disaster triage
DESCRIPTION
presentasi kuliahTRANSCRIPT
Managing Multiple Casualty Incidents The Hospital/Pre-hospital Interface
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Definitions:
• MCI – Multiple Casualty Incident – Any incident where the number/severity of patients exceeds the capacity of local resources.
• Local Healthcare Team – All elements of a response: Dispatch, Fire/EMS, Law Enforcement, Hospitals, Public Health (HSPD-8)
• START – Simple Triage And Rapid Transport
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Learning Objectives• Effectively identify & communicate critical
pieces of information. (dispatch, scene, hospital) using good radio etiquette.
• Establish & implement the Incident Command System in a MCI situation.
• Describe key roles, responsibilities and functions necessary to manage an MCI
• Use START triage system to categorize patients during an MCI.
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If you get a report that the scene has 5 yellow
patients and 3 red patients, do you know
what that means?
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S.T.A.R.T. Triage SystemS.T.A.R.T. (Simple Triage And Rapid Transport)
Example of a triage method that quickly classifies victims and prioritizes treatment
MINOR
DELAYED
IMMEDIATE
MORGUE
•Little or no care needed,
•Delay care, injuries not life-threatening
•Immediate care for life-threatening situation
•No care, mortal injuries, cannot be savedn_Da 5
Types of Multiple Casualty Incidents
• Trauma• Acute Medical• Biological
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How Responses are Organized
• Disaster plans are prepared • Responders become familiar with the plan
• Plans include the use of:– Communication Plan– Incident Command System (ICS/HICS)
• Provides leadership and structure• Identifies Roles and Responsibilities
– Triage • Used to manage limited resources• Prioritize patient care based on “survivability”
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Module One: Communications
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Question
What problem is most commonly identified after exercises or real events in the Post Incident Review or After Action Report?
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Implementing the Communications Plan (Group Discussion)
Do you have a communications plan? What are your Dispatch Procedures – responder
notification? How is the Hospital Notified? How does On-Scene Command Communicate
with the Hospital? How do you Communicate with other hospitals? How/when do you communicate with the
public?
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WHAT TO COMMUNICATE FIRST
• Initial contact – scene/situation size-up– Safety
• Assume/Announce Command• Request Resources• Identify location, access and positioning• Assign/Allocate Resources
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“Dispatch: Local Ambulance: On scene of a multiple vehicle crash with approximately 20 casualties. Local Ambulance will be I-90 Command on the east bound Gold Creek Off ramp.”
Size-Up, Assume Command
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Keys to Clear Radio Communication
• Key microphone 2 seconds before speaking on a repeater based radio system
• Say who you want to talk to first then say who you are.
• Use clear text (plain language NO TEN CODES) – Speak slowly and clearly (practice this)
• Repeat back communications to acknowledge receipt of message.– Assume messages not acknowledged were not
heard and repeat initial messagen_Da 13
Keys to Clear Interpersonal Communications
• Develop/refine and practice your communications plan
• Organize your thoughts to present the information clearly and concisely (SBAR)
• Have a back-up plan (runners, written notes)
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“I am 10-23 at a 10-50. 10-52
times two and a 10-51.
“Dispatch: HP 1: I am on scene at a car crash with
casualties. I need 2 ambulances and a wrecker.”
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Don’t use 10-Codes!
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“Hospital: Medic 1: Enroute to your facility with a TBI. 2 min LOC and
GMS with GCS of 9.”
“Hospital: Local Ambulance: Transporting Pt. #3 triaged as red/immediate, due to head injury with respiratory rate of 40, radial pulse present, and
responds to pain only.”
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Avoid Acronyms and Abbreviations!
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SBAR (focused communication)
• Situation: “En route with 52 year old male triaged as Red ”
• Background: “Motor vehicle crash – ejected”• Assessment: “Head and chest injuries”• Recommendations: “Activate Trauma Team”
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Public Information
• If pub info isn’t addressed early/ aggressively it will impact the incident and incident communications – this is one of the reasons phones go down and
your hospital becomes overwhelmed with people seeking information
• Assign people to answer phones, craft messages for media, meet with families, track patients.
