Managing Multiple Casualty Incidents The HospitalPrehospital Interface

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Managing Multiple Casualty Incidents The
Hospital/Pre-hospital Interface
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Your Instructors

• Earl Hall
• Steve Glow

Montana Bioterrorism Training Project
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• This project is made available bySt. Vincent
  Healthcare Foundation and the University of
  Montana School of Pharmacy through a grant funded
  by the U.S. Department of Health and Human
  Services (HHS) and the office of the Assistant
  Secretary for Preparedness and Response (ASPR).

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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 System All elements of a
  response Dispatch, Fire/EMS, Law Enforcement,
  Hospitals, Public Health (HSPD-8)

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Learning Objectives

• Identify critical pieces of information and
  demonstrate how to communicate them effectively.
• Describe Incident Command System and how to
  implement it in a MCI
• Describe a triage system and how to implement it
  during an MCI
• Integrate Communications, ICS and Triage into an
  effective response system

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What this course is designed to do

• Teach local Healthcare system personnel basic
  processes for response, triage, treatment,
  transport and transfer of victims of a multiple
  casualty incident using the START triage system
• Provide opportunities to practice learned skills
  in a simulated multiple casualty incident
  exercise.
• Teach skills to organize a response using the
  Natl Incident Management System (NIMS) ICS
• Provide a NIMS compliant model/standard from
  which current capabilities can be assessed.

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What this course is not designed to do

• Write plans and local procedures for you.
• Provide you with additional resources/equipment
• Mandate the use of a specific triage system
• Certify or qualify
• Teach specific medical interventions other than
  triage.

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Yes, it can happen here

• Examples of MCIs in Montana
• Polson Deck collapse
• Ennis Shooting
• Red Lodge CO Poisoning
• Alberton Chlorine release

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Types of Multiple Casualty Incidents

• Trauma
• Acute Medical
• Biological

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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 hotwash 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 that
  may be impacted by the incident or impact the
  incident?

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Keys to Clear Communications

• 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)
• Speak slowly and clearly (practice this)
• Repeat back communications to acknowledge receipt
  of message
• Assume messages not acknowledged were not heard
  and repeat initial message
• Develop/refine and practice your communications
  plan

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I am 10-23 at a 10-50. 10-52 times two and a
10-51.
911 HP 1 I am on scene at a car crash with
casualties. I need 2 ambulances and a wrecker.
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Hospital Medic 1 Enroute to your facility with
a TBI. 2 min LOC and GMS with GCS of 9. ETA 2
min.
Hospital Medic 1 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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Establish Command-Overview

• Initial contact scene/situation size-up
• Safety
• Assume/Announce Command
• Request Resources
• Identify location, access and positioning
• Assign/Allocate Resources
• Plan for Demobilization

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Scene/situation size-up

• First responsibility is a walk around
  assessment of the scene or situation
• Goal is to determine the extent of the problem
• Initial communications should include the nature
  and scope of the incident and initial tactical
  objectives

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Assume/Announce Command

• Responsibility of the first arriving unit is to
  establish command by announcing the name of the
  incident, incident commander and the location of
  the command post
• Command may be passed to another person once they
  are in a position to assume control

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Request Resources

• Resources adequate to resolve the problem should
  be requested and dispatched as they become
  available.
• They should be told 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 (supervisor).
• A tactical objective to accomplish.
• A location to work.
• Once the assignment has been completed, the
  individual or team needs to know where to report
  for another assignment or demobilization.

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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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Module 2 ICS
President
Unified Command
FEMA
Incident Command
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An Organized Response

• Requires planning
• Coordinates resources and personnel

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Key Principles of NIMS ICS

• Span of Control
• Unity of Command
• Accountability

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What is Span of Control?
Span-of-Control means that one person can only
supervise 3-7 people and/or be responsible for
3-7 functions effectively.
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Span-of-Control

• Refers to number of subordinates that one
  supervisor can manage effectively.
• Ideal ratio is 5-to-1
• ICS structure can expand or contract to maintain
  adequate span-of-control by adding/removing
  sections, branches, divisions, groups, teams.

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What is Unity of Command?
Unity of Command means that you answer to only
one person for tasks and assignments.
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Unity of Command

• Each person reports to only one individual
• ICS organizational chart indicates who that is
• What would you do if someone other than your
  assigned supervisor asks you to do something
  other than what you were assigned?

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What does Accountability Mean?

• There are two types of Accountability
• You know who is on-scene/site, where they are,
  what they are assigned to do and if they are
  safe.
• Each person does what they were expected to do.

