Rapid Assessment & Triage Methods: The University of South Alabama Center for Strategic Health Innovation Funding for these courses provided through HRSA funds administered by Alabama Department of Public Health Rapid Assessment & Triage Methods: On-scene to the ER © University of South Alabama Center For Strategic Health Innovations. All Rights Reserved. These slides are a part of the ARRTC program and cannot be reproduced for commercial purposes.

simsf@cityofmobile.org 251.208.5873 Doug Sims RN MPA REMTP simsf@cityofmobile.org 251.208.5873

Objectives Identify situations when standard triage methods may be inadequate. Identify appropriate triage locations for different types of mass casualty events. Identify MCI triage acronyms: MASS, START, JumpSTART, SLUDGEM 4. Identify discipline-specific staffing needs for the four (4) main triage categories.

Mass Casualty Incident: What Is It? An incident can be considered a mass casualty incident whenever the number of victims is greater than your resource capability to provide usual and customary standards of care. Example: 20 victim incident for small, rural hospital to manage can be as much of a “mass” casualty incident as a hundred victim incident in a large metropolitan area with multiple hospitals / trauma unit(s).

Needs out of proportion Disaster Triage What’s a disaster? Needs out of proportion to resources.

Disaster Triage Why Do I Need It????

Disaster Triage At least 4 die in gym shooting near Pittsburgh At least 10 shooting victims arrived at the three major hospitals in the area. A spokeswoman for Mercy Hospital confirmed five female shooting victims arrived at the facility with multiple gunshot wounds. Three were in serious condition, and two were listed as critical, she said.

Disaster Triage Fort Hood, Texas Mass shooting killed 12 soldiers and one civilian and wounded 38 people at the Fort Hood Army Post in Texas.

Disaster Triage Gunman Opens Fire at Orlando Office A gunman opened fire Friday in the offices of an engineering firm where he was let go more than two years ago, killing one person and injuring five others.

Disaster Triage West Nickel Mines School Shooting 10 young girls, between the ages of six and 13, all had at least one gunshot wound.

Disaster Triage Flight 1404 (Denver) Thirty-six patients were initially identified as requiring transport

Principles of Disaster Triage Do the greatest good for the greatest number of people Employ the most efficient use of available resources Treat as many as possible who have a chance of survival. Base treatment on exclusion criteria Agreed upon criteria = Triage Process Return key personnel to duty as quickly as possible

Factors for Successful Triage Focus on easily treated conditions Perform rapid, accurate but assessments Continually reassess and retriage

On-Scene Rapid Assessment Assorted Methods START : Simple Triage And Rapid Treatment JumpSTART (Pediatric Version of START) MASS : Move, Assess, Sort, & Send Triage Sieve: Ambulate, Breathing, Pulse Rate Pediatric Triage Tape: Length, Weight, Age Care Flight Triage Algorithm: Qualitative Observations Sacco Triage Method: Mathematical Model MASS is a modified military triage method. In essence, both MASS and START involve rapid assessment and sorting of victims by physiological criteria so treatment of the most critical can be initiated before those less critical. JumpSTART is the START method revised to work with ages 1 through 8. Note that Triage does NOT equate to treatment; other than repositioning airway to reestablish respirations, treatment should be initiated in the treatment area AFTER the patient is transferred there.

On-Scene Rapid Assessment Secondary Methods SAVE Triage: Detailed Guidelines Triage Sort: Used in Conjunction with Triage Sieve MASS is a modified military triage method. In essence, both MASS and START involve rapid assessment and sorting of victims by physiological criteria so treatment of the most critical can be initiated before those less critical. JumpSTART is the START method revised to work with ages 1 through 8. Note that Triage does NOT equate to treatment; other than repositioning airway to reestablish respirations, treatment should be initiated in the treatment area AFTER the patient is transferred there.

START (Simple Triage And Rapid Treatment) Developed by staff at Hoag Hospital and the Newport Beach Fire Department Newport Beach, CA. in 1986

START Triage Triage = “Sorting” Not a treatment role! Only 2 treatments allowed: Open & clear airway Control of major external hemorrhage ~30 seconds per patient!

Respirations Airway / Breathing Pulse Circulation START Triage Exclusion criteria - based on rapid assessment of “RPM” Respirations Airway / Breathing Pulse Circulation Mental Status Disability

Remember... Once any RED criteria are met, tag patient and move on! All patients are reassessed at treatment areas.

On-Scene Rapid Assessment Immediate Scene Assessment This fits with the concept of “Situational Awareness”, and must be done before actual assessment / triage begins.

