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

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.

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.

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.

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

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

Initial Problem

 Casualties outweigh resources of responding unit

Goal

 Provide adequate resources to meet the needs of the casualties to maximize the number of survivors

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

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

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

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

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

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

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

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

Necessary Field Functions

       Command Safety Communications Triage Treatment Staging Transportation

Communication Links –

needs to be on the same page Everyone Field Personnel Hospitals Responding Units

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

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

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

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

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

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

Secondary Triage

  A dynamic, fluid process Patient condition may change throughout the process requiring upgrading or downgrading as determined by the reassessment

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

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

Smart Triage for Adults

Radial pulse or capillary refill

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

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

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

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

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

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

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

Primary Triage Practice

  Review the following cases Determine the primary triage category basing decisions on:     ability to walk respirations pulses ability to follow commands

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

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)

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

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

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

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

PEDIATRIC TRIAGE JumpSTART

PRIMARY vs JumpSTART TRIAGE

Radial pulse or capillary refill

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

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

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”

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

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

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

Practice Answers

  Case #1  Green – able to walk  Respirations >15 and <45 adequate  Palpable pulses present Case #2    Red – unconscious Enough information has been obtained to categorize the patient at this point Absence of radial pulse also a category red criteria but triage beyond unconsciousness was not necessary and a waste of time – patient already known to be a red

Practice JumpSTART

  Case #3  8 year-old boy unable to walk but follows commands   Case #4  9 year-old male standing, supporting a fractured arm; able to follow commands  Respirations 24  Respirations 28 Radial pulse present Radial pulse present

Answer Key JumpSTART

  Case #3  Yellow – unable to walk but follows commands   Respirations >15 and <45 Radial pulse present Case #4  Green – able to walk; following commands   Respirations >15 and <45 Radial pulse present

Smart Disaster Tags

    Universally used color-coded tag for easy communication Once tagged, prevents inappropriate retriage of same patient Can be used as a tracking system during treatment and/or transportation With SMART tags, severity level can be quickly revised by refolding the tag

Smart Triage Tags One tag – three levels of priority

Smart Tag System

 Areas provided for documentation  Patient details/demographics     Past medical history Patient assessment Treatment/interventions/vital signs Secondary triage   GCS Respiratory rate   Systolic blood pressure Tracking system

Treatment Area

  Patients retriaged upon arrival into treatment area Patients separated into areas based on color category   Red for critical patients Yellow for noncritical  Green for those patients requiring very little care

Secondary Triage

     Ongoing Occurs when patients moved into treatment areas Occurs during stay in treatment area Continues during transportation Continues at the receiving hospital

Secondary Triage

   Includes evaluation of GCS Converted points of GCS added to respiratory rate and systolic B/P Secondary triage also known as the “Triage Score”

Secondary Triage

Combining GCS with RR and systolic B/P

Practice Secondary Triage

  Review the following cases Determine secondary triage level based on adding 3 factors:    GCS  Convert GCS score of 3-15 to equivalent 0-4 Respiratory rate (0 - 4 points) Systolic blood pressure (0 – 4 points)

Secondary Triage Practice

  Case #1  20 year old female, eyes open but not able to walk   Follows commands Obvious injury is a fractured left leg    Capillary refill 1 second Triage category = Green (12 points)  Respirations 22 Radial pulse present (96); B/P 124/76 GCS (15) 4 + RR 4 + B/P 4 = 12

Secondary Triage Practice

 Case #2  36 year-old male lying on ground; eyes open and moving spontaneously    Soot around face; voice is croaky Respirations 34 Radial pulse present; B/P 150/110  Triage category = Yellow (11 points)  GCS (15) 4 + RR 3 + B/P 4 = 11

Secondary Triage Practice

 Case #3  30 year-old male sitting next to the previous patient; eyes open    Some dried blood noted on face and arms Respiratory rate 20 Radial pulse present; B/P 130/80  Triage category – Green (12 points)  GCS (15) 4+ RR 4+ B/P 4 = 12

Secondary Triage Practice

 Case #4  27 year-old female walking around with burns to their arms; eyes open    Crying out in pain Respiratory rate 32 B/P 120/80  Triage category = Yellow (11)  GCS (15) 4 + RR 3 + B/P 4 = 11

Smaller Scaled Incidents

   Some principles of SMART triage can be applied regardless of size of incident For smaller sized incidents, patients meet criteria as a Category I, II, or III trauma patient  Hospital report can include physiological assessment and the ECRN can even categorize the patient Hospital report can include categorization from the field (“We have a Category I trauma patient”)

Category I Patient

  Unstable patient from traumatic or medical issues When possible: 

