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 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 communicate critical pieces of
  information. (dispatch, scene, hospital)
• Implement the Incident Command System in a MCI
  situation.
• Describe key roles, responsibilities and
  functions necessary to manage an MCI
• Describe a triage system and how to implement it
  during an MCI

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What this course is designed to do

• Teach radio protocol/etiquette
• Identify what should be communicated
• Teach skills to organize a response using the
  Natl Incident Management System (NIMS) ICS

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What this course is designed to do (continued)

• Identify Roles/Responsibilities/Tasks
• Teach START triage system
• Provide opportunities to practice learned skills
  in a simulated multiple casualty incident exercise

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

• S.T.A.R.T. (Simple Triage And 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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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
• Identifies Roles and Responsibilities
• Triage
• Used to manage limited resources
• Prioritize patient care based on survivability

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For More Information On

• Add urls here

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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 (make you an expert)
• 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
• Everyday serious MVAs

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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 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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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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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.
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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)
• 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

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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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Dont 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 isnt addressed early/ agressively 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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Scenario

• You will be given handouts that begins to
  describe the scenario that will be used
  throughout the course.
• As we cover new material we will build on the
  same incident to provide examples of an
  appropriate response.

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Show Scenario Here
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Scene/situation size-up

• First responsibility is a walk/look around
  assessment of the scene or situation
• What do I have?
• What do I need to do?
• What resources do I need?
• 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 (EMS,
  Fire, Law) 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

• Call for help early (you can always turn them
  around).
• Call for enough help (order early, order often,
  be specific)
• 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.
• Where to go.
• What to do when you are done with your 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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Show Scenario Here
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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
• Personnel
• Tasks
• Refer to FEMA Emergency Management Institute
  (EMI) for further training at http//training.fem
  a.gov/IS/crslist.asp

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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 how many people one person can
  supervise well.
• 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

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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 on arrival
• Get an assignment (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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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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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/HICS

• 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/HICS Characteristics

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

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On-Scene Incident Command Structure
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Emergency Dept Hospital Incident Command
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Group Activity

• Given a scenario, create an organizational chart
  and assign roles.

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Show Scenario HereHand out 201 forms
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Mobilization of Resources

• ICS is just a tool to manage resources
• People
• Things

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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
• Technical Rescue
• MDs, 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, MHMAS )
• Federal (DMAT, SNS, FEMA)
• Create

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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?

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Module 3 Basic Multiple Casualty Incident
Command Roles and Responsibilities
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ICS/MCI Roles Responsibilities

• 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

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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

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

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Predicting Casualty Flow
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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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On-Scene Triage Group Supervisor
Responsibilities/Tasks

• See each patient rapidly and categorize using a
  standard triage system (coordinate with treatment
  and extrication)
• Move patients to treatment area
• Get enough help and ensure safety
• Document triage activities
• Communicate with Medical Branch Director
• Establish initial morgue

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Hospital Triage Unit Leader 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 Group Supervisor
Responsibilities/Tasks

• Locate suitable treatment area and communicate
  with Transportation Group.
• Request and allocate resources required for
  patient treatment.
• Assign, direct, supervise, and coordinate
  personnel within your group and ensure safety.
• Provide lifesaving basic life support before
  advanced life support.
• Provide updates to Medical Branch Director.
• Document activities

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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.
• 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 Group Supervisor
Responsibilities/Tasks

• Establish/communicate patient loading
  areas/landing zones.
• Report transport requirements to Medical Branch
  Director or Staging and report progress.
• Coordinate with Treatment Group and determine
  destination for patients.
• Communicate with Hospitals
• Supervise assigned personnel and ensure safety.
• Track ALL patient movement.
• Document activities.

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Hospital Transfer Unit Leader 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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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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Hospital Incident Command System (HICS)
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Staying Organized

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

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Incident Action Plans

• Initially are verbal (written if there are going
  to be multiple operational periods or hazmat).
• Identifies/Describes the plan.
• Who (org chart)
• What (resources)
• Where (map)
• When (time, date)
• Why (objectives)

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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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Show Scenario HereContinue filling out 201 form
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Break
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Module 4 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.

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

• S.T.A.R.T. (Simple Triage And 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
84
START uses R P M

• Respirations (gt30)
• Perfusion (no radial pulse or cap refill gt3
  seconds.)
• Mental status (unable to follow simple commands)

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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 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 RPM 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 gt30 breaths per minute RED
  tag
• Breathing regularly (go to next step in flow
  chart - PERFUSION)

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Second Step Blood Flow

• 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

• 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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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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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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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 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

100

• 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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Review

• Communication
• Organization
• Resource Management
• Roles and Responsibilities
• Prioritization (triage)
• 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.

103
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
105
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
106
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

107
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
108
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

109
Basic HICS/ICS Organizational Structure
Command Staff
General Staff
110
Hospital ICS Chart