The Israeli Triage System (ITS): A Model of Centralized Adaptation for Dynamic Threat Environments

The Israeli Triage System (ITS) represents far more than a simple set of clinical protocols; it is a holistic national doctrine strategically developed to manage high-frequency, high-complexity Mass Casualty Events (MCEs) resulting from sustained geopolitical conflict and terrorist threats. The foundational tenet of the system is robust centralization, driven by the understanding that decentralized management cannot efficiently coordinate critical resources during a national crisis. This centralized approach, overseen by the Ministry of Health (MOH), ensures standardized quality of care, resource efficiency, and coordinated integration of all medical services, irrespective of their ownership (public or private).

The success of the ITS is rooted in its highly adaptive structure. It integrates global clinical triage models, such as the Simple Triage And Rapid Treatment (START) system, but modifies them significantly to address unique local operational challenges, notably through the introduction of threat-specific color codes for pediatrics and chemical contamination. These clinical adaptations are seamlessly integrated into a sophisticated logistical framework designed for dynamic casualty load balancing—known as Patient Distribution (PD) and Scattering (SD)—which actively prevents the saturation and failure of regional receiving hospitals.

Furthermore, the ITS is underpinned by explicit ethical preparedness. Recognizing the inevitability of resource scarcity during extreme events, national guidelines, developed by a multi-disciplinary Joint Commission encompassing medical, legal, ethical, and religious experts, provide a transparent and objective framework for allocating scarce resources, such as ventilators or ICU beds. This framework reflects both universal humanitarian principles and local sensitivities, ensuring consistency, equity, and public trust during catastrophic conditions. Ultimately, the ITS demonstrates a strategic mandate to prioritize system resilience alongside individual patient outcomes, a critical lesson for any nation operating under sustained security threats.

The Organizational Architecture of Mass Casualty Management in Israel

A. The Strategic Framework: Ministry of Health (MOH) and Centralized Governance

The defining characteristic of Israel's emergency response doctrine is its rigorous centralized management structure. This governance model is institutionalized under the Strategic Health Authority (SHA), which is headed by the Director General of the Ministry of Health (MOH). The SHA's mandate is comprehensive: it oversees the preparedness of the entire healthcare system for emergencies and assumes operational control and management of all medical agencies—encompassing both public and private institutions—during a crisis.

This consolidated authority is crucial. By mandating control over all health resources, regardless of proprietary ownership, the state effectively assumes total medical sovereignty during times of disaster. This arrangement bypasses potential jurisdictional conflicts and bureaucratic delays that often hinder rapid resource reallocation and coordination in decentralized systems. Centralized medical management is deemed necessary to ensure standardized quality of care across all treating facilities, reduce administrative expenses, and facilitate the effective coordination, integration, and precise timing of all involved services and organizations. This singular, nationwide strategic view is essential for mounting a coherent, high-volume medical response during widespread conflict or terrorist attacks.

The operational arm of the SHA is the Emergency Division, Medical Department (EDMD). This branch functions through specialized committees and task forces composed of senior personnel from various agencies. During an emergency, the EDMD is directly responsible for operating the management and treatment doctrine, coordinating the continuity of care for the general population, and managing comprehensive debriefings covering managerial, logistical, and medical treatment aspects of the emergency situation.

B. Integrated Command: Coordination between Civilian and Military Assets

Effective disaster management in Israel relies on seamless coordination between the civilian healthcare apparatus and military structures. This integration is facilitated by the IDF Home Front Command (HFC), a military organization that coordinates constantly with civilian agencies such as the MOH, police, fire department, and local municipalities during both routine and emergency situations.

The HFC plays a pivotal role in resource and transport management, particularly concerning the tactical element of Patient Distribution (PD). The IDF is instrumental in coordinating the transfer of casualties, especially those transported by helicopter. This is often necessary to bypass local hospitals overwhelmed by a massive influx of patients and rapidly move critical casualties to more distant, specialized Level I trauma centers located in the central regions of the country. Israel’s trauma system is notably distinguished by the significant resources available for vigorous ground and air transport, particularly when compared to low- or middle-income countries, contributing to commendable rapid transport times.

The robust infrastructure and consistent exposure to high-threat scenarios have necessitated a system that incorporates continuous feedback and policy refinement. This environment ensures that clinical and logistical doctrines are continuously tested and revised based on real-world outcomes.

