Region X Multiple Patient Plan – Triage & Categorization

1. Region X Multiple Patient Plan – Triage & Categorization December 2010 CE Condell Medical Center EMS System Site Code #107200E - 1210 Prepared by: Sharon Hopkins, RN, BSN, EMT-P EMS Educator

2. Objectives Upon successful completion of this module, the EMS provider will be able to: 1. Define a multiple patient incident. 2. Discuss time management at the scene of a multiple patient incident. 3. Define the National Incident Management System. 4. List field functions necessary at a multiple patient incident.

3. Objectives cont’d 5. Describe responsibilities and duties of the initial responding fire department unit. 6. Define triage, primary triage, and secondary triage. 7. Describe when primary and secondary triage techniques should be implemented. 8. List the three universal triage categories. 9. Describe the START system.

4. Objectives cont’d 10. Describe the JumpSTART system 11. Describe the Smart disaster tag 12. Identify criteria for Category I, Category II, and Category III patients. 13. Discuss when to complete an After Action Report and how to forward it. 14. Actively participate in role playing in table top drills.

5. Overview Note • Region X Multiple Patient Plan undergoing revisions • Based on in-put requested and received from EMS providers • Revisions should be distributed Spring 2011 • Some verbiage will be changing • Many actions taken during any multiple patient incident will not • Triage, categorization not changing

6. Defining a Multiple Patient Incident • Any incident that depletes available resources at the time of the incident • Difficult to put a number of patients on a plan or the easiest/hardest times of day to respond to an incident • What is taxing to one department can be handled with in-house resources by another

7. Initial Problem • Casualties outweigh resources of responding unit

8. Goal • Provide adequate resources to meet the needs of the casualties to maximize the number of survivors

9. Golden Period • A 60 minute time frame in which the patient has to reach definitive care from time of onset of injury • Odds of successful recovery diminish once the golden period has been reached

10. Time Management • What needs to be accomplished at the scene • Command structure set up • Safety observed at all times • Assessment – of situation and patient • Communication – to a wide variety of persons • Triage – right patient to right area • Treatment – red, yellow, green patients • Transportation – to definitive care

11. DRILL, DRILL, DRILL • Universally accepted plans • Should be understood by all responding departments • Allows mutual aid response to function shoulder to shoulder without the need for detailed instructions/explanations

12. Resources • National Incident Management System (NIMS) • Developed to provide a common system utilized at local, state, and federal levels • Incorporates the Incident Management System (IMS) • A process with procedures for organizing and operating an on-scene management structure practiced by emergency services agencies

13. Incident Command • Most important functional area of IMS • Person who runs the entire incident • Has the ultimate decision making authority • Needs to coordinate many activities • Must delegate functions and responsibilities to others • Based on size and type of incident and resources being utilized

14. Command • In both small and large scale events, still need “command” at the scene • Someone needs to coordinate activity • Which responding unit cares for which patient • Coordinate transportation so patients can be spread between receiving hospitals, as necessary • Even with 2 patients, one person needs to have control/command of the scene and make decisions

15. Who is Command Initially? • Generally, first arriving vehicle must assume command until additional resources arrive and take over the task • “Windshield survey” taken • Relay information to dispatch • Contact hospital • Closest for small scale • Resource for larger events – they will act as your resource

16. Functions in the Field • Field tasks/jobs must be completed • Tasks in smaller scaled incidents can be completed by a minimum of persons • Larger scaled events may involve multiple persons needed to oversee the different field functions that need to be completed

17. Necessary Field Functions • Command • Safety • Communications • Triage • Treatment • Staging • Transportation

18. Communication Links – Everyone needs to be on the same page Field Personnel Hospitals Responding Units

19. General Duties • First responding unit • Begin communications early • Can’t get help to the scene unless dispatch knows what you have and what you need • Hospital cannot prepare for increased volume and acuity of patients unless notified • It takes EMS time to set up; it also takes the hospitals time to prepare

20. SAFETY! SAFETY! SAFETY! • Safety is everyone’s responsibility • Larger scaled incidents will need one person to oversee the safety of the scene • Process less formalized but just as important in smaller sized incidents

21. Triage • Definition • The act of sorting patients • Based on severity of injuries or the illness • Object/goal • To do the most good for the most people • Triage process influences other decision making

22. Definition – Primary Triage • Primary triage • Performed at first contact with the patient • Must be performed rapidly and with efficiency • Provides a basic categorization • Must be reproducible results from one evaluator to another

23. Universal Triage Categories • Red • Immediate care necessary • Yellow • Treatment can be delayed • Green • Patient requires minimal to no treatment • Black • Patient is dead or is expected to die

24. Definition – Secondary Triage • An ongoing process • Takes place throughout the incident • As patients are moved to the treatment area • As patients are in the treatment area • As patients are being transported • Upon arrival at the receiving facility • During their time at the receiving facility

25. Secondary Triage • A dynamic, fluid process • Patient condition may change throughout the process requiring upgrading or downgrading as determined by the reassessment

26. START System • Widely used triage process in disaster/multicasualty incidents • JumpSTART used in the pediatric population • Need to accommodate physiological differences between the adult versus pediatric populations • START can be modified when responding to smaller scaled incidents • Does not require a diagnosis to sort patients • Objective evaluation of signs observed

27. START Triage Areas • Ability to walk • Helpful in larger scaled incidents • Respiratory effort • Check for open airway • Check respiratory rate • Pulses/perfusion • Check radial pulse • Neurological status • Determine ability to follow commands

