disaster triage

Managing Multiple Casualty Incidents The Hospital/Pre-hospital Interface

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Definitions:

• MCI – Multiple Casualty Incident – Any incident where the number/severity of patients exceeds the capacity of local resources.

• Local Healthcare Team – All elements of a response: Dispatch, Fire/EMS, Law Enforcement, Hospitals, Public Health (HSPD-8)

• START – Simple Triage And Rapid Transport

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Learning Objectives• Effectively identify & communicate critical

pieces of information. (dispatch, scene, hospital) using good radio etiquette.

• Establish & implement the Incident Command System in a MCI situation.

• Describe key roles, responsibilities and functions necessary to manage an MCI

• Use START triage system to categorize patients during an MCI.

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If you get a report that the scene has 5 yellow

patients and 3 red patients, do you know

what that means?

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S.T.A.R.T. Triage SystemS.T.A.R.T. (Simple Triage And Rapid Transport)

Example of a triage method that quickly classifies victims and prioritizes treatment

MINOR

DELAYED

IMMEDIATE

MORGUE

•Little or no care needed,

•Delay care, injuries not life-threatening

•Immediate care for life-threatening situation

•No care, mortal injuries, cannot be savedn_Da 5

Types of Multiple Casualty Incidents

• Trauma• Acute Medical• Biological

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How Responses are Organized

• Disaster plans are prepared • Responders become familiar with the plan

• Plans include the use of:– Communication Plan– Incident Command System (ICS/HICS)

• Provides leadership and structure• Identifies Roles and Responsibilities

– Triage • Used to manage limited resources• Prioritize patient care based on “survivability”

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Module One: Communications

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Question

What problem is most commonly identified after exercises or real events in the Post Incident Review or After Action Report?

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Implementing the Communications Plan (Group Discussion)

Do you have a communications plan? What are your Dispatch Procedures – responder

notification? How is the Hospital Notified? How does On-Scene Command Communicate

with the Hospital? How do you Communicate with other hospitals? How/when do you communicate with the

public?

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WHAT TO COMMUNICATE FIRST

• Initial contact – scene/situation size-up– Safety

• Assume/Announce Command• Request Resources• Identify location, access and positioning• Assign/Allocate Resources

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“Dispatch: Local Ambulance: On scene of a multiple vehicle crash with approximately 20 casualties. Local Ambulance will be I-90 Command on the east bound Gold Creek Off ramp.”

Size-Up, Assume Command

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Keys to Clear Radio Communication

• Key microphone 2 seconds before speaking on a repeater based radio system

• Say who you want to talk to first then say who you are.

• Use clear text (plain language NO TEN CODES) – Speak slowly and clearly (practice this)

• Repeat back communications to acknowledge receipt of message.– Assume messages not acknowledged were not

heard and repeat initial messagen_Da 13

Keys to Clear Interpersonal Communications

• Develop/refine and practice your communications plan

• Organize your thoughts to present the information clearly and concisely (SBAR)

• Have a back-up plan (runners, written notes)

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“I am 10-23 at a 10-50. 10-52

times two and a 10-51.

“Dispatch: HP 1: I am on scene at a car crash with

casualties. I need 2 ambulances and a wrecker.”

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Don’t use 10-Codes!

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“Hospital: Medic 1: Enroute to your facility with a TBI. 2 min LOC and

GMS with GCS of 9.”

“Hospital: Local Ambulance: Transporting Pt. #3 triaged as red/immediate, due to head injury with respiratory rate of 40, radial pulse present, and

responds to pain only.”

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Avoid Acronyms and Abbreviations!

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SBAR (focused communication)

• Situation: “En route with 52 year old male triaged as Red ”

• Background: “Motor vehicle crash – ejected”• Assessment: “Head and chest injuries”• Recommendations: “Activate Trauma Team”

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Public Information

• If pub info isn’t addressed early/ aggressively it will impact the incident and incident communications – this is one of the reasons phones go down and

your hospital becomes overwhelmed with people seeking information

• Assign people to answer phones, craft messages for media, meet with families, track patients.