C. The Policy Mandate for Localization

The structure of the Israeli healthcare system itself demands a localized approach to emergency planning. Unlike many international models, existing triage algorithms (such as the PERSEE Algorithm) do not fully align with the specific operational demands of the Israeli system, necessitating a custom-tailored, structured approach to referral decision-making and crisis management.

A significant underlying advantage supporting the localization of triage is Israel's socialized healthcare system, which provides universal coverage to every citizen. This crucial structural element eliminates the component of triage decision-making that, in other countries, must account for financial barriers to care. By ensuring that lack of health coverage is rarely a reason for not seeking or receiving medical attention, the system can focus its triage criteria purely on clinical urgency, predicted likelihood of benefit, and resource allocation efficiency during MCEs.

The following table summarizes the core components of this centralized operational architecture:

Table 2: Key Infrastructure Components of Israel's Centralized MCE Management

Pre-Hospital Triage (Primary and Secondary): Adaptation of International Algorithms

A. Foundational Triage Systems Adopted and Modified

Israel’s primary field triage protocols are rooted in internationally accepted standards, notably the Simple Triage And Rapid Treatment (START) system, which originated in the United States and is widely used across various NATO countries, including Israel. The core principle of START is rapid assessment, classifying injured adults (typically older than 8 years) in 60 seconds or less (preferably 30 seconds), based on three key physiological checks summarized by the mnemonic RPM: Respiration, Perfusion, and Mental Status.

The operational environment of constant conflict and frequent MCEs in Israel necessitates speed and simplicity, aligning well with the algorithmic approach of START. However, the ITS incorporates pragmatic modifications based on field experience. While the original START criteria often utilize Capillary Refill Time (CRT) for assessing perfusion , many agencies, including those in Israel, recognize that determining CRT can be challenging in real-world adverse conditions, such as darkness, cold weather, or chaotic scenes. Consequently, operational protocols frequently favor the "no radial pulse" criterion as an alternative, more reliable indicator of circulatory status in the initial rapid triage phase.

B. ITS Triage Categories and Color Coding: Beyond the Four Colors

The ITS utilizes the standard four-color coding system for prioritizing casualties, which is recognized globally in disaster response:

1. Red (Immediate): Assigned to patients with life-threatening injuries who require immediate medical intervention to maximize their chance of survival. This category is triggered by severe respiratory, perfusion, or mental status compromise.

2. Yellow (Delayed): Assigned to serious patients whose injuries are non-life-threatening but require definitive care. These patients can safely wait until those in the Red category have been treated and transported.

3. Green (Minimal): Designated for the ambulatory injured—the "walking wounded"—who have minor injuries. They are assessed last and often directed to move to a safe holding area or self-transport.

4. Black (Expectant/Deceased): Reserved for patients who are apneic after airway repositioning or who have injuries deemed incompatible with survival given the limited resources available in an MCI setting.

Specialized Color Adaptations: Blue and Grey

A critical distinction of the Israeli field triage system, reflecting its adaptation to specific local security threats and population vulnerabilities, is the use of two additional color codes: Blue and Grey. These specialized colors transform the basic triage tag from a purely clinical marker into a crucial logistical and threat-mitigation command.

1. Blue (Children): This category is used specifically to tag pediatric patients. Children have unique physiological responses to trauma that make the strict application of adult START criteria potentially dangerous, leading to undertriage. The Blue tag signals the necessity of utilizing specialized protocols, such as JumpSTART, which modifies the Respiratory, Perfusion, and Mental Status parameters appropriate for children. This adaptation ensures that this vulnerable population receives appropriate acuity assessment and is prioritized correctly.

2. Grey (Combined Trauma/Contamination): The Grey tag is reserved for patients suffering from combined injuries, typically physical trauma alongside chemical, biological, radiological, or nuclear (CBRN) contamination. This is a strategic adaptation rooted in anticipating complex terrorist attacks involving non-conventional weapons. The Grey tag immediately flags the patient as a biohazard risk, mandating that they are diverted to a decontamination pathway before receiving definitive medical care. This protocol protects healthcare workers, restricts the spread of hazardous material, and safeguards critical hospital infrastructure from secondary contamination, thereby maintaining system integrity during a high-stakes, multi-faceted attack.

This expansion of the traditional four-color schema reflects a sophisticated operational adaptation to the specific risk profile of the country.

Table 1: Comparison of Core Field Triage Categories (Standard vs. Israeli ITS Adaptations)

C. The Magen David Adom (MDA) Model and Field Implementation

Magen David Adom (MDA), Israel's national civilian Emergency Pre-Hospital Medical Organization, is central to the operational execution of pre-hospital triage. MDA employs a paramedic-based system that traditionally adheres to the "scoop and run" doctrine, prioritizing rapid transport to definitive care and minimizing on-scene time. This approach is vital in a conflict environment where the scene may remain unsafe or under continuous threat.

