• Use RPM as your anchor. Respirations, perfusion, mental status. Drill the sequence until it’s reflexive, not just remembered.
• Train with physical triage tags. Tabletop exercises without tags leave a gap. Physically marking a simulated victim builds the muscle memory that carries over to the field.
• Rotate your scenarios. Don’t always train on vehicle collisions. Run structure fire, industrial, and school scenarios to keep responders adaptable across incident types.
• Add JumpSTART to the curriculum. If your response area includes schools, parks, or venues likely to have children, both protocols need to be trained.
• Debrief every drill. The moments where responders hesitate reveal exactly where more repetition is needed. Document the hesitation points and address them in the next session.
• Time your assessments. Run drills with a stopwatch. If your crew averages more than 90 seconds per victim, slow down in training until the steps are cleaner before pushing for speed.

Keeping physical training materials on hand makes all of this easier to execute consistently. The START training cards give each responder a portable reference during tabletop and field exercises, reinforcing the sequence between full drill sessions.

Mass-casualty incidents don’t allow for uncertainty. START reduces that uncertainty by giving every person on scene a shared language and a shared process. An organized, memorable method is the difference between a well-managed incident and a chaotic one. Train your crew on the algorithm, run the drills, time the assessments, and make the system as familiar as the equipment on their belt. When the call comes in with a 911 victim count that changes everything, you want the response to be automatic.