Triage Tags follow the 4 Color Triage Categories: Adaptable for almost any type of incident, w/ SLUDGEM assessment triggers for chemical event Identify triage category and contamination status Provide easy record of vital patient data & tx that stays with patient Bar codes enable patient ID (including valuables / clothing) throughout triage, tx, morgue Do a talk through with class of how to use these tags:

On-Scene Rapid Assessment Next slide has diagram for discussion of this subject. 2. Set-up of Victim Staging Areas

Transportation: Process and Problems On-Scene Rapid Triage Transportation: Process and Problems

On-Scene Rapid Assessment Information Exchange to ER at Patient Delivery

Tips and Pitfalls in Triage Move Quickly Do Not Second Guess Let the most experienced lead Plan Ahead

JumpSTART: Pediatric START Triage Method Developed by Lou E. Roming MD, FAAP, FACEP Miami Children’s Hospital Miami-Dale Fire Rescue Department Medical Director, FL/5 DMAT

The JumpSTART Field Pediatric Multicasualty Triage System © (Patients aged 1- 8 years) Black = Deceased/expectant Red = Immediate Yellow = Delayed Green = Minor/Ambulatory Identify and direct all ambulatory patients to designated Green area for secondary triage and treatment. Begin assessment of nonambulatory patients as you come to them. Proceed as below: MINOR Spontaneous respirations? YES NO Check resp. rate Open airway < 15/min or > 40/min or irregular 15 - 40/ min, regular Spontaneous respirations? NO YES Peripheral pulse? NO Peripheral pulse? IMMEDIATE IMMEDIATE YES NO YES DECEASED Still follows the RPM method, but with values and interventions appropriate for children. Triage sorting categories are the same. Perform 15 sec. Mouth to Mask Ventilations Check mental status (AVPU) IMMEDIATE Spontaneous respirations? A V P (appropriate) P (inappropriate) U YES IMMEDIATE NO DECEASED IMMEDIATE DELAYED © Lou Romig MD, FAAP, FACEP, 1995

Alabama Trauma System Good trauma care is no accident! Designated Trauma Centers Classified by Level I,III,III Four Entry Criteria

EMS & Trauma Regions

Alabama Trauma Communications Center 1-800-359-0123 Business Phone 205-975-2400 SouthernLink : Fleet 55 Talkgroup 10 or private 55*380 Nextel 154*132431*4

Entry Criteria Physiological Physiologic Criteria (generally triaged to Level I Trauma Center) A systolic BP<90mmHg in an adult or <80mmHg in a child 5 years old or younger Respiratory distress - A respiratory rate of <10 or >20 in adults or <20 or >40 in a child one year old or younger Altered mental status as evidenced by Glasgow Coma Score of 13 or less GCS of 9 or less go to Level I GCS of 10-13 go to Level II or possible Level III if they have neurosurgical coverage

Entry Criteria Anatomical Anatomic Criteria (generally triaged to Level I Trauma Center) Flail chest Two or more obvious proximal long bone fractures (humerus, femur) Penetrating injury of the head, neck, torso, or groin (not just laceration) Has in the same body area a combination of trauma and burns (partial and/or full thickness) of 15% or greater Amputation proximal to the wrist or ankle One or more limbs that are paralyzed Unstable pelvic fracture, as evidenced by a positive "pelvic movement" exam

Entry Criteria Mechanism of injury Mechanism of Injury Criteria (may go to Level II or III if closer than Level I Trauma Center) A patient with the same method of restraint and in the same seating area as a dead victim Ejection of the patient from an enclosed vehicle Motorcycle/bicycle/ATV crash with the patient being thrown at least 10 feet from the vehicle Auto versus pedestrian with significant impact with the patient being thrown, or run over by a vehicle An unbroken fall of 20 feet or more onto a hard surface

Entry Criteria EMT Discretion EMT Discretion Criteria (May go to a Level II or III if closer than Level I Trauma Center) If the EMT is convinced the patient could have a severe injury that is not yet obvious, the patient should be entered into the trauma system The EMT's suspicion of severity of trauma/injury may be raised by the following factors: Age >55 Age <5 Environment (hot/cold) Patient's previous medical history: Insulin dependent diabetes Cardiac condition Immunodeficiency disorder Bleeding disorder COPD/Emphysema Pregnancy Extrication time >20 minutes with heavy tools utilized History of more than momentary loss of consciousness

Entry Criteria Special Cases No Airway - to closest emergency department Unable to control severe hemorrhage - to closest emergency department Hemodynamically unstable and unable to establish IV - to closest emergency department Age 14 years old or younger Pediatric Level I Center if transport is <45 minutes Closest Level I or II Trauma Center if >45 minutes to Pediatric Center Closest Level III if transport is >45 minutes to Level I or Level II Pregnancy To Level I if <45 minutes transport To Level II or III if >45 minutes transport Hospitals will also be able to enter patients into the Trauma System

Transition

ER ~ Secondary Triage & Tx 1. Set-up and appropriate staffing for Emergency Room and Adjacent Treatment Areas

ER ~ Secondary Triage & Tx Hand-off/Information Exchange from EMS/Ambulance Services

Triage Tags follow the 4 Color Triage Categories: Adaptable for almost any type of incident, w/ SLUDGEM assessment triggers for chemical event Identify triage category and contamination status Provide easy record of vital patient data & tx that stays with patient Bar codes enable patient ID (including valuables / clothing) throughout triage, tx, morgue Do a talk through with class of how to use these tags:

ER ~ Secondary Triage & Tx 3. Management of Self Referral (walk-up) Patients

ER ~ Secondary Triage & Tx Secondary triage methods: START Categories* vs. ER Categories * (START, Jump-START, MASS, etc..)

ER ~ Secondary Triage & Tx 5. Staffing and Resource Issues

ER ~ Secondary Triage & Tx 6. Re-Transport

Lessons learned from disasters Actions which save lives (early) ABC’s control of hemorrhage chest decompression Actions which save lives (delayed) IV antibiotics dressings & splints

Lessons learned from disasters The hopelessly injured die regardless. Unrealistic triage results in increased death rates among those who could & should survive.