MDA is accustomed to operating flexibly in mixed civilian/military scenarios and often faces the extreme challenges of navigating active combat zones. This reality frequently impedes safe access to victims and constrains evacuation strategies, requiring EMS teams to execute multiple rounds of casualty collection and expedite transport to medical centers.

To manage these complex operational demands, MDA utilizes an advanced, two-way dispatching system developed exclusively for the organization. This system connects the control center with individual volunteer and professional crews based on their real-time location and the event location, allowing for immediate reporting back to the control center on departure, arrival, and field information. This technical integration and efficiency are crucial for supporting the coordination required by the centralized MOH Patient Distribution protocols.

Logistical Operations and Dynamic Patient Distribution

A. Centralized Patient Distribution (PD) and Scattering (SD) Protocols

The strategic genius of the Israeli system lies in its recognition that effective triage must extend beyond the individual casualty to encompass the entire receiving health system. All ambulance services nationwide are managed as a national resource under the Ministry of Health’s Emergency Operations Center (EOC) for the purpose of Patient Distribution (PD)—the initial transport from the field—and Patient Scattering (SD)—the subsequent transfer of patients between hospitals.

The MOH EOC is responsible for determining the optimal destination hospitals. This decision-making process is dynamic and based on real-time assessments of hospitals' current capacity and load, with a clear priority given to supra-regional trauma centers. This centralized approach transforms hospital capacity data into an operational triage criterion. The rationale is that relying solely on proximity, which often coincides with the blast radius of an attack, would immediately overwhelm local facilities, such as Soroka and Barzilai Medical Centers, which are frequently inundated during conflict.

The distribution criteria for PD decisions include several objective factors: the vicinity of the trauma center, the injured patient’s health status, the hospital’s current situation (often using a Hospital Load Index or similar real-time assessment), other events taking place, and the prioritization of spreading the burden among multiple hospitals. This system-level triage actively prevents regional system failure. For instance, while casualties taken by ground vehicles are generally brought to nearby hospitals, critically injured patients may be transported by IDF Home Front Command helicopters to more distant trauma centers in the center of Israel to avoid overloading facilities closer to the incident zone.

B. Continuity of Care: Standardization of Handover and Documentation

The effective transition of care between the pre-hospital environment (MDA) and the Emergency Department (ED) is essential for continuity and patient safety. While the handover often begins verbally, legal and clinical requirements underscore the need for structured, recorded documentation provided by the Pre-Hospital Emergency Medical Service (PEMS).

A standardized patient transfer process is designed to organize and store patient information, which minimizes the risk of errors, data loss, and adverse events that frequently occur during the verbal-only transfer of complex clinical data. This structured documentation also supports the continuous improvement loop inherent in the Israeli system. The Israel Defense Forces Trauma Registry is one of the world's largest and oldest computerized military trauma registries, capturing detailed point-of-injury and pre-hospital documentation. Analysis of this registry data has shown a marked improvement in the quantity and quality of pre-hospital documentation over the years, directly contributing to the refinement of operational guidelines and clinical policy.

In-Hospital Triage and Management in Surge Conditions

A. Hospital Preparedness and the All-Hazards Approach

Standardized protocols developed by the Office of Emergency Preparedness within the MOH mandate specific operating procedures (SOPs) for conventional MCIs across all hospitals nationwide. These SOPs emphasize immediate staff call-in, rapid establishment of a clear chain of command, organization of critical services, and the crucial process of discharging existing, non-critical patients to free up beds and resources in preparation for incoming casualties.

Israeli hospital preparedness includes mandatory adaptations to the physical layout and organization of patient flow. Each hospital must designate a preassigned triage area, typically located outside the main Emergency Department (ED). Separate treatment sites must be established for casualties based on injury severity (severe, moderate, mild), as well as specialized zones for vulnerable groups such as pediatric patients and individuals suffering from psychiatric trauma. To manage the inevitable overflow, alternate treatment sites—including hospital lobbies and corridors—must be predefined to quickly absorb incoming patients and keep the ED and trauma bays clear for continuous reception.

