Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Marin CountyMarin CountyMultiple Patient Management Plan Multiple Patient Management Plan

Training ModuleTraining Module

June 2013

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

This training presentation is intended for use by EMS, hospital and law enforcement

personnel in Marin County, California. It may not be used without expressed permission

from the Marin County EMS Agency.

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

IntroductionIntroduction

• Marin County’s guide for managing MCIs has been the 1999 Emergency Medical Response Plan

• The Multiple Patient Management Plan (MPMP) replaces the EMRP effective July 1, 2013

• The MPMP integrates guidance from:– FIRESCOPE Field Operations Guide 420-1 (aka “FOG” Manual) – California Public Health and Medical Emergency Operations

Manual (aka “EOM”)

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

ReferencesReferences

• National Incident Management System (NIMS)

• Standardized Emergency Management System (SEMS)

• Incident Command System (ICS)• Simple Triage and Rapid Treatment

(START) and JumpSTART• FIRESCOPE FOG 420-1 • California Master Mutual Aid

Agreement• California Government Code • California Emergency Services Act

• Marin County Fire Service Mutual Aid Plan

• California Public Health and Medical Emergency Operations Manual

• California Patient Movement Plan (TBD)

• County of Marin Emergency Operations Plan

• County of Marin Medical and Health Annex

• County of Marin ACS Plan• County of Marin FTS Guide (TBD)

This Plan meets the standards of the following by reference or incorporation and may be used for guidance when required:

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

EMRP vs. MPMPEMRP vs. MPMP

EMRPEMRP• Uses “START” triage• Incident organization based on

FIRESCOPE model• 4 response levels• Hospital most distant from the

incident is assigned as the Coordinating Hospital

MPMPMPMP• Uses “START” triage• Incident organization based on

FIRESCOPE model• “Local MCI” plus 3 response

levels• Level III Trauma Center is the

Coordinating Hospital• Integrates with State’s Public

Health & Medical Emergency Operations Manual

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

MCI Activation LevelsMCI Activation Levelsin MPMPin MPMP

Local MCILocal MCI Level IIILevel IIILevel IILevel IILevel ILevel I

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Local MCILocal MCI(6-15 patients*)(6-15 patients*)

Example: Multiple vehicle collision involving 15 patients requiring transportation.

• Operational Focus is on incident management including the use of resources necessary to mitigate the problem (scene safety, security, specialty response, on-scene triage, patient transportation, etc.).

• Managed with local jurisdiction (i.e., ALS zone) resources• EMS system modifications may be implemented. (e.g. canceling

diversions, using private ambulances for 9-1-1 calls, amending dispatch criteria, etc.)

* Guideline only – actual number of patients may vary

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Level ILevel I(16-30 patients*)(16-30 patients*)

Example: Aircraft collision, skilled nursing facility evacuation, large motor vehicle collision, involving 20-30 patients.

• Operational and Strategic Focus shifts from individual incident management to maintaining the County’s EMS system and a possible transition from focused patient care to population based care.

• In-county mutual aid from other ALS zones will be requested. • EMS system modifications to be implemented.

* Guideline only – actual number of patients may vary

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Level IILevel II(31-100 patients*)(31-100 patients*)

Example: Large aircraft collision, hospital facility evacuation, isolated natural incident, involving 80 patients.

• Operational and Strategic Focus is on scene management, resources necessary to mitigate the incident and maintain the County’s EMS System. This includes a transition from focused patient care to population based care.

• The use of out-of-county mutual aid resources is anticipated.• Modifications to the daily 9-1-1 system are made to support the

incident and stability of the system.

* Guideline only – actual number of patients may vary

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Level IIILevel III(> 100 patients*)(> 100 patients*)

Example: Significant natural disaster or other incidents involving more than 100 patients.

• Operational and Strategic focus is on scene management, resources necessary to mitigate the incident and maintain the County’s EMS System. This includes a transition from focused patient care to population based care.

• The use of out-of-county mutual aid resources from regional, state and federal partners is anticipated.

• Activation of Operational Area Patient Distribution Center likely• Includes significant modifications to support the incident and

maintain 9-1-1 response.

* Guideline only – actual number of patients may vary

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

MCI Alert & ActivationMCI Alert & Activation

• The IC may initiate either an ALERT or an ACTIVATION– ALERT: Notifies all EMS system participants of a potential multi-

casualty event– ACTIVATION: Notifies all EMS system participants of a multi-

casualty event in progress– “Alert” or “Activation” should be cancelled when no longer needed

• Marin County Communications is responsible for sending the alert/activation/cancellation to EMS system participants

Patient Distribution

• MPMP allows for immediate transport of patients to local hospitals prior to a communications link being established with the Coordinating Hospital

• For a Local MCI, Marin’s hospitals will accept:– 1 Immediate– 1 DelayedDelayed– 2 Minor– Trauma Triage Tool may still be considered

• For a Level 1 or higher, Marin’s hospitals will accept:– 2 Immediate– 2 DelayedDelayed– 4 Minor

MPMP Forms

• MPMP includes several forms that may be used by on-scene personnel:– Patient Routing Worksheet for Local MCI & Level I– Patient Routing Worksheet for Levels II & III– ICS 214 Unit Log– ICS 206 Incident Medical Plan– Transportation Group Supervisor Worksheet– ICS 255 Patient Status Sheet (for Marin)– Job Action Checklists

