2. Date of CE presentation: June/ July, 2016 Topic: Mass Casualty and Triage Behavioral Objectives: Upon successful completion of this module, the EMS provider will be able to: Describe the components of the Nations Incident Management System (NIMS). Describe the purpose and function of triage, treatment, and transportation sectors. Review the Region X Multiple Patient Plan. Review the documentation process related to a variety of levels of disaster response. Describe and demonstrate how to use SMART Triage Tags. Compare the START and JumpSTART triage processes. Review the 2015 Selective immobilization protocol. Review correct procedure to size and apply c-collar. Actively participate in mass casualty scenarios Bibliography https://emilms.fema.gov/IS200b/ICS0101100text.htm Region X Multiple Patient Management Plan, Amended March 1, 2013 Region X SOP ’ s, IDPH Approved, April 10, 2014 Hopkins, Sharon, Multiple Patient PowerPoint; June/July 2015 http://www.jumpstarttriage.com/uploads/MCI_Primary_and_Secondary_Triage_exercise.doc http://www.jumpstarttriage.com/uploads/The_START_and_JumpSTART_MCI_Triage_Tools.ppt Condell Medical Center EMS Education Program Skill Performance Manual, 8/2014-6/2015, pg. 61

3. MASS CASUALTY INCIDENT, START TRIAGE, JUMPSTART TRIAGE, AND SELECTIVE IMMMOBILIATION BY: ELIZABETH PEASLEE, RN

4. OBJECTIVES 1.Describe the components of the Nations Incident Management System (NIMS). 2.Describe the purpose and function of triage, treatment, and transportation sectors. 3.Review the Region X Multiple Patient Plan. 4.Review the documentation process related to a variety of levels of disaster response. 5.Describe and demonstrate how to use SMART Triage Tags. 6.Compare the START and JumpSTART triage processes. 7.Review the 2015 Selective immobilization protocol. 8.Review correct procedure to size and apply c-collar. 9.Actively participate in mass casualty scenarios.

5. NATIONAL INCIDENT MANAGEMENT SYSTEM (NIMS) “A systematic, proactive approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector to work together seamlessly and manage incidents involving all threats and hazards-regardless of cause, size, location, or complexity-in order to reduce loss of life, property, and harm to the environment.” –www.fema.gov

6. WHY NIMS?  A plan that is applicable for all potential incidents  Improves the communication and working relationships between all public and private agencies involved  Provides a common standard so that all reporting agencies know what to expect and procedures they will follow

7. NIMS COMPONENTS  Preparedness  Communication and Information Management  Resource Management  Command and Management  Ongoing Management and Maintenance

8. PREPAREDNESS  Necessary for effective incident and emergency management  Continuous cycle of planning, organizing, training, equipping, exercising, evaluating, and taking corrective action to maintain readiness

9. COMMUNICATIONS AND INFORMATION MANAGEMENT  Provides a standard overview of incident  Makes sure all agencies involved have the same understanding and knowledge of the incidents status  Keeps all agencies up-to-date with on-going operations

10. RESOURCE MANAGEMENT  Know the resources available and what is needed  Coordinates resources to provide timely response  Will continue to evaluate throughout incident to order and deploy resources as necessary  Inventories all resources at end to account for resources used

11. COMMAND AND MANAGEMENT  Facilitates effective and efficient incident management and coordination  Comprised of…  Incident Command System (ICS)  Standardized on-scene emergency management tool to assist with use of facilities, equipment, personnel, procedures and communication.  Multiagency Coordination System (MACS)  Common support system for prioritization of resources, allocation of communication systems, and information coordination  Public Information  Manages public information

12. ONGOING MANAGEMENT AND MAINTENANCE  Homeland security is required to routinely coordinate with agencies involved with NIMS to ensure the most effective plan is in place  Also coordinate with Technology Directorate to update and develop programs to assist with efficient large scale incidents

13. TRIAGE  One of the first functions that must be done at any incident  To sort patients based on severity of injuries  Do the most good for the most patients with the least amount of resources  Drives subsequent operations

14. TREATMENT SECTOR  Set up of area needs planning  Requires availability of medical equipment  Color zones with universal colors to separate patients  Patients are separated into categories  Prioritization based on patient needs and acuity  Initiate treatment and continued on-going assessment  Be organized moving patients in and out to transport sector

15. TRANSPORT SECTOR  Transport officer has to coordinate with staging and treatment officer for patient movement from scene  One pathway for ambulances to move through scene  Communicate essentials from scene to receiving hospital  Remove SMART transport tag when patient leaving scene, as a way to track patients

16. MULTIPLE PATIENT PLAN  Each ambulance should have guidelines in the ambulance  First responding unit will be acting commander, until relieved and will activate plan  Plan is to be activated as soon as possible to allocate all necessary resources  Endorsed by MABAS Divisions, medical directors and Disaster Management Services Committee of Region X  Approved by Region X Trauma/EMS Advisory Committee and IDPH

17. PURPOSE  Enables Fire/EMS agencies and region X hospitals to respond effectively and efficiently to multiple patient incidents.  Not to tax the resources of any single pre-hospital provider or healthcare facility  Assign specific responsibilities to EMS and hospitals  Promotes orderly disbursement of patients  Uniforms operational guidelines  Links communication between all responding Fire/EMS, receiving hospitals and resource hospital  Establishes responsibility of EMS responders  Gives guidelines for emergency evacuation of a healthcare facility