The Israeli Defense Forces Field Hospital (IDF-FH), a WHO-certified Type 3 Emergency Medical Team (EMT), exemplifies this organizational doctrine, especially in international disaster relief. The IDF-FH model utilizes a structured ED layout featuring initial registration and triage, a resuscitation zone, an acute care area, and an ambulatory care area. A key operational consensus within the IDF-FH is the strict prohibition of patient "boarding" in the ED, even in a disaster zone, demonstrating a commitment to maximizing patient flow and throughput.

B. Modification of Acuity-Based Systems for ED Triage

For routine daily operations, and as a foundation for surge preparation, Israeli Emergency Departments often utilize a modified acuity-based triage system. This approach combines elements of the internationally validated Manchester Triage System (MTS) and the Emergency Severity Index (ESI), classifying patients into five levels of urgency. Acuity-based triage is standard practice globally, sorting and prioritizing patients based on the urgency required for medical intervention, and it is performed by nursing staff immediately upon arrival (within 10 minutes for walk-ins and immediately for emergency transport patients).

During an MCE surge, the internal process of the hospital becomes a secondary triage mechanism. The hospital may be reconfigured entirely as a triage hospital when operating under extreme load. The internal protocols facilitate the rapid channeling of patients from the triage area along three primary pathways: to pre-determined treatment sites (ED/trauma area), to alternate overflow treatment sites to empty the ED, and onward to definitive critical services (operating rooms, ICUs, or hospital wards).

C. Unique Triage Challenges in Prolonged MCEs

Recent high-intensity conflicts, such as the October 7, 2023, attacks, have exposed unique challenges that test the limits of even the highly adapted Israeli system. In this event, local Level 1 trauma centers received hundreds of injured individuals, vastly exceeding the typical threshold for a large MCE. The incident was characterized by a dispersed attack and a sustained, prolonged chaotic phase, rather than the defined chaotic, plateau, and resolution phases typically observed.

This necessitated a critical adaptation: the maintenance of parallel pathways. While prioritizing the massive influx of life-threatening trauma patients, the system also had to sustain care for routine emergencies unrelated to the attack. This balancing act ensures that acute patients suffering from common medical conditions are not abandoned, underscoring the necessity of disaster plans that build systemic resilience into the core structure.

Furthermore, the continuous influx of severely injured patients—many with penetrating injuries—created immediate and extreme pressure on specialized services like imaging. This required the implementation of real-time imaging triage, sometimes occurring at the scanner itself. Dynamic redistribution of patients across shielded scanning areas was necessary, particularly during active missile alerts, demonstrating that the triage process is continuous and must adapt to immediate security and logistical constraints even within the hospital walls.

VI. The Ethical and Policy Framework for Resource Allocation

A. The Israeli National Bioethics Commission Guidelines

The high-frequency exposure to disaster scenarios, coupled with the unique ethical and resource dilemmas presented by events like the COVID-19 pandemic, compelled the Israeli government to develop a formal, national policy for allocating scarce, life-saving resources. The Director General of the Ministry of Health appointed a Joint Commission composed of senior experts spanning medicine, ethics, law, sociology, and representatives from Jewish, Christian, and Islamic law.

The resulting guidelines offer a pragmatic medical and societal roadmap for managing resource scarcity. Crucially, these emergency triage protocols are applicable only in crisis situations and are triggered by a formal declaration from the Ministry of Health that the healthcare system is overwhelmed. This formal governmental announcement is viewed as essential for maintaining public trust and ensuring transparent application of the exceptional triage criteria.

B. Guiding Principles in Resource Scarcity

The national policy is founded upon a synthesis of universal ethical principles and local societal sensitivities. Core guiding principles explicitly detailed in the policy include: the supreme value of life, the equality of all individuals, transparency, consistency, equity in access, and the ethical mandate to achieve the "greatest good to the greatest number".

To ensure objective and fair distribution, the guidelines mandate the use of objective, functional clinical criteria. Triage decisions concerning resources like ventilators or ICU beds must prioritize patients with the highest predicted probability of short-term survival. The Commission specifically included the patient’s Performance Status as an important measurement, as it is a known predictor of in-hospital mortality, ensuring the algorithm maintains predictive power and equity.

The policy absolutely prohibits discrimination in triage decisions based on non-clinical characteristics, explicitly listing race, religion, sex, nationality or citizenship, sexual orientation, socioeconomic status, age, or disability as irrelevant factors. This strong ethical stance ensures that resources are allocated strictly on clinical potential.

