Transcript Disaster traige - Advocate Health Care

Review of START and
JumpStart Triage
Condell Medical Center EMS System
ECRN Disaster Training Module
March 2009
Material development by Illinois EMSC and children’s Memorial
Hospital. Modified for CMC staff by Sharon Hopkins, RN, BSN,
EMT-P
Rationale for the Packet
 Without training you will be ill-prepared to
respond to a disaster/multiple patient incident
 START and JumpSTART triage is the triage
process in the Region X Multiple Patient Plan
for disaster management
 This training is to review the triage processes
referred to as START for the adult and
JumpStart for the pediatric patient
 This triage is usually performed in the field but
can be adapted to be performed in the ED
Pediatric Disaster Triage
Utilizing the JumpSTART Method
March 2009
Development of this educational program was sponsored by Illinois EMSC and
Children’s Memorial Hospital and supported in part by an Assistant Secretary for
Preparedness and Response (ASPR) grant. This program was adapted from a module
developed through HRSA funding by the Chicago Department of Public Health.
Program adapted to Condell ECRN CE by Sharon Hopkins, RN, BSN 3.09
Disclaimer
NOTE:
This slide set and all related training information provided in this
session is in accordance with current practice at the time that this
program was developed.
This program was developed utilizing federal grant funding, therefore
all training materials are considered under public domain and can
be utilized by others in the conduction of similar educational
programs, provided there is acknowledgement of the source of
these materials. When using these training materials, please
include appropriate acknowledgements which can be found on the
last slide in this presentation.
These training materials are available on the Illinois EMSC website
http://www.luhs.org/emsc
Objectives
 Review unique pediatric issues in a disaster
situation
 Review incorporating pediatrics into your disaster
planning
 Review triage and the pediatric patient
 Review START and JumpSTART triage
 Complete triage scenario exercises in the packet
 Complete the quiz with a score of 80% or better
“That
Won’t
Happen in
My
Backyard”
Disaster
“A medical disaster occurs when the
destructive effects of natural or man
made forces overwhelm the ability of a
given area or community to meet the
demand for health care.”
ACEP Policy Statement June 2000
Mass Casualty Incident
Any incident in which there are more patients than
rescuers with inadequate resources to immediately
care for them
Natural Disasters





Earthquake
Flood
Snow/ice storm
Tornadoes
Others
At least 19 dead, including 8 at the high school as
tornadoes rip through the South.
March 2, 2007
Enterprise, Alabama
Natural Disasters can involve
pediatric patients
Terrorist events




