Simply Triage

In emergency medicine circles, START stands for Simple Triage and Rapid Transport.

But how simple is a system that includes as many as 20 individual steps? Not simple enough for Marian Nowak, MEd, MPH, MSN, CSN, FCN, RN.

As a school nurse in Hammonton, NJ at the time, Nowak knew she needed training in triage for two reasons.

“From a medical standpoint, you are doing good nursing,” she said. “From a legal standpoint, you are protecting the school.”

By 2007, Nowak had begun creating her own, simplified version of START, typing it on a trusty index card.

That card came in handy in 2009, when a nearby forest fire engulfed the high school where Nowak worked in smoke. She assessed all her students for inhalation injury then sent them home according to medical priority, beginning with children with heart disease or asthma.


Emergency Management Planning

A resource guide for nurses responding to a disaster brought to you by ADVANCE for Nurses.

“You can triage 55 people in 1 minute – if you do it accurately,” she said. “Something with three steps rather than 15 or 20 is very easy to understand.”

Nowak never dreamed that her quest for simplicity in a pre-hospital disaster response model for nurses would create worldwide interest.

Yet, to date, public health officials from Japan, China, Indonesia, Guam, Egypt, Saudi Arabia, Canada and Poland have invited her to explain her model in person.

“Nurses in Japan told me they were very stressed that they couldn’t remember all those steps,” she said. “They were very happy to learn I had developed a shorter model.”

Cognitive Neuro-Learning

While researching disaster response models in 2009, Nowak heard that researchers at Harvard University’s Mind, Brain and Education Institute were studying strategies in cognitive neuro-learning.

One strategy focused on a pictoral view of information, usual visuals as memory cues.

That’s when her big idea struck: why not graft a visual-cue technique onto her abbreviated disaster response model? It was a brainstorm, and soon became the subject of her master’s thesis in public health.

“One thing led to another,” said Nowak, now an associate professor in public health nursing at La Salle University School of Nursing and Health Sciences in Philadelphia. “It was a class project that just grew and grew.”


Essentially, Nowak’s three-step model of disaster response embodies: 1) a racing car, 2) a traffic light, and 3) the pneumonic “32cue”.

First, the racing car:

“In an emergency situation, your pulse is beating hard and your heart rate is up,” she explained. “A racing car helps you remember three assessment criteria: respiration, pulse and mental status.”

Second, the traffic light:

“A traffic light’s colors of red, yellow and green represent the categories of triage, with red being urgent,” Nowak said. “When doing START rapid triage, you literally tag people so when the ambulance arrives, EMTs see the most urgent cases. People who can walk on their own are tagged green.”

Third, the pneumonic:

“’32-cue’ stands for 30 respirations, plus two for capillary refill, and cue, referring to when a triage patient can or can’t answer appropriately to verbal cues,” she said.

“I lecture on my model and I repeat ’32-cue’ at least 6 times during that hour. When the brain absorbs a phrase so often, it retains it. That’s cognitive learning.”

Hong Kong Conference

Nowak refined her model, conducted additional research, conferred with colleagues and submitted an abstract to the School Nurses International Conference committee – it was accepted.

In July, she gave a multimedia workshop on her triage method at that conference, which was held in Hong Kong and drew 350 attendees from 29 countries.

“The energy of all those nurses from different countries comparing evidence-based practices was amazing,” she said. “School nursing in China is only a year old. They had a lot of questions.”

Coming up in May, Nowak will present her technique to undergrad nursing students at Case Western Reserve University in Cleveland, where she is pursuing a doctorate in nursing practice.

And she plans to follow up with another lecture at the 2013 School Nurses International Conference in Slovenia.


Heart Sounds

Accurate cardiac assessment is a technique that is learned over time with practice and patience.

Meanwhile, the National Association for Student Nurses notified Nowak it wants to implement her system online as part of its certificate program.

“With a disaster like 9/11, nurses see action either in a hospital or in a community medical shelter or at the site itself,” she noted. “So they need to know rapid triage in these three settings. That’s where the curriculum needs to improve.”

As for her future, Nowak said:

“I will probably do more workshops and finish my doctorate. I’m going to research other disaster response models for nursing. There is some research suggesting the teaching of these models is not consistent. I would like to develop the core skill, START rapid triage.”

And have fun all the while. “I enjoy teaching,” she said. “There is no financial gain for me. I generally share my ideas with colleagues.”

Michael Gibbons is an editor at


About The Author