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Request Resources
• Call for help – You can always cancel them if not needed– Be specific about what units and capabilities you want– Order enough resources
• Tell them where to report & how to access the scene– If coming in a vehicle, where should it be positioned?
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Assign/Allocate/Reassign Resources
• Individuals or resources should be assigned:– Someone to report to (a boss).– A task TO ACCOMPLISH– Where to go.– What to do when done with THE task.
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Group Activity
• Photo/description of MCI Incident• Divide into groups (Pre-hospital/Hospital)• Play act initial establishment of command for
each area and communication between groups
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An Organized Response
• Requires planning
• Coordinates resources and personnel
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Report to Staging Area
• Sign in when you arrive; Sign out when you leave
• Bring ID, credentials
• Find your designated supervisor
• Follow directions– If asked to leave or provide
care else where – do so
Medical volunteers at staging area
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Accountability: Task
• Tell them what needs to be done• Ensure assignment is understood• Give them the tools they need • Tell them what to do when done
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Use SMART Objectives
• Specific • Measurable• Action Oriented• Realistic• Timeframe
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Break
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On-Scene Incident Command Structure
Incident Commander
Safety Officer
Medical Branch Director
Triage Group Supervisor
Technical Rescue
Treatment Group Supervisor
Transport Group Supervisor.
Dive Team
Extrication Team
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Emergency Dept Hospital Incident Command
Incident Commander Cindy
TriageUnit Leader
Paula
Treatment Unit LeaderDr. Jones
TransferUnit Leader
Bob
Communications Unit Leader
BobImmediate Red Team
Delayed Yellow Team
Minor Green Team
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WHAT ARE YOUR Local Resources?
• Ground Ambulances• Air Ambulances• Fire/Rescue Vehicles• ED beds• Hospital beds• Operating Rooms• Blood Supply• Imaging/Lab Capacity• Ventilators
• EMTs• Flight Crews• Firefighters• Technical Rescue• MDs, RNs, CNAs• Surgeons, OR Crews• Blood Bank Staff• Imaging/Lab Staff• Resp Therapists
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Group Activity
What resources are available to my
community during an MCI?
• Where are they?
• How do we contact them?
• How long will they take to arrive?n_Da 32
• Because you could have multiple incidents going on simultaneously.
• Helps avoid confusion.
Why is it important to “give the incident a
name?”
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Assessment and Care of Multiple Patients
On-Scene• Rescue/Extrication• Triage• Treatment• Transport
*see slide
Hospital• Decon• Triage/Re-Triage• Treatment• Admission/Discharge/
Transfer
* see slide
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On-Scene Triage Group Supervisor Responsibilities/Tasks:
• Ensure safety• See each patient rapidly, categorize and label
patients using a standard triage system • Communicate triage decisions with Medical Branch
Director, and coordinate with treatment and extrication groups.
• Track Patients:– Remove patients to the treatment area– Red Patients move first!
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Hospital Treatment Unit Leader Responsibilities
• Provide definitive care: identify and fix the problem• Provide lifesaving basic life support before
advanced life support..• Match patient needs with provider skills.• Use available resources, making decisions about
resource allocation at each step.• Use tools to document and aid organization • Transport/Transfer/Admit them to the place where
these needs can be met.
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Rescue Group(s)
• Rescue and triage are happening simultaneously
• Rescue Groups focus on: – Extrication– Technical Rescue (high/low angle)– Dive Teams– HazMat, Decon– Patient Movement (out of hazard zone to patient
collection area/treatment)
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Staying Organized
• Organizational Tools– Plans– Protocols– Forms– Job Action Sheets
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Triage Systems
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START Triage
A process in which victims are sorted into groups; priorities of care are established and resources are allocated.