Arson
Bombings
Shootings
Use of chemical,
biological or nuclear
agents
The Old Way of
Thinking…
Kids were
secondary victims
of terrorism and
inadvertently
targeted
The new way of thinking …
Children
may be
intentionally
targeted
Photo courtesy of Charles H Porter IV
Are you
prepared?
Illinois Demographics
 Illinois is the 5th most populous state with a
population of 12.7 million
 Over 3 million children <18 years of age
 900,000 are age five and younger.
 Percent of Illinois children <18 y/o increased
10% between 1990 - 2000
 In the event of a disaster or terrorist event,
children would be one of our most vulnerable
populations
Basic Pediatric
Differences
Airway
 Mouth and nose are smaller
 More easily obstructed
 Infants are nose breathers so secretions
can be a major issue
 Trachea is much shorter
 ETT can be displaced easier
 Narrow Airways
 Easily obstructed
 Diaphragm
 Infants depend on diaphragm to breathe
so abdominal distention can be
problematic
Oral explorers
 Germs with feet
Large Head =
Risk of head injury
Large unprotected
intraabdominal organs =
Risk liver, spleen
& bowel injury
Large Body Surface area = hypothermia
Vulnerability of Children:
Anatomic & Physiologic Issues
 Children are particularly vulnerable to
aerosolized biological or chemical agents
and radiation
 Some agents (e.g., Sarin and Chlorine and
radiation) are heavier than air and
accumulate close to the ground—in
breathing zone of children.
 Children have faster ventilatory rates than
adults
 Inhale larger doses of the substance in the
same period of time.
Vulnerability of Children:
Anatomic & Physiologic Issues
 Thinner skin and proportionately greater
Body Surface Area (BSA)
 Increased risk for hypothermia during field
decontamination and treatment
 Increased susceptibility to chemical agents
 Vesicating agents (Nitrogen/Sulfur Mustard,
Lewisite)
 Nerve agents (Sarin, VX, Tabun, Soman)
 Irritants and corrosives (chlorine, ammonia,
phosgene)
 Increased susceptibility to infections
 Newborns
 Children with chronic illnesses
Vulnerability of Children:
Anatomic & Physiologic Issues
A child’s condition can rapidly go from stable to
life-threatening
 Children have smaller circulating blood volumes than adults.
 They have less blood and fluid reserves
 More vulnerable to the effects of agents that produce vomiting and/or diarrhea -- can
become dehydrated faster
 Blood/fluid loss can lead to irreversible shock or death
 More sensitive to changes in body temperature
 Higher basal metabolic and cellular growth rates
 Increased susceptibility to radiation, chemical agents
 Increased leukemia and cancer risk to radiation exposed children age < 5y/o
Vulnerability of Children :
Developmental Considerations
 Can’t anticipate, recognize or flee from dangerous situations
 Fear of strangers – inability to cooperate or communicate with
officials/providers
 Family separation – unaccompanied minors
 Sensitive to emotional state of parents
 Children, Terrorism & Disasters Toolkit (AAP)
at www.aap.org further identifies these vulnerabilities
Decon Considerations
 Unlikely to be cooperative
 Will be frightened of process and
staff in protective gear
 Hypothermia risk
 Slippery when wet
 How best to get them through
the decon shower system
 Laundry baskets
 Car seats with padding removed.
Strap them in.
 Hospital plastic bassinettes
 Stretcher or conveyor system
 Strip them, including the
diaper!
“Hello. Come with me. I’m going to
take you thru this shower over here”
Decon Considerations
 Warm Water
 High Volume/Low Pressure
 Keeping the family unit
together as much as possible
 How will they hear you?
 Showering process will take
more time with children
 Identification issues
Lessons learned
 Decontamination of kids is “not a fun
time”
 Decon brushes can be rough on skin
 Blankets, booties and towels work well
 Age specific decision tree
 Use ink markers to write directly on skin
to identify
EMS systems need plans to establish
communication and restore unity of
families
Pediatric Identification
Kids come with
Parents
You can find the CHAD sticker
order form at www.dot.il.gov
1.
Using the tool bar; select Doing
Business
2.
From the drop-down menu
select Forms
3.
Click on Traffic Safety Forms
4. Scroll down to the bottom
5.
Select TS 2268 Public
Information and Education
Materials
6.
Fax your completed form to
(217) 557-5937 or mail it to
Melissa Schaive, Illinois
Department of Transportation
7.
3215 Executive Park Drive,
Springfield, IL 62794
Pediatric Identification
School Identification
Medical History
School
identification
Children with Special Health
Care needs (CSHCN)
 Technology Dependent