A fundamental component of this framework addresses the operational reality of crisis decision-making. The governmental development and dissemination of these national guidelines provide a critical societal and medical roadmap. This framework serves to legally and morally protect frontline medical staff who are required to make difficult and rapid decisions under extreme duress. By formalizing criteria through a national consensus document, the state assumes responsibility for the ethical policy itself, allowing clinicians to focus on the pragmatic medical execution. While national policy requires consultation with two senior physicians for local triage decisions, mandating the establishment of a formal institutional triage committee is deemed unworkable in the local, high-speed emergency setting. This deliberate flexibility balances the need for policy adherence with the urgency of crisis operations.

Table 3: Triage Decision Criteria During Resource Scarcity (MOH/IMA Principles)

Analysis and Continuous System Evolution

A. Empirical Validation and Quality Assurance

The effectiveness of the Israeli Triage System and its resulting trauma care is subject to rigorous evaluation, primarily through the use of the national trauma registry. This registry is crucial for quality control, continuously measuring health outcomes, including survival rates, morbidity, complications, and mortality rates.

Data collected through this mechanism provides empirical validation of the system's performance. For example, comparisons among Level I trauma centers in Israel have historically shown significantly lower mortality rates for severely injured patients at centers such as Rambam Hospital, along with shorter average lengths of stay in the Emergency Room, demonstrating measurable success in optimizing clinical flow and outcomes.

Furthermore, the meticulous use of the Israel Defense Forces Trauma Registry, recognized as one of the largest and oldest computerized military trauma registries globally, has driven policy evolution. Historical data documented a major improvement in the quantity and quality of point-of-injury and pre-hospital documentation over time, directly correlating with subsequent modifications to clinical guidelines and policy refinement. Comprehensive evaluation of this complex healthcare system in emergency conditions is consistently emphasized as crucial for saving lives and improving care quality amidst resource limitations.

B. Lessons Learned from Recent High-Intensity MCEs

The system’s continuous evolution is fundamentally informed by experience gained from actual high-intensity events. The October 7, 2023, attacks served as a mega MCE, highlighting both the strength of the coordinated response and areas requiring further resilience enhancement.

The scale and duration of the event posed exceptional operational challenges for the civilian Emergency Medical Service, Magen David Adom (MDA), requiring teams to navigate active combat zones and constrained evacuation strategies. However, the foundational rapid evacuation protocols and effective primary triage, combined with the initial Patient Distribution (PD) to multiple hospitals, allowed for the rapid conclusion of the event at the scene and prevented the immediate, catastrophic collapse of the closest receiving hospitals.

Analysis of the response underscores the importance of reinforcing healthcare resilience, particularly through streamlined communication and the continued national centralization of pre-hospital resource coordination and patient evacuation management. The necessity of sustaining parallel acute care pathways during prolonged surge events—ensuring that non-trauma acute patients are not neglected—is now formally recognized as a critical resilience measure for adapting to sustained crisis scenarios.

C. Conclusions and Recommendations

The Israeli Triage System demonstrates that optimal disaster response is achieved through strategic, centralized governance that mandates operational flexibility and ethical preparedness. The successful adaptation of international triage models into the ITS is defined by macro-level logistical control and localized clinical refinement.

Nuanced Conclusions:

1. Triage as System Management: The ITS transcends mere clinical classification, functioning instead as a system-wide management doctrine. The use of real-time capacity data, such as the Hospital Load Index, to drive Patient Distribution (PD) ensures system survival by mitigating localized saturation, even if it requires deviating from the simplest transport route.

2. Strategic Clinical Adaptations: The deliberate integration of specialized color categories (Blue for pediatric needs, Grey for contamination threats) transforms the standard START algorithm into a bespoke instrument capable of addressing the high-acuity, complex nature of the specific security threats faced by the country.

3. The Necessity of Ethical Pre-Emption: The development of a national ethical and legal policy for resource scarcity triage—formulated by a governmental joint commission prior to a severe crisis—is indispensable. This pre-emptive policy provides essential legal protection and moral clarity to frontline practitioners, ensuring that difficult life-and-death decisions during resource deprivation are guided by objective criteria and consistency.

Recommendations for Global Adoption:

Countries operating in high-threat environments or those susceptible to high-frequency MCEs should prioritize the establishment of a centralized command authority (mirroring the MOH/SHA structure) capable of exerting control over all medical assets during a crisis. Furthermore, they must adopt the model of pre-emptive ethical and legal policy development for resource allocation, ensuring that foundational principles are agreed upon and formalized before the inevitable necessity of scarcity triage arises. This preparedness ensures that clinical triage operates effectively within a robust, ethically sound national framework.