RESPIRATIONS
Morgue
POSITION AIRWAY
Minor
<30/Min. or >10/Min.
>30/Min. or <10/Min.
MENTAL STATUS
PULSEImmediate
Delayed
Can’t Follow Simple
Commands
Can Follow Simple
Commands
ALL WALKING WOUNDED
Radial Pulse Absent
ControlBleeding
YESNO
NO YESImmediate
Immediate
Immediate
Radial Pulse Present
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S.T.A.R.T. Triage SystemS.T.A.R.T. (Simple Triage And Rapid Transport)
Example of a triage method that quickly classifies victims and prioritizes treatment
MINOR
DELAYED
IMMEDIATE
MORGUE
•Little or no care needed,
•Delay care, injuries not life-threatening
•Immediate care for life-threatening situation
•No care, mortal injuries, cannot be savedn_Da 41
START uses R P M
• Respirations (<10 OR >30)
• Pulse (no radial pulse)
• Mental status (unable to follow simple commands)
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Triage Flow Chart
Flow Chart Decisions:1. Separate walking
wounded from others
2. Use RPM life functions to tag remaining patients: a. Respirationsb. Circulationc. Mental Status
RESPIRATIONS
MENTAL STATUS
PULSE
Minor
ALL WALKING WOUNDED
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First Step: Breathing
RESPIRATIONS
Morgue
POSITION AIRWAY>30/Min.
or <10/Min
(check) PULSE
Immediate
YESNO
NO YES
Immediate
<30/Min. or
>10/Min
Cannot breathe on own after airway opened – [BLACK tag] Breathing rapidly >30 breaths per minute – [RED tag] Breathing regularly (go to next step in flow chart - PERFUSION)n_Da 44
Second Step: Blood Flow
(check)MENTAL STATUS
PULSE
Radial Pulse Absent
ControlBleeding
Immediate
Radial Pulse Present
If detectable radial pulse, go to step 3: Mental Status
If no detectable radial pulse - check capillary refill Refill more than 2
seconds – control bleeding - [RED tag]
Capillary refill less than 2 seconds - go to step 4: Mental Status
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Third Step: Mental Status
MENTAL STATUS
Delayed
Can’t Follow Simple Commands
Can Follow Simple Commands
Immediate
Cannot follow simple command - [RED tag] Can follow simple command - [YELLOW tag]
End of algorithm – all victims should be “tagged” now.n_Da 46
PATIENTS ARE RED IF THEY HAVE EVEN ONE FINDING OF:
• RR <10 OR > 30• No Radial Pulse• Cannot follow simple commands
RESPIRATIONS
MENTAL STATUS
PULSE
Can’t Follow Simple Commands
Radial Pulse Absent
Immediate
Immediate
Immediate
>30/Min. or
<10/Min.
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Activity:Triage Practice Case #1
• A woman runs up to you, supporting her left arm, and says, “I think it’s broken.”
• Respiratory rate is 24/minute• Radial pulse rate is 120/minute
How would you label her?
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Activity:Triage Practice Case #2
• You approach a man who is lying on the ground • He is taking 36 breaths per minute • You cannot find a radial pulse • He moans when you use a painful pinch
How would you label him?
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Activity:Triage Practice Case #3
• A woman is sitting slumped over, not breathing• You open her airway – still not breathing• There is no radial pulse
– Her carotid pulse is 30 beats/minute
• She does not respond to noise, touch, or painful stimuli
How would you label her?
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Triage Organizes Priorities
• Normal Circumstances– Use all available manpower and supplies– Resource use focuses on saving one life
• Mass Casualty Situation– Number of injured exceeds ability to treat in
normal manner– Resource use focuses on saving as many lives as
possible• Minor injuries wait for care• Severe injuries receive immediate care• Mortal injuries do not receive caren_Da 51
What Makes Triage Difficult
• More patients than resources• Victims who are “Beyond Rescue”
– Black tag (morgue) category• To NOT treat such patients will oppose all your training and
instincts
• Example:– Patient has no pulse and is not breathing
• Routine situation compared to a mass casualty situation
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Now that you understand START;
• Does the triage system you use daily in the ED work for MCI’s?