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Accountability People

• It is the responsibility of the incident
  commander to know who is on-scene, to make sure
  they are doing what is needed and No one is left
  behind
• Check In
• No freelancing
• Report to supervisor
• Check Out/Demobilize

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Responder Etiquette
Report to a staging area, not the disaster site
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Accountability Task

• Give clear assignments
• Ensure assignment is understood
• Provide adequate resources
• Task Completion

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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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Break
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Incident Command System

• Used to organize multiple groups/agencies into
  one cohesive team
• Responses and responders may vary, but the
  organizational principles of ICS remain the same

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Initiating ICS

• When an event occurs, initial actions should
  include
• Scene size up safety
• Assume/Announce Command (Even if you are the only
  person on scene)
• Initially organizing the response Assign Tasks
• Notifying affected agencies (hospitals, LE,
  Fire/EMS)
• Maintain Command role until Command is transferred

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ICS Characteristics

• Critical Characteristics of ICS (7 of 14)
• Common Terminology
• Management by Objective
• Chain of Command/Unity of Command
• Resource Management
• Integrated Communications
• Manageable Span of Control
• Accountability of personnel and resources

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Basic ICS Organizational Structure
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Small Scale On-Scene ICS
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Emergency Dept ICS
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Larger Scale Hospital ICS
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Mobilization of Resources
What resources are available to my community
during an MCI?
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Predicting Casualty Flow
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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
• MDs, RNs
• RNs, CNAs
• Surgeons, OR Crews
• Blood Bank Staff
• Imaging/Lab Staff
• Resp Therapists

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External Resources

• Refer to the External Resources handout in your
  packet
• Regional (ChemPaks, Antibiotics, Antivirals)
• State (MCI trailers in Helena, MHMAS )
• Federal (DMAT, SNS, FEMA)

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ICS/MCI Roles Responsibilities

• Every incident must have an Incident Commander.
• In the next few slides we will describe the
  positions/functions within the Incident Command
  System critical to managing multiple casualty
  incidents.

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Key ICS Roles in a MCI

• IC Every incident must have an IC
• Medical Branch Director Only if the incident is
  big enough and you have the resources to fill the
  position.
• Triage Group Supervisor
• Treatment Group Supervisor
• Transport/Transfer Group Supervisor
• Rescue or Decon Group Supervisor

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The Incident Commander

• Role
• Assumes and announces command
• Leads response effort

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IC Responsibilities

• Assess incident and communicate an Incident
  Action Plan (IAP)
• Ensure the safety of responders
• Request additional resources
• Develop organizational structure that effectively
  manages incident (Assign, Delegate)
• Develop plans that stay ahead of the need for
  resources
• Maintain Command until Command is transferred.

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Assessment and Care of Multiple Patients

• On-Scene
• Rescue/Extrication
• Triage
• Treatment
• Transport
• see slide 40

• Hospital
• Decon
• Triage/Re-Triage
• Treatment
• Admission/Discharge/Transfer
• see slide 41

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Medical Branch Director Responsibilities

• Takes the medical burden off the IC or Operations
  Section Chief
• The Medical Branch Director assigns and
  supervises the triage, treatment and transfer
  group supervisors
• The Medical Branch Director reports to the
  Operations Section Chief or the IC

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Rescue Group(s)

• This and triage are happening simultaneously in
  concert with each other.
• Extrication
• Technical Rescue
• Dive Teams
• HazMat Decon
• Patient Movement (out of hazard zone to patient
  collection area/treatment tarps)

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On-Scene Triage Responsibilities

• Size up number and acuity of patients
• See each patient rapidly and categorize using a
  standard triage system
• Document the triage category assigned
• Communicate (with who) the order of treatment
  (who needs help first?)

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Hospital Triage Responsibilities

• Identify the location(s) where triage will occur
• Ensure safe access and egress
• Anticipate self transporting patients
• Implement hospital MCI triage protocol
• Communicate / document triage decisions to
  Treatment Group

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Scene Treatment Responsibilities

• Locate a suitable treatment area and report that
  location to Triage Group Supervisor and Command.
• Evaluate resources required for patient
  treatment, and report those needs to Command
• Provide suitable immediate and delayed
  treatment areas.
• Assign, direct, supervise, and coordinate
  personnel within your group.
• Allocate resources.
• Provide lifesaving basic life support before
  advanced life support.
• Match patient needs with provider skills
• Report progress to Command

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Hospital Treatment Responsibilities

• Provide definitive care identify and fix the
  problem
• Provide lifesaving basic life support before
  advanced life support.
• Organize care providers into efficient teams
• use ICS principles to maintain control.
• 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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Scene Transport Responsibilities

• Establish/communicate location of ambulance
  staging (if Command has not already done so) and
  patient loading areas.
• Report resource requirements to Command
• Establish/manage a helicopter landing site if
  warranted
• Communicate with Command and Hospitals to obtain
  medical facility status and treatment
  capabilities.
• Supervise assigned personnel
• Coordinate with other divisions/groups
• Efficiently and safely move patients to the next
  location in the continuum of care while providing
  for their medical needs enroute.
• Report progress to Command

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Hospital Transfer Responsibilities

