How SMART is your triage?

CarolinaFireJournal - Jeremy Hill
Jeremy Hill
10/14/2010 -

When training or preparing for the call that stretches you and your service to the limit, a consistent and efficient approach to triage is advantageous. The SMART triage system provides the user with a simple, clear, and concise methodology to completing field triage of patients in the setting of a mass causality incident.


Since North Carolina, as well as several other states, have already adopted the use of the SMART triage systems statewide, we need to ensure technicians receive the proper training to include a practical application of the system. Merriam-Webster defines triage as a: “the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors; b: the sorting of patients (as in an emergency room) according to the urgency of their need for care.” Sounds simple enough, right? With inadequate training or improper use of the equipment, the art of triage can be lost in translation.

What is wrong with the old triage system?

There’s room for improvement! The older system required the technician to make a decision without a clearly defined algorithm, thus giving room for inconsistency. Patients that a senior EMS technician may prioritize as a Yellow, a rookie technician may classify as a Red. During an event such as a Mass Casualty Incident, the scenes are chaotic enough. Taking the guesswork out of triage will assist the triage officer tremendously. The SMART system, when used properly, prevents patients from being over prioritized based on visible injuries instead of actual conditions. Have you ever witnessed a patient be prioritized as a Red based on appearance and not actual assessment findings?

One area that the SMART triage tag really excels is the adult triage algorithm (Figure A). The ability to have consistency amongst technicians, new or seasoned, is crucial. Additionally, the older systems did not allow you room to upgrade or downgrade the priority without using a new tag. Once the old tag was torn at the perforation, you were stuck with that color and priority level until a new card could be located. The SMART system allows you to re-prioritize the patient without the use of a new tag.

At first glance, the SMART Triage system looks like the same old song and dance with a new beat. Once you remove the product and review the material, it starts to make better sense. The tag system that is applied to the patient (Figure B) has the familiar color-coding that we are all accustomed.

  • Red (priority 1) patients are those needing definitive care the quickest.
  • Yellow (priority 2) is used for those patients who need acute medical care after the priority one patients have been properly managed.
  • Green (priority 3) is used for those walking wounded and “worried well” patients found at the incident.

When teaching triage, I often relate the three-tier color system to the red traffic light. When you arrive on scene where triage has been completed and see a green tag patient, you keep going in search of those patients in worse condition. A yellow tag patient makes you slow up and look around to ensure there are no higher priority patients. The notorious red tags patients are the ones you immediately stop and provide treatment. Black tags are used for those patients that have expired prior to your arrival, or no signs of life are found during your assessment. The SMART system allows you to add a Blue mark to those Red priority one patients who, during triage, you expect will not remain viable long enough to be relocated to the field hospital. The SMART Triage PAC (Figure C) is a supped up “fanny pack” that allows the user to have all of the components of the system within hands reach while giving you the versatility of hands-free for your assessment. The adult triage algorithm is attached to the pack, which allows the user to review the decision tree with each patient encountered. Using very simple assessments, such as the patient’s ability to ambulate unassisted, respirations, capillary refill, and their ability to obey commands, the user is able to prioritize the patient quickly and efficiently.

This approach takes the guesswork out of triage and provides consistency during the incident, which will in turn ensure you identify the proper resources needed to manage your incident. The casualty count card allows the user to accurately count each patient to report accurate counts to the EMS operation staff on-site. Red glows sticks supplied in the pack are used for nighttime operations that can be activated and affixed to the patient for easy identification of the priority patients.

In the post 9/11 era that we live, the need to ensure technicians have knowledge on the proper management of patients that have been exposed to hazardous materials is crucial. The SMART triage system has an additional feature that slides into the triage sleeve giving the user the ability to flag the patient as contaminated, which includes chemical, biological, radiological, or infectious, and a decontamination status.

Once the patients have all been initially triaged, prioritized, and moved to the field hospital or patient collection points, the SMART System kicks into overdrive with a comprehensive scoring system that allows the user to reassess the patient to ensure accurate priority assignment. The reassessment of the patient evaluates the Glasgow Coma Score (GCS), total respiratory rate, and systolic blood pressure, to prioritize the patient. This ensures that patients sitting in your field hospital or patient collection area are properly prioritized and confirms the right patients are getting the right care at the right time.

So, you made the decision to purchase the SMART triage or you have the pack already on your unit. Do you know how to correctly use them? A progressive training program is available via TSG Web site and you can even find some online training resources on their Web site,

The training component should include a didactic and practical component that ensures the technicians have retained the information. A few months back, Lenoir Community College trained all local EMS staff using this approach and the practical component is what ties it all together. Some services in our area have implemented triage Tuesdays. During this day, the EMS technicians triage every patient encountered to ensure technician familiarity with the system. These approaches to triage are sound practices and should enhance patient outcomes during the next mass causality system.

Now that we have taken a close look at the SMART triage system, how does it stack up to your current method? After a thorough review, hands-on training, and practical application, I give the SMART triage system an A+!

Jeremy Hill has been involved in EMS for 14 years. He is currently a full-time instructor with Lenoir Community College in Kinston, North Carolina teaching the Emergency Medical Science Program. He has work in an administrative capacity with Lenoir County EMS, Duplin County EMS, and served as an Eastern Regional Specialist with the North Carolina Office of EMS. Hill can be reached at [email protected]. LCC offers EMS online, the only community college in North Carolina with such a program.

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