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Request Resources

• Call for help – You can always cancel them if not needed– Be specific about what units and capabilities you want– Order enough resources

• Tell them where to report & how to access the scene– If coming in a vehicle, where should it be positioned?

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Assign/Allocate/Reassign Resources

• Individuals or resources should be assigned:– Someone to report to (a boss).– A task TO ACCOMPLISH– Where to go.– What to do when done with THE task.

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Group Activity

• Photo/description of MCI Incident• Divide into groups (Pre-hospital/Hospital)• Play act initial establishment of command for

each area and communication between groups

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An Organized Response

• Requires planning

• Coordinates resources and personnel

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Report to Staging Area

• Sign in when you arrive; Sign out when you leave

• Bring ID, credentials

• Find your designated supervisor

• Follow directions– If asked to leave or provide

care else where – do so

Medical volunteers at staging area

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Accountability: Task

• Tell them what needs to be done• Ensure assignment is understood• Give them the tools they need • Tell them what to do when done

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Use SMART Objectives

• Specific • Measurable• Action Oriented• Realistic• Timeframe

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Break

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On-Scene Incident Command Structure

Incident Commander

Safety Officer

Medical Branch Director

Triage Group Supervisor

Technical Rescue

Treatment Group Supervisor

Transport Group Supervisor.

Dive Team

Extrication Team

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Emergency Dept Hospital Incident Command

Incident Commander Cindy

TriageUnit Leader

Paula

Treatment Unit LeaderDr. Jones

TransferUnit Leader

Bob

Communications Unit Leader

BobImmediate Red Team

Delayed Yellow Team

Minor Green Team

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WHAT ARE YOUR Local Resources?

• Ground Ambulances• Air Ambulances• Fire/Rescue Vehicles• ED beds• Hospital beds• Operating Rooms• Blood Supply• Imaging/Lab Capacity• Ventilators

• EMTs• Flight Crews• Firefighters• Technical Rescue• MDs, RNs, CNAs• Surgeons, OR Crews• Blood Bank Staff• Imaging/Lab Staff• Resp Therapists

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Group Activity

What resources are available to my

community during an MCI?

• Where are they?

• How do we contact them?

• How long will they take to arrive?n_Da 32

• Because you could have multiple incidents going on simultaneously.

• Helps avoid confusion.

Why is it important to “give the incident a

name?”

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Assessment and Care of Multiple Patients

On-Scene• Rescue/Extrication• Triage• Treatment• Transport

*see slide

Hospital• Decon• Triage/Re-Triage• Treatment• Admission/Discharge/

Transfer

* see slide

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On-Scene Triage Group Supervisor Responsibilities/Tasks:

• Ensure safety• See each patient rapidly, categorize and label

patients using a standard triage system • Communicate triage decisions with Medical Branch

Director, and coordinate with treatment and extrication groups.

• Track Patients:– Remove patients to the treatment area– Red Patients move first!

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Hospital Treatment Unit Leader Responsibilities

• Provide definitive care: identify and fix the problem• Provide lifesaving basic life support before

advanced life support..• Match patient needs with provider skills.• Use available resources, making decisions about

resource allocation at each step.• Use tools to document and aid organization • Transport/Transfer/Admit them to the place where

these needs can be met.

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Rescue Group(s)

• Rescue and triage are happening simultaneously

• Rescue Groups focus on: – Extrication– Technical Rescue (high/low angle)– Dive Teams– HazMat, Decon– Patient Movement (out of hazard zone to patient

collection area/treatment)

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Staying Organized

• Organizational Tools– Plans– Protocols– Forms– Job Action Sheets

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Triage Systems

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START Triage

A process in which victims are sorted into groups; priorities of care are established and resources are allocated.

RESPIRATIONS

Morgue

POSITION AIRWAY

Minor

<30/Min. or >10/Min.