28. Smart Triage for Adults Radial pulse or capillary refill

29. START System Step #1– Ability to Walk • Not necessary if your resources can perform efficient and timely triage to the number of victims present • Start by asking all patients, who can walk, to get up and come to you • Initially this patient is “green” but will need to be retriaged for appropriate treatment area • Move onto next patient

30. Ability to Walk • Recognize that some of the “walking” patients may actually be “yellow” • Recognize that some patients that cannot walk, especially due to a leg injury, may be eventually triaged as “green” • Remember: Triage is dynamic – always ongoing; subject to change

31. Start System • Separating the walking patients • This process decreases the number of patients who cannot leave the area • You are sorting down to a number of victims that will be quicker to move through to perform triage • You have moved the less critical out of the way leaving a smaller number of patients, those potentially more critical, to sort through

32. START Step #2 – Respiratory Effort • Begin to triage non-walking patients • Tag patient as you triage them • Treatment limited • Correct airway problem • Correct severe bleeding • Move onto next patient

33. START – Respiratory Effort • Patient not breathing • Manually open airway • If breathing resumes, tag as “red” • If no breathing, tag as “black” • Patient breathing • Evaluate respiratory rate • RR > 30 tag as “red” • Move onto next patient • RR < 30 go to next assessment step

34. START Step #3 – Pulse/Perfusion • Check for radial pulse – preferred method • No radial pulse, tag as “red” • Move onto next patient • Delayed capillary refill not reliable in adults • Can be compromised by cold weather and normally delayed in certain persons • Respirations < 30 and radial pulse present, continue to next assessment step

35. START System Step #4 – Neurological Status • Ask a quick, simple question • “grip my hands” • If patient cannot follow simple commands, tag as “red” • Move onto next patient • If patient can follow simple directions, tag as “yellow” • Move onto next patient

36. Primary Triage Practice • Review the following cases • Determine the primary triage category basing decisions on: • ability to walk • respirations • pulses • ability to follow commands

37. Practice Triage • Case #1 • 30 year-old female, walking around • Obvious injury is right arm fracture • Case #2 • Unconscious male 20’s • Respirations 36 • No radial pulse

38. Practice Triage Answers • Case #1 • Green – able to walk on own • Reassessment will determine any conditions that may indicate a yellow status • Case #2 • Should stop triage at unconsciousness • Tag patient at red • Further assessment in initial triage not necessary to categorize this patient (and is therefore a waste of time if many patients need to be triaged)

39. Primary Triage Practice • Case #3 • Male approximately 18 • Walking around, confused • Case #4 • 60 year-old female with fractured leg • Respirations 26 • Radial pulse 86 • Obeys commands

40. Practice Triage Answers • Case #3 • Green – able to walk • Reassessment may reveal indications for reassignment to yellow (or even red) • Case #4 • Unable to walk • Respirations <30 • Radial pulse present • Obeys commands • Tag patient as yellow

41. JumpSTART Triage • A process developed in 1995 by a pediatric emergency physician • Parallels structure of START for adults • Optimizes triage of injured children • Enhances resource allocation • Facilitates rapid decision making eliminating subjective opinions influencing triage decisions

42. JumpSTART Pediatric Triage • Children are not small adults • An adult system will not be accurate for children • A child’s length is proportional to their physiology • A child at 8 years-old becomes physiologically similar to the adult • JumpSTART used if the patient appears to be a child (a subjective assessment) • Pediatric triage has to satisfy the same criteria as the adult: dynamic, fast, safe, and reproducible

43. PEDIATRIC TRIAGE JumpSTART

44. PRIMARY vs JumpSTART TRIAGE Radial pulse or capillary refill

45. JumpSTART Triage – Step #1 Walking • If the patient is able to walk or be carried to another area tag the patient as Green • You will retriage this patient in treatment for appropriateness of category/priority using the Secondary Triage process • We know some people who can walk may have potentially life threatening injuries • Retriage/secondary triage in treatment should be performed to validate the appropriate category

46. JumpSTART Step #1 cont’d • Modifications for nonambulatory children • May not be walking due to chronological age, developmental delay, acute injury preventing walking before incident, chronic disability • For infants not walking yet, remove them from the site & evaluate them in the secondary triage area using the JumpSTART process • Start assessment at the “breathing” evaluation step

47. JumpSTART Step #2 - Breathing • Spontaneous, move onto next assessment step • Apneic or irregular breathing, open airway • If breathing resumes, tag as “red” • If not breathing, check for pulse • If no pulse, tag as “black” • If pulse, give 5 breaths • If breathing resumes, tag as ”red”

48. JumpSTART Step #2 - Breathing Assessment cont’d • If pulse difficult to assess (ie: cold weather) • Give trial of 5 breaths unless clear signs of death • If breathing resumes, tag as “red” • If no spontaneous breathing, tag as “black” • Move onto next patient

49. JunpSTART Step #3 - Perfusion • Evaluate in least injured extremity • Palpable pulse, move to next step • No peripheral pulse, tag as “red” • Move onto next patient

50. Practice JumpSTART • Case #1 • 2 year-old female standing while being held • Moving arms and kicking legs • Respirations 28 • Radial pulse present (126) • Case #2 • 5 year-old unconscious, withdraws from pain • Respirations 38 • No radial pulse