Presence of undertriage and overtriage in simple triage and rapid treatment


  • J. J. Hong, MEd
  • Gerard Carroll, MD
  • Rick Hong, MD



START, triage, overtriage, undertriage


Objective: We evaluated the use of the Simple Triage and Rapid Treatment (START) method by Emergency Medical Services (EMS) and hypothesized that EMS can categorize patients using the START algorithm accurately.

Design: Retrospective Chart Review.

Setting: Inner-city Tertiary-Care Institutional Emergency Department (ED).

Participants: Patients 18 years transported by EMS with a START color of Red, Yellow, or Green during the state triage tag exercise, October 9-15, 2011.

Interventions: EMS assigned each patient a START triage tag. Chart review of the electronic EMS run sheets was performed by investigators to determine a START color.

Main Outcome Measures: START triage colors were re-categorized as Red = 1, Yellow = 2, and Green = 3. The difference between the investigators’ color and EMS color were coded as: 0 for agreement in triage, -1 for undertriage by one category, -2 for undertriage by two categories, 1 for overtriage by one category, 2 for overtriage by two categories.

Results: Of 224 participants, START triage colors were: Red = 7.1 percent, Yellow = 19.2 percent, Green = 73.7 percent. The mean difference in triage categories was 0.228 (95% CI: 0.114-0.311, p<.001). 71.0 percent of patients were triaged to the same category, 5.8 percent undertriaged by one category, 0 percent undertriaged by two categories, 17.9 percent overtriaged by one category, and 5.4 percent overtriaged by two categories.

Conclusion: EMS was more likely to overtriage using START. All patients who were overtriaged by two categories were ambulatory at the scene, which implies other findings not in START may affect triage.

Author Biographies

J. J. Hong, MEd

Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey

Gerard Carroll, MD

Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey

Rick Hong, MD

Cooper University Hospital, Cooper Medical School of Rowan University, Camden, New Jersey


Cook L: The World Trade Center Attack: The Paramedic Response: An Insider's View. Critical Care. 2001; 5(6): 301. Web. 8 Mar. 2017.

Jenkins, JL, McCarthy ML, Sauer LM et al.: Mass-casualty triage: time for an evidence-based approach. Prehosp. Disaster Med. 2008; 23(1): 3-8. Web.

Arshad FH, Williams A, Asaeda G. et al.: A modified simple triage and rapid treatment algorithm from the New York City (USA) Fire Department. Prehosp. Disaster Med. 2015; 30(2): 199-204. Web.

Garner A et al: Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med. 2001; 38(5): 541-548. Web.

Bhalla MC, Frey J, Rider C et al: Simple triage algorithm and rapid treatment and sort, assess, lifesaving, interventions, treatment, and transportation mass casualty triage methods for sensitivity, specificity, and predictive values. Am J Emerg Med. 2015; 33(11): 1687-1691. Web.

Cross KP, Mark XC: Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann. Emerg Med. 2013; 61(6): 668-676.e7. Web.

Gebhart ME, Robert P: START triage: Does it work? Disaster Manag Response. 2007; 5(3): 68-73. Web.

Kahn CA et al.: Does START triage work? An outcomes assessment after a disaster. Ann Emerg Med. 2009; 54(3): 424-430.e1. Web.

Ersoy N, Ashhan A: Triage decisions of emergency physicians in Kocaeli and the principle of justice. Turkish J Trauma Emerg Surg. 2010; 16(3): 203-209. Print.

Schenker JD et al.: Triage accuracy at a multiple casualty incident disaster drill: The emergency medical service, fire department of New York city experience. J Burn Care Res. 2006; 27(5): 570-575. Web.

Kilner T: Triage decisions of prehospital emergency health care providers, using a multiple casualty scenario paper exercise. Emerg Med J. 2002; 19(4): 348-353. Web.

Frykber ER, Joseph JT: Terrorist bombings. Ann. Surg. 1988; 208(5): 569-576. Web.



How to Cite

Hong, MEd, J. J., G. Carroll, MD, and R. Hong, MD. “Presence of Undertriage and Overtriage in Simple Triage and Rapid Treatment”. American Journal of Disaster Medicine, vol. 12, no. 3, July 2017, pp. 147-54, doi:10.5055/ajdm.2017.0268.




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