>30/Min. or <10/Min.

MENTAL STATUS

PULSEImmediate

Delayed

Can’t Follow Simple

Commands

Can Follow Simple

Commands

ALL WALKING WOUNDED

Radial Pulse Absent

ControlBleeding

YESNO

NO YESImmediate

Immediate

Immediate

Radial Pulse Present

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S.T.A.R.T. Triage SystemS.T.A.R.T. (Simple Triage And Rapid Transport)

Example of a triage method that quickly classifies victims and prioritizes treatment

MINOR

DELAYED

IMMEDIATE

MORGUE

•Little or no care needed,

•Delay care, injuries not life-threatening

•Immediate care for life-threatening situation

•No care, mortal injuries, cannot be savedn_Da 41

START uses R P M

• Respirations (<10 OR >30)

• Pulse (no radial pulse)

• Mental status (unable to follow simple commands)

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Triage Flow Chart

Flow Chart Decisions:1. Separate walking

wounded from others

2. Use RPM life functions to tag remaining patients: a. Respirationsb. Circulationc. Mental Status

RESPIRATIONS

MENTAL STATUS

PULSE

Minor

ALL WALKING WOUNDED

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First Step: Breathing

RESPIRATIONS

Morgue

POSITION AIRWAY>30/Min.

or <10/Min

(check) PULSE

Immediate

YESNO

NO YES

Immediate

<30/Min. or

>10/Min

Cannot breathe on own after airway opened – [BLACK tag] Breathing rapidly >30 breaths per minute – [RED tag] Breathing regularly (go to next step in flow chart - PERFUSION)n_Da 44

Second Step: Blood Flow

(check)MENTAL STATUS

PULSE

Radial Pulse Absent

ControlBleeding

Immediate

Radial Pulse Present

If detectable radial pulse, go to step 3: Mental Status

If no detectable radial pulse - check capillary refill Refill more than 2

seconds – control bleeding - [RED tag]

Capillary refill less than 2 seconds - go to step 4: Mental Status

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Third Step: Mental Status

MENTAL STATUS

Delayed

Can’t Follow Simple Commands

Can Follow Simple Commands

Immediate

Cannot follow simple command - [RED tag] Can follow simple command - [YELLOW tag]

End of algorithm – all victims should be “tagged” now.n_Da 46

PATIENTS ARE RED IF THEY HAVE EVEN ONE FINDING OF:

• RR <10 OR > 30• No Radial Pulse• Cannot follow simple commands

RESPIRATIONS

MENTAL STATUS

PULSE

Can’t Follow Simple Commands

Radial Pulse Absent

Immediate

Immediate

Immediate

>30/Min. or

<10/Min.

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Activity:Triage Practice Case #1

• A woman runs up to you, supporting her left arm, and says, “I think it’s broken.”

• Respiratory rate is 24/minute• Radial pulse rate is 120/minute

How would you label her?

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Activity:Triage Practice Case #2

• You approach a man who is lying on the ground • He is taking 36 breaths per minute • You cannot find a radial pulse • He moans when you use a painful pinch

How would you label him?

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Activity:Triage Practice Case #3

• A woman is sitting slumped over, not breathing• You open her airway – still not breathing• There is no radial pulse

– Her carotid pulse is 30 beats/minute

• She does not respond to noise, touch, or painful stimuli

How would you label her?

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Triage Organizes Priorities

• Normal Circumstances– Use all available manpower and supplies– Resource use focuses on saving one life

• Mass Casualty Situation– Number of injured exceeds ability to treat in

normal manner– Resource use focuses on saving as many lives as

possible• Minor injuries wait for care• Severe injuries receive immediate care• Mortal injuries do not receive caren_Da 51

What Makes Triage Difficult

• More patients than resources• Victims who are “Beyond Rescue”

– Black tag (morgue) category• To NOT treat such patients will oppose all your training and

instincts

• Example:– Patient has no pulse and is not breathing

• Routine situation compared to a mass casualty situation

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Now that you understand START;

• Does the triage system you use daily in the ED work for MCI’s?