Ventilators
G-Tubes
Shunts
Insulin Pumps
Developmentally Disabled
Chronic Diseases
Immunocompromised
Psychiatric/Behavioral Illnesses
Children with Special Health
Care needs (CSHCN)
 18% (13.5 million) of U.S.
kids meet criteria
 Over 20,000 families in
Illinois receive services from
the Division of Specialized
Care for Children (DSCC)
 CSHCN are
disproportionately poor &
socially disadvantaged
 Strong need for healthcare
provider education &
awareness
Key Principles of Medical Care
Conventional Medical Care
The objective of conventional medical care is to…
Do the greatest good for the individual patient.
Disaster Medical Care
The key principle of disaster medical care is to…
Do the greatest good for the greatest number of patients.
Briggs, S and Brinsfield, K (eds), Advanced Disaster Medical Response for Providers. Harvard Medical
International, 2003.
Triage
 “To Sort”
 Look at medical needs and
urgency of each individual patient
 Triage in Daily Emergencies
 Do the best for each individual
 Disaster Triage
 Do the greatest good for the greatest
number
 Make an impossible task manageable
Triage
 Primary Triage
 Triage that is performed at the scene or
point of first contact with patients.
 Secondary Triage
 Triage that is performed after further
intervention is provided. Usually done in a
medical sector.
80% of casualties self or buddy
transport to the closest hospital
Important Triage Concepts
 Helps to prioritize patients in a systematic
and organized fashion
 Helps in resource allocation
 Provides an objective framework for
stressful and emotional decisions
 MCI (mass casualty incident) triage is
different than daily triage, in both field
and ED settings
MCI (Mass Casualty
Incident) Triage
 In order for MCI triage to work effectively,
all victims must have equal importance at
the time of primary triage.
 No patient group can receive special
consideration other than that dictated by
their physiologic state. This includes
children!
Adapted from the Dr. Lou Romig slide set available at www.jumpstarttriage.com/
Triage Categories
 RED - Immediate/emergent
 YELLOW - Urgent
 GREEN - Nonurgent
 BLACK- Dead/little to no hope of
survival
BLACK
RED
YELLOW
GREEN
RED - Immediate
 Severely injured but treatable injuries
and able to be saved with relatively
quick treatment and transport
 Examples
 Severe bleeding
 Shock
 Open chest or abdominal
wounds
 Emotionally out of control
Yellow - Delayed
Injured and unable to walk on
their own. Potentially serious
injuries but stable enough to
wait a short while for medical
treatment
 Examples
 Burns with no respiratory
distress
 Spinal injuries
 Moderate blood loss
 Conscious with head
injuries
Green – Non-Urgent
 Minor injuries that can wait for a longer
period of time for treatment.
 May or may not be able to ambulate
 Examples
 Minor fractures
 Minor bleeding
 Minor lacerations
Black - Deceased
 Dead or obviously dying. May have signs of
life but injuries are incompatible with survival.
 Handle based on local protocols
 Examples
 Cardiac arrest
 Respiratory arrest with a pulse
 Massive head injury
 Can be psychologically difficult to tag a child as
black
Review of START and
JumpSTART MCI Triage Tools
Photo courtesy of Miami Dade Fire
Rescue
© Lou Romig MD, 2006. Used with permission.
START
 Simple Triage and Rapid Transport
 Joint development by the Fire & Marine
Department and Hoag Hospital in New Port
Beach, California
 Gold standard for field adult MCI triage in U.S.
and numerous other countries
 Utilizes the standard four color triage
categories
 Used for primary triage
 More information at www.start-triage.com
START vs JumpSTART
Triage
 START triage
 Used for the adult population (non-pediatric)
 JumpSTART
 Used when the victim appears to be a child
 Adult and pediatric patients do not share the
same normal values for vital signs hence the
need for 2 different tools
 At approximately age 8, the pediatric patient
is similar anatomically with the adult airway
ED Triage
 Primary START or JumpSTART triage
does not have to be repeated at the point
of entry to the ED when patients are
transported by EMS
 But, not all patients will come by EMS
 Historically, we know patients will selftransport
 Triage will be a valuable tool to perform
quick sorting when dealing with multiple
patients at one time
Understanding Field Triage
 The ED staff need to understand the
triage performed in the field
 Helps with the flow of continuity of care
 If ED staff understand START and
JumpSTART triage, they will understand
how EMS made the decisions they did
 START and JumpSTART triage is a
process that can be duplicated and
performed in the ED as needed – not all
patients come by EMS!!!
START Triage
 This is just the 1st process of triage
 It is meant to quickly and initially separate those
with life threatening injuries from the less
seriously wounded/ill
 Secondary triage will allow retriage of a patient
 Patient may be placed into a different triage
category
 Decision will be based on physiological
criteria
 START triage attempts to remove the emotional
reaction from the decision process
START Triage
 Start at the top of the algorithm
 As soon as patient has been categorized,
stop assessment and move onto the next
patient
 Triage proceeds through a process
Can patient get up and walk to triage area?
Evaluate respirations (presence & rate)
Evaluate circulation (capillary refill)
Evaluate neurological status (obeys simple
commands)
START Triage Algorithm –
Used For Adults
JumpSTART Triage
 Pediatric patients do not fit the START
triage criteria




The youngest of our patients don’t walk yet
Respiratory rates are different
Circulation assessment is altered
Ability to follow directions changes with age
 START triage has been modified to be
able to be applied to this unique
population
JumpSTART Triage
 Tool for pediatric mass casualty triage
 Provides objective framework
 Based primarily on physiologic
differences between children and adults
 Designed for use in Disaster/MCI (mass
casualty incident) events
Adapted from the Dr. Lou Romig slide set available at www.jumpstarttriage.com
Differences Between
START and JumpSTART
 If positioning airway does not restart
breathing, a ventilatory trial is administered
in JumpSTART (pediatrics)
 Capillary refill is used to assess perfusion in
START (adult) while peripheral pulse is used
in JumpSTART (pediatrics)
 The ability to follow command is used to
assess mental status in START (adult) while
the AVPU scale is used in JumpSTART
(pediatrics)
JumpStart

In children,
circulatory failure
usually follows
respiratory failure.