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Incident CommandIncident Command

• First-arriving unit will establish Incident Command

• Then:– Initiate an MCI Alert or

Activation

– Assign ICS roles as needed

– Identify incident command post and staging area(s)

– Request tactical radio frequencies as needed

– Order additional resourcesIncident Command Post

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

MCI OrganizationMCI OrganizationIncident Commander

Operations Section

Medical Group

Triage Unit Treatment Unit

Single Resources

Morgue

Patient Transport Unit

Fire Group

Medical CommunicationsCoordinator

Ground Ambulance Coordinator

Staging

Air Ambulance Coordinator

Immediate

Delayed

Minor

Extrication Unit

CoordinatingHospital

(Adapted from FIRESCOPE Field Operations Guide 420-1)

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

““Broad Street MCI”Broad Street MCI”Incident Staging

AmbulanceStaging

Minor

Immediate

Delayed

Morgue

To Hospital

MCI Scene

Eastern Street

Bro

ad S

tree

t

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

S.T.A.R.T. ReviewS.T.A.R.T. Review• Verbally direct “walking wounded”

patients to one area– These are patients

• For each remaining patient assess: – Respirations (<30/min.)

– Perfusion (Cap refill <2 sec.)

– Mental Status (follows commands)

• Tag if any of above not met

• Tag if “30 – 2 – Can Do”

MINOR

IMMEDIATE

DELAYED

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Triage TagTriage Tag

• Marin EMS providers use a triage tag similar to the one shown

• Remove “contaminated” strip if not applicable

• Remove all colored triage strips below the one selected

• Attach tag to arm, leg or neck

Front Back

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

MCI Trailers (50 pts)MCI Trailers (50 pts)

• Marin County maintains three trailers stocked with equipment and supplies for an MCI

• Each can manage about 50 patients

• Trailers may be ordered by the IC

MCI Trailer

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

MCI Trailers (25 pts)MCI Trailers (25 pts)

• Eight low-profile trailers are strategically located throughout Marin

• Each can manage about 25 patients.

Low Profile MCI Trailer

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Air OperationsAir Operations

• Ordering air ambulances is at the discretion of the IC

• Air ambulance transportation will be directed by the Air Ambulance Coordinator

• Air ambulances will generally be used to transport immediate patients to hospitals outside Marin County

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Dispatch CenterDispatch Center

• Marin County Communications Center will:– Notify hospitals, providers, law

enforcement, and EMS Agency of a multi-casualty incident

– Assign radio frequencies as needed for the incident

– Dispatch additional incident resources as requested by the IC9-1-1 Communications

Center

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Coordinating HospitalCoordinating Hospital

• The Coordinating Hospital will: – Initiate an MCI using

ReddiNet®

– Coordinate patient distribution with the Medical Communications Coordinator (MedComm)

– Use ReddiNet® to track all patients from an incident

• Level III Trauma Center (Marin General Hospital) is the coordinating hospital for MCIs

Marin General Hospital

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

EMS AgencyEMS Agency

• Marin County EMS Agency will: – Be notified of all MCI alerts or

activations

– May send an Agency Rep to the incident scene if requested

– Activate an Operational Area Patient Distribution Center if large numbers of patients must be transported outside Marin

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

OA Patient Distribution CenterOA Patient Distribution Center

• Large numbers of patients to be transported out of Marin may require activation of an OAPDC

• OAPDC works with Coordinating Hospital, MedComm, nearby OAs, Region II and State to distribute patients to medical facilities outside Marin

• Directed by the MHOAC (Medical Health Operational Area Coordinator) and staffed by EMS Agency

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Reno Championship Reno Championship Air Races CrashAir Races Crash

September 16, 2011

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

The VenueThe Venue

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Minutes BeforeMinutes Before

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Milliseconds BeforeMilliseconds Before

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

The ImpactThe Impact

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

The SceneThe Scene

• A highly-modified P-51 “Mustang” flown by veteran pilot, James “Jimmy” Leeward, suddenly dives directly into a VIP grandstand packed with spectators

• Initial response includes four ALS ambulances• The pilot and 6 spectators are dead on arrival

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

The AftermathThe Aftermath

• 54 patients are triaged and transported in 62 minutes:– 25 Immediate25 Immediate– 18 Delayed18 Delayed– 11 Minor11 Minor– 7 Dead7 Dead

• 4 patients later die in the hospital

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

Now assume this incident has just occurred at Gnoss Field in Novato, and you are on duty…

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

QuestionsQuestions

1. What would the initial dispatch of resources likely include?

2. When would you request an MCI activation?

3. Discuss the ICS organization needed for this incident.

4. How would you handle all the walking wounded?

5. What level MCI would this incident fall under according to the MPMP?

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

More QuestionsMore Questions

6. How many ambulances will you need for this incident? Who orders them?

7. How many air ambulances?

8. Which ICS role handles patient distribution with the Coordinating Hospital?

9. How many patients can be sent to Marin’s three acute hospitals right away?

10.How will patients be tracked from the scene to the hospital?

Marin County Emergency Medical Services“Excellent Care – Every Patient, Every Time”

For a copy of Marin County’s Multiple Patient Management Plan or this

training presentation please go to:

www.MarinEMS.org

Copyright © 2013

All rights reserved by Marin County EMS Agency