• If not, you need to decide whether during an MCI you will:– Stay with START system initiated pre-hospital or-– Adapt your current system to include a category

for the patients who are expected to die given maximum treatment with the available resources

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• What Triage system does your ED use everyday?

• MCI Triage Options:– Stay with the START

system initiated pre-hospital or-

– Adapt your current system to include a category for the patients who are expected to die even if they are given maximum treatment with the available resourcesn_Da 54

Tools for S.T.A.R.T.

Left side used for notes on injuries and vital signs

Right side contains decision flow chart (algorithm)

Note the four color-coded categories at the bottom

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Tools for S.T.A.R.T.

Triage kit MAY include:•Tape to create triage areas •Patient triage tags•Clipboards & Tracking tools•ID Vests

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Review

• Communication• Organization• Resource Management• Roles and Responsibilities• Prioritization (triage)• Accountability (Personnel, Patients, Tasks)

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For More Information HICS:

http://www.emsa.ca.gov/hics/hics.asp

NIMS: http://www.dhs.gov/interweb/assetlibrary/NIMS-90-web.pdf

FEMA (Certificate in basicICS): http://training.fema.gov/EMIWeb/IS/is195.asp

OSHA: http://www.osha.gov/SLTC/etools/ics/org.html

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More Information on Triage

For additional practice:http://www.citmt.org/start/exercise.htm

For more information on tags:http://www.mettag.com

To find out to fill out a tag:http://www.digisys.net/oes/triagetag.htm

MINOR

DELAYED

IMMEDIATE

MORGUE

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Basic HICS/ICS Organizational Structure

Incident Commander

OperationsSection Chief

Public InformationOfficer

Safety Officer

Liaison Officer

Planning Section Chief

Logistics Section Chief

FinanceSection Chief

Branch Director

Division/Group Supervisor

Command Staff

General

Staff

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Hospital ICS ChartHospital

Incident Commander

Medical Branch Director

Planning Section Chief

Safety Officer

Liaison Officer

Safety Officer

Operations Section Chief

Logistics Section Chief

Finance Section Chief

Human Services Branch Director

Ancillary ServicesBranch Director

Staging Manager

Immediate Care Unit Leader

Delayed Care Unit Leader

Minor Care Unit Leader

Triage Unit Leader

TransferUnit Leader

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References• Brady, Paramedic Emergency Care, Bledsoe, Porter, Shade• NIMS ICS Field Guide, 1st Edition – Infomed• Disaster Medicine, 2002 Lippincott Williams & Wilkins, Hogan and Burnstein• Emergency Medical Services at a Mass Casualty Incident, Joseph Cahill, Domestic

Preparedness Journal V. III, Issue 7, July 2007• Creating Order from Chaos: Part II: Tactical Planning for Mass Casualty and Disaster Response

a Definitive Care Facilities, Baker, Michael S., Article Military Medicine, Mar 2007• In a Moment’s Notice: Surge Capacity for Terrorist Bombings, Challenges and Proposed

Solutions, CDC, April 2007• International Nursing Coalition for Mass Casualty Education, Educational Competencies for

Registered Nurses Responding to Mass Casualty Incidents, August 2003• Mass Casualty Incident Program, Initial Triage Training, AEMS, courtesy of Pheonix FD.• Virginia Mass Casualty Incident Management, Secondary Triage• Improving health system preparedness for terrorism and mass casualty events,

Recommendations for action, July 2007, AMA/APHA Consensus report• Mass Medical Care with Scarce Resources, A Community Planning Guide, Health Systems

Research Inc., Feb. 2007• Nancy Caroline’s, Emergency Care in the Streets, Sixth Edition• National Incident Management System, Principles and Practice, Walsh, Christen, Miller,

Callsen and Maniscalco

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