Apnea may occur
relatively rapidly,
rather than after a
prolonged period of
hypoxia.
 There may be a
brief period when
the child is apneic
but not yet
pulseless since the
heart has not yet
experienced
prolonged hypoxia.
It is felt that
providing a brief
trial of ventilations
may help
“jumpstart” their
respirations.
The Pediatric Patient
 What age?
What age
defines peds?
JumpSTART: Age
The ages of “tweens and teens” can
be hard to determine so the current
recommendation is:
. to be a child,
If a victim appears
use JumpSTART.
If a victim appears to be a young
adult, use START
Adapted from the Dr. Lou Romig slide set available at www.jumpstarttriage.com
Triage – First Step
 At a MCI there is panic and people are
looking for someone to “take charge”
 The initial sorting is to determine who can
follow directions and walk
 Helpful is to call out for patients to selfsegregate (“if you can walk go over to …”)
sending patients to a close but alternate
site (ie: the tree, the fence, the desk)
 Patients will be triaged and sorted again at
this next site
 There is NO treatment at triage
Using JumpSTART Triage
Kids are good at
following directions
Anyone that can
hear me, get up
and walk if you can
and come to…
The big tree
START & JumpSTART:
Step 1
Patients who are able to walk are
assumed to have stable, well compensated
physiology, regardless of the nature of their
injuries or illness. Tag these patients GREEN
Walking & Carried Patients
 These patients need to be triaged
immediately in the new area
 Think, no-one has really looked at or
evaluated these patients
 This group of patients were able to walk to
an alternate site as a process to “thin” the
group of patients that are potentially more
critically injured/ill
 Start with the secondary triage process to
determine the color category (GCS, RR,
systolic B/P to get RTS)
JumpSTART: Step 2
Next begin triaging the remaining victims
 Position the upper airway of the apneic
child.
 If they start to breathe, tag them as RED
JumpSTART: Step 3
If the patient has a palpable pulse, give 5 mouth-tobarrier breaths to open the lower airways. Tag as
below, depending on response to ventilations.
BLACK
RED
DO NOT
CONTINUE TO
VENTILATE THE
PATIENT.
RESUME TRIAGE
DUTIES TO THE
OTHER
PATIENTS.
JumpSTART: Step 4
Assess the respiratory rate
of the spontaneously
breathing child.
JumpSTART: Step 4
 If respiratory rate is 15-45 breaths/minute,
move to perfusion assessment.
 If respiratory rate is <15 or >45, tag the
patient as RED
JumpSTART: Step 5
 If the child’s pulse is palpable, move on to
the next assessment.
 If no palpable pulse, tag the patient as RED
JumpSTART: Step 6
 If patient is alert, responds to voice or
appropriately responds to pain/touch, tag as
YELLOW
 If patient is inappropriately responsive to
pain, posturing, or unresponsive, tag as RED
AVPU
 Alert/awake – not necessarily oriented
 Verbal – responds to verbal stimuli before
tactile/touch stimuli
 You shout for the patient to open their eyes and their
eyelids flicker or they open their eyes
 In non-verbal children, evaluate the cry
 Painful – responds to tactile stimuli; does not
have to be painful stimuli but can be to touch
 A flicker of the eyelids is a positive response
 Unresponsive – there is absolutely no response
large or small
Children who classify as
“non-ambulatory”
 Infants who normally can’t walk yet
 Children with developmental delay
 Children with acute injuries which
prevented them from walking before the
incident occurred
 Children with chronic disabilities
CHILDREN MEETING THIS CRITERIA SHOULD BE
EVALUATED USING THE JumpSTART ALGORITHM
BEGINNING WITH STEP 2 - BREATHING
Modification for Nonambulatory
Children (and used for adults)
All children carried to the GREEN area by other
ambulatory victims must be the first assessed
by medical personnel in that area.
If patient meets any red criteria tag as RED
If patient meets yellow criteria and has significant
external signs of injury, tag as YELLOW
If patient has no significant external signs of
injury, tag as GREEN
SMART Triage System
 System of triage
adopted by Illinois
 Triage tags have
standard barcodes for
tracking patients
 Triage tags have a
unique folded design
that allows patients to
be re-triaged to another
color classification
without having to
replace the tag
Folding Triage Tags
 Tags will only show one color at a time
 If the triage category changes, refold the
card to reflect the new color status and
replace into the plastic sleeve
 Triage cards are dynamic – they can
change if the patient changes
 Space provided to write notes, record
vital signs, GCS, tally RTS (revised
trauma score), treatments