• Communicate with treatment group supervisor for
  information about patients who need transfer to
  other facilities
• Determine the number and type of transportation
  resources needed and available.
• Arrange transport to referral centers (stage
  resources early?)
• Stage resources until needed
• Efficiently and safely move patients to the next
  location in the continuum of care while providing
  for their medical needs enroute.
• Communicate with receiving facilities to
  determine capacity and provide advance information

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Staying Organized

• Organizational Tools
• Plans
• Protocols
• Forms
• Job Action Sheets

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Group Activity

• Working with your group take ten minutes to
  prepare a VERBAL Incident Action Plan (IAP) for
  the first 15 minutes of the incident.
• Describe the situation, what you are going to do
  about it, and who is going to help you do it.
• Select a spokesperson and be prepared to
  verbalize the IAP

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Break
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• This page is intentionally left blank

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Module 3 Triage System
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Triage French to sort

• A process in which victims are sorted into
  groups priorities of care are established and
  resources are allocated.

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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 care

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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)
• Provides leadership and structure
• Triage
• Used to manage limited resources
• Prioritize patient care based on survivability

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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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Protocols for Triage and Treatment

• Must develop protocols BEFORE they are needed
• Keep protocols and treatment plans up-to-date
• Practice triage method
• Practice getting organized to do triage
• Remember Triage is a continuous process

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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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What are the problems with START? (Group
Discussion)

• Does not take resources into account
• Some are more Red than others
• Uses a limited number of physical parameters
  (RPM)
• Not commonly used during daily operations

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S.T.A.R.T. Triage System

• S.T.A.R.T. (Simple Triage Rapid Transport)
• Example of a triage method that quickly
  classifies victims and prioritizes treatment

• Little or no care needed,
• Delay care, injuries not life-threatening
• Immediate care for life-threatening situation
• No care, mortal injuries, cannot be saved

MINOR
DELAYED
IMMEDIATE
MORGUE
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S.T.A.R.T. Patient Tag

• 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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S.T.A.R.T. Triage Kit

• Triage kit includes
• Tape to create triage areas
• Patient triage tags
• Clipboards
• ID Vests

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Tools Triage Flow Chart

• Flow Chart Decisions
• 1. Separate walking wounded from others
• 2. Use life functions to tag remaining patients
• a. Respirations
• b. Perfusion
• c. Mental Status

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First Step Breathing

• Cannot breathe on own after airway opened
  BLACK tag
• Breathing rapidly RED tag
• Breathing regularly (go to next step in flow
  chart - PERFUSION)

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Second Step Blood Flow

• If detectable pulse, go to step 3 Mental Status
• If no detectable radial pulse - check capillary
  refill
• Refill more than 2 seconds needs to control
  bleeding - RED tag
• Capillary refill less than 2 seconds - go to step
  4 Mental Status

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Third Step Mental Status

• Cannot follow simple command - RED tag
• Can follow simple command - YELLOW tag
• End of algorithm all victims should be tagged
  now.

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• RED
• RR gt 30
• No Radial Pulse or cap refill gt 2 sec
• Cannot follow simple commands

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ActivityTriage Practice Case 1

• A woman runs up to you, supporting her left arm,
  and says, I think its broken.
• Respiratory rate is 24/minute
• Radial pulse rate is 120/minute
• How would you label her?

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ActivityTriage 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
• Capillary refill takes almost 5 seconds
• He moans when you use a painful pinch
• How would you label him?

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ActivityTriage 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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Now that you understand START

• Does the triage system you use daily in the ED
  work for MCIs?
• 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 resources

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Summary

• Communication
• Organization
• Prioritization (triage)
• Resource Management
• Accountability (Personnel, Patients)

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Applied Exercise

• After lunch, something bad is going to happen
• During Lunch (provided) spend some time talking
  with your group about how you would manage an MCI
  
• Of the people in your group who would assume
  what role(s)?
• No performance anxiety.

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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-w
  eb.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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Acknowledgements
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More Information on Triage
MINOR

• 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

DELAYED
IMMEDIATE
MORGUE
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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 Moments 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 Carolines, Emergency Care in the Streets,
  Sixth Edition
• National Incident Management System, Principles
  and Practice, Walsh, Christen, Miller, Callsen
  and Maniscalco

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NIMS ICS Titles(not negotiable)
Title
Organizational Level
Incident Commander
Incident Command
Officer
Command Staff
Chief
General Staff (Section)
Director
Branch
Supervisor
Division/Group
Leader
Unit
Leader
Strike Team/Task Force
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Discussion/Group Activity List

• Group Activities
• Module 1, Slide 20, Communications Practice
• Module 2 Slide 61, Verbal IAP
• Module 3 Slide 78-80 Triage Practice
• Discussions
• Slide 15 Communications Plan
• Slide 40-41 ICS Roles
• Slide 45 Local Resources
• Slide 55 of Providers/colored patient
• Slide 69 Problems with START
• Slide 82 START vs. ESI