• If not, you need to decide whether during an MCI you will:– Stay with START system initiated pre-hospital or-– Adapt your current system to include a category
for the patients who are expected to die given maximum treatment with the available resources
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• What Triage system does your ED use everyday?
• MCI Triage Options:– Stay with the START
system initiated pre-hospital or-
– Adapt your current system to include a category for the patients who are expected to die even if they are given maximum treatment with the available resourcesn_Da 54
Tools for S.T.A.R.T.
Left side used for notes on injuries and vital signs
Right side contains decision flow chart (algorithm)
Note the four color-coded categories at the bottom
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Tools for S.T.A.R.T.
Triage kit MAY include:•Tape to create triage areas •Patient triage tags•Clipboards & Tracking tools•ID Vests
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Review
• Communication• Organization• Resource Management• Roles and Responsibilities• Prioritization (triage)• Accountability (Personnel, Patients, Tasks)
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For More Information HICS:
http://www.emsa.ca.gov/hics/hics.asp
NIMS: http://www.dhs.gov/interweb/assetlibrary/NIMS-90-web.pdf
FEMA (Certificate in basicICS): http://training.fema.gov/EMIWeb/IS/is195.asp
OSHA: http://www.osha.gov/SLTC/etools/ics/org.html
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More Information on Triage
For additional practice:http://www.citmt.org/start/exercise.htm
For more information on tags:http://www.mettag.com
To find out to fill out a tag:http://www.digisys.net/oes/triagetag.htm
MINOR
DELAYED
IMMEDIATE
MORGUE
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Basic HICS/ICS Organizational Structure
Incident Commander
OperationsSection Chief
Public InformationOfficer
Safety Officer
Liaison Officer
Planning Section Chief
Logistics Section Chief
FinanceSection Chief
Branch Director
Division/Group Supervisor
Command Staff
General
Staff
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Hospital ICS ChartHospital
Incident Commander
Medical Branch Director
Planning Section Chief
Safety Officer
Liaison Officer
Safety Officer
Operations Section Chief
Logistics Section Chief
Finance Section Chief
Human Services Branch Director
Ancillary ServicesBranch Director
Staging Manager
Immediate Care Unit Leader
Delayed Care Unit Leader
Minor Care Unit Leader
Triage Unit Leader
TransferUnit Leader
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References• Brady, Paramedic Emergency Care, Bledsoe, Porter, Shade• NIMS ICS Field Guide, 1st Edition – Infomed• Disaster Medicine, 2002 Lippincott Williams & Wilkins, Hogan and Burnstein• Emergency Medical Services at a Mass Casualty Incident, Joseph Cahill, Domestic
Preparedness Journal V. III, Issue 7, July 2007• Creating Order from Chaos: Part II: Tactical Planning for Mass Casualty and Disaster Response
a Definitive Care Facilities, Baker, Michael S., Article Military Medicine, Mar 2007• In a Moment’s Notice: Surge Capacity for Terrorist Bombings, Challenges and Proposed
Solutions, CDC, April 2007• International Nursing Coalition for Mass Casualty Education, Educational Competencies for
Registered Nurses Responding to Mass Casualty Incidents, August 2003• Mass Casualty Incident Program, Initial Triage Training, AEMS, courtesy of Pheonix FD.• Virginia Mass Casualty Incident Management, Secondary Triage• Improving health system preparedness for terrorism and mass casualty events,
Recommendations for action, July 2007, AMA/APHA Consensus report• Mass Medical Care with Scarce Resources, A Community Planning Guide, Health Systems
Research Inc., Feb. 2007• Nancy Caroline’s, Emergency Care in the Streets, Sixth Edition• National Incident Management System, Principles and Practice, Walsh, Christen, Miller,
Callsen and Maniscalco
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