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Altered Standards of Care in Mass Casualty Events

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness (PHEP) program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Appendix B. Preliminary Review of Selected Emergency Response Protocols and Models

A preliminary review of a number of triage protocols and preparedness models was conducted prior to the expert meeting to assess the extent to which these documents provided explicit guidance on the issue of altered standards of care in the context of a mass casualty event. Brief summaries of the review of several field triage protocols and the Modular Emergency Medical System (MEMS) are presented below.

Field Triage Protocols

One category of altered standards of care focuses on specific methods for field triage. In a mass casualty situation of any magnitude, methods of triage, or sorting victims according to their condition and resources available, are used to identify and, if possible, move to immediate treatment those who are most likely to survive or can benefit the most from treatment. Thus, triage standards address who receives care and when care is provided or the urgency with which it is provided. Triage is performed most often by first responders.

Triage begins in the field if there is a fixed event site; however, it also occurs within care settings, such as hospitals and alternate care sites, where individual victims may present themselves for care independent of organized responses. Secondary triage also may be necessary within a facility, such as a hospital, as demands on the system grow.

Several well-established standards for triage are currently in use.1-5 Triage systems include START; JumpSTART (a pediatric modification to START); START, then SAVE; MASS; and others. Each system seeks to establish a small number of categories among victims that indicate the urgency with which they should be treated. Colors are often used to represent the categories—for example, red (immediate care); yellow (delayed); green (ambulatory and minor injuries); and black (dead and/or expectant).

The adequacy of the triage system used depends on the nature of the event and the population affected. For example, systems such as START and JumpSTART are trauma-oriented and may be effective in an explosive event. Traditional epidemic approaches to triage, considered more appropriate for biological events, sort infected patients into three categories: susceptible individuals, infected individuals, and removed individuals (by successful immunization, recovery, or death).

These standards have the impact of allocating resources for patient care. The standards are relevant to pre-hospital, hospital, and alternate care sites and to a situation where resources are constrained and demand is so great that rationing is required. While most systems offer detailed clinical measurements of status for triage purposes, they do not, by definition, provide actual clinical protocols for the treatment that would follow.

Modular Emergency Medical System

Another type of standard that is pertinent to this discussion is one that addresses the organization of care and provides a context in which triage and medical care guidelines would be used. The Modular Emergency Medical System (MEMS) offers a comprehensive plan of operations and standards for responding to a mass casualty event of such size that alternate care delivery sites would be required.

MEMS emerged in response to Title IV of The Defense against Weapons of Mass Destruction Act of 1996 (Public Law 104-201). The law required that the Secretary of Defense develop and carry out a program to improve the responses of Federal, State, and local agencies to emergencies involving biological and chemical weapons. In response, the U.S. Department of Defense (DOD) created the Biological Warfare Improved Response Program. DOD then invited the Departments of Health and Human Services (HHS), Energy (DOE), and Agriculture (USDA), and the Federal Emergency Management Agency (FEMA), the Federal Bureau of Investigation (FBI) and the Environmental Protection Agency (EPA), as well as emergency responders and managers from multiple States and local communities, to participate.

MEMS offers detailed standards for a system of care that can be expanded and contracted in modular units as the need arises. It provides a framework for the organization of care, particularly for setting up predetermined, special-use alternate care sites. Thus, MEMS answers the questions of what general kinds of care are provided and where (alternate site standards). In specifying the staffing required for alternate care sites, MEMS also addresses who will provide care. One of the underlying assumptions in MEMS is that resources will be brought in or created within the area most affected by the mass casualty event. Exhibit B-1 (49 KB) graphically depicts the operation of MEMS.

Appendix B References

1. Wackerle, J.F. Disaster planning and response. N Eng J Med 1991; 324:815-21.

2. Romig L. The "JumpSTART" Rapid Pediatric Triage System. Available at:

3. Benson M, Koenig K.L., Schultz C.H. Disaster Triage. START, then SAVE—A New Method of Dynamic Triage for Victims of a Catastrophic Earthquake. Prehospital and Disaster Medicine April-June 1996; 11(2).

4. MEDDAC Non-Commissioned Office Development Program. Emergency Management Planning slide presentation. Fort Carson, CO. Available at: Accessed December 2004.

5. Burkle, F.M. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decision. Emergency Med Clin N Am 2002; 20:409-36.

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AHRQ Publication No. 05-0043
Current as of April 2005


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