Trauma

to the patients should be transported

highest level Trauma Center within 25 minutes



Medical

closest

patients are transported to the Emergency Department

Category I Patient Criteria

 Unstable vital signs      Adult systolic B/P < 90 on 2 readings Pediatric (<15 years old) systolic B/P < 80 on 2 readings Glasgow Coma Scale < 10 or deteriorating mental status Respiratory rate < 10 or > 29 Revised Trauma Score < 11

Category I Patient Criteria

 Anatomical injuries  Penetrating injuries to head, neck, torso, or groin     Combination trauma with burns > 20% TBSA 2 or more proximal long bone fractures Unstable pelvis Flail chest    Limb paralysis &/or sensory deficits above wrist or ankle Open & depressed skull fracture Amputation proximal to wrist or ankle

Category II Trauma Patient

  This is a patient with the potential to become critical / unstable due to the mechanism of injury or nature of the complaint but is relatively stable for now These patients should be transported to the

closest trauma center

for

traumatic

insult injuries or to the closest Emergency Department for a medical

Category II Trauma Patient

 Mechanism of injury       Ejection from automobile Death in the same passenger compartment Motorcycle crash > 20 mph or with separation of rider from bike Unrestrained in a rollover Falls > 20 feet for adults and x3 the height for pediatrics Pedestrian thrown or run over

Category II Trauma cont’d

    Auto vs pedestrian / bicyclist with > 5 mph impact Extrication > 20 minutes High speed MVC: speed > 40 mph, intrusion > 12 inches; major deformity > 20 inches Co-morbid factors    Age < 5 without car / booster seat Bleeding disorders or on anticoagulant Pregnancy > 24 weeks

Category III Trauma Patient

  All other trauma that does not meet criteria for Category I or II Typically simple trauma     Lacerations Simple burns One extremity fracture Hip fracture

After Action Report

   Form to be completed at end of every call involving 2 or more traumatically injured patients This is a PI tool to evaluate the current process  Allows for review of systems/processes/procedures/operations to determine what works and what needs revision Fax (or leave form) to Resource Hospital for PI review

Scenario Practice

   Review the scenario Place the incident somewhere in your town/village/city Determine how you would respond to the call and how you would handle the call  What roles are necessary?

  What additional resources are necessary?

When and how is report called to the hospital?

Case Scenario Practice

    Use the following scenarios as a base Can add/delete patients to meet your needs Add physiological findings based on how you want to use the scenario Best if all at the department drill together  Need to appreciate the roles taken by every person at the scene

Well person check turned bad!

 Newspaper delivery boy called 911   Newspapers not picked up for 2 days The weather is chilly and furnaces have been turned on in homes

Case Scenario #1

    Upon entry into the home, you find one adult victim lying on the floor inside the front door Another adult victim is collapsed on the stairs Another adult victim is collapsed in the kitchen 3 children are found unresponsive in their beds  One adult is triple zero; all other victims have poor respirations and weak pulses

Case Scenario #1

  What are your first thoughts and considerations?

 Safety is number one   What would make entry into the scene safer?

Evaluate what kind of additional resources are necessary   Are you thinking CO exposure?

Contact closest hospital to coordinate transportation What category are these patients?

 You have one dead  You have 5 critical patients  Category I patients for medical reasons

  

Multiple vehicle crash

At least 10 vehicles involved At least 18 victims As first responding unit, what do you do?

Case Scenario #2

    Do a windshield survey Need to activate additional help immediately  What would you request?

Remember an early phone call to alert the hospital What scene safety issues must be considered?

Case Scenario #3

  1 vehicle rolled, 5 teenager passengers All patients with unstable vital signs and altered level of consciousness

Case Scenario #3

      With first responding unit, what needs to happen?

What resources are necessary?

Who and when are you notifying the hospital?

How do you assign triage?

How do you coordinate transportation?

How do you communicate with the hospital?

 

Case Scenario #3

High speed MVC 4 occupants – 1 ejected; driver DOA

Case Scenario #3

   As a responding unit with 2(3) crew, how do you begin triage?

What additional resources do you need to request?

How do you coordinate this scene?

 Communication    Triage Treatment Transportation

Multiple Vehicle Incident >40mph

 5 patients between the 3 cars

Case Scenario #4

   2 patients in first car  Driver wants to sign a release  Passenger complains of back pain 1 patient in middle vehicle   Asking repetitive questions; unable to follow commands Moves only right extremities 2 patients in truck  Driver wants to sign a release  Passenger complains of knee and hip pain

Case Scenario #4

     Start with 1 responding unit Can add additional help per department guidelines Discuss assessment provided Can any of these patients sign a release?

 Any patient awake and oriented can sign a release Do any of these patients meet criteria for withholding full spinal immobilization?

 MVC >40mph so all patients require spinal immobilization based on mechanism of injury

Bibliography

    Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall. 2009.

Region X Multiple Patient Management Plan, 2009.

Region X SOP’s March 2007, Amended Version May 1, 1008.

Smartmci.com (TSG Associates Ltd 2004 – 2008)