18. PLAN BREAKDOWN  “Business as usual”  Less than 3 ambulances  Small Scale  3-6 ambulances  Medium Scale  6-10 ambulances  Large Scale  Greater than 10 ambulances

19. “BUSINESS AS USUAL”  Less than 3 ambulances  Managed with routine resources  Command and general staff usually not activated  No written Incident Action Plan (IAP) required  Often done within one hour

20. SMALL SCALE INCIDENT  3-6 ambulances  Requires more than routine resources  Command and General Staff only if required  One operational period in control phase  No written Incident Action Plan required

21. EMS/FIRE RESPONSIBILITY  Contact closest appropriate hospital (if on bypass, ER doctor will determine to divert or accept patients)  Report description, number of patient, general patient descriptions, and closest appropriate hospitals  Incident command will assign other hospital destination if closest cannot take all patents. No more than 2 patients to each remaining hospital.  If more than 2 needed, ECRN at closest hospital will seek approval  All ambulances are to contact receiving hospital with patient care report  Complete After-Action report and submit it to EMS office at resource hospital within 48 hours.

22. MEDIUM SCALE  6-10 ambulances  Exist when capabilities exceed the typical initial emergency response  Some or all of the Command and General Staff positions will be activated, as well as Group Supervisors or Unit Leaders  May extend into multiple operational periods  A written Incident Action Plan may be required

23. LARGE SCALE  Greater than 10 ambulances  Extends beyond the capabilities of local control  Most or all Command and General Staff positions are filled  Multiple operational periods  Written Incident Action Plan may be required for each operational period

24. EMS RESPONSIBILITIES (MEDIUM/LARGE)  Contact resource hospital IMMEDIATLEY  Utilize the Field Provider Log Form for assistance with communication  Report events, estimated number of patients, patient acuities, closest hospitals  Provide resource hospital with call back number  After resource hospital relays capabilities, record information, assign patient and destination to ambulances  Hospitals on bypass must receive patients during plan  Maintain contact with Resource Hospital until scene is cleared (report ambulance number, acuities of patients and destinations  Complete After-Action Report and turn into EMS office of Resource Hospital within 48 hours

25. SMART TRIAGE TAG  Standard for Region X triage  Specific triage tags that show only one color at a time  May refold to reflect another color with changes in patient status

26. COMPONENTS OF TRIAGE PACK  Folding SMART triage tags  Mini light sticks to identify RED patients at night  Dead tags  START triage prompt cards  JumpSTART triage prompt cards  Dynamic record of casualities already triaged  Pencil

27. TRIAGE STAGES  Primary (first)  Sort patients into groups based on vital signs and level of consciousness  Secondary  Prioritize treatment and transport based on anatomical and physiologic criteria

28. PRIMARY 1.Obtain triage pack 2.PPE 3.Request all ambulatory victims to move to a safe area (GREEN or priority 3) 4.Approach remaining patients and use START triage for adults and Jump START triage for pediatrics 5.Remove SMART tag from plastic sleeve and replace with proper color showing 6.Attach elastic band to victims’s upper extremity

29. PRIMARY CON’T 7.If dark, use mini-light stick in addition to RED triage tag to designate most serious victims 8.Life support interventions limited to opening the airway and hemmorrage control 9.After finished with initial triage, patients are moved to designated color-coded areas

30. SECONDARY TRIAGE 1.In the collection area patients will be reassessed using GCS, respiration rate and systolic BP 2.Determine treatment and transport priorities 3.May also now change original priority code, refold original tag 4.Prior to transport, remove transport strip from tag and tag is kept by transport officer

31. C-COLLAR 1.Partner maintains manual immobilization 2.Assess necessity 3.Appropriately size (measure from shoulder to horizontal line drawn from jaw) 4.Place chin groove under patient chin 5.Bring collar behind patient neck and secure into place without movement of cervical area

32. START/JUMPSTART TRIAGE  Separates sickest patients  Ask all patients who can walk to go to designated “GREEN” area  Begin to triage those patients left at the sceen  Use SMART triage tags  Once a color is designated, move on to next patient  Limit life support interventions  Adult  Attempt to open airway and provide hemorrhage control  Pediatric  Repostion airway, deliver 5 rescue breaths

33. TABLE TOP TRIAGE INSTRUCTIONS SET UP: Place each “patient” in accident area. Set up color coded triage areas to receive patients. Team leader will direct: Assign 2 people to be “first on scene”, these people will triage the accident scene and direct movement of patients to designated area. The rest will be working the triage area. TO START: Team leader will inform players of scene. *Two families caravanning in minivans swerve to avoid an oncoming car. One van rolls, the other slams into an overpass embankment. The weather is warm but roads are slick from recent rain. “First on Scene” *Will go through accident victims in numerical order *Place the victims to designated areas on table Team Leader *After initial triage is done, team leader will check for right placement by looking to second card in the stack. Triaged Sector *The rest of the team in the triage sector will work together for second assessments on the patients. *Flip to the next card to know what your patient is presenting with. *Now discuss possible treatment options (the following card will give suggestions) *Now give second triage color, change if necessary, and list priority