1. Region X Multiple Patient Management Plan
Condell Medical Center
EMS System CE
July 2009
Site Code #107200E-1209
Prepared by: Steve Holtz, FF/PM Libertyville Fire Department
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives
Upon successful completion of this module, the EMS provider will be able to:
1. Explain the purpose of the Region X Multiple Patient Management Plan.
2. Define Class 1, Class 2, and Class 3 incidents.
3. Identify responsibilities of the fire department for each class.
4. Define criteria for Category I, Category II, and Category III trauma patients.
5. Define primary, secondary, and reverse triage.
6. Identify the components of the EMS Division of the Incident Management System.
7. Identify the communication process for Class 1, Class 2, and Class 3 incidents.

3. Objectives cont’d
8. Describe documentation requirements for Class 2, Class 2, and Class 3 incidents.
9. Describe the purpose of the After Action Report.
10. Define triage
11. Identify the principles of START and JumpStart triage.
12. Identify when primary and secondary triage techniques should be implemented.
13. Identify the components of the SMART Triage Packs.
14. Identify the role of critical incident stress management (CISM) in MCI.
15. Given a simulation, correctly triage patients using START triage.
16. Given a simulation, correctly perform a secondary triage.

4. Purpose of the Region X Multiple Patient Management Plan
An approach to emergency preparedness for all situations
To provide a communication tool for quick, easy, and appropriate disbursement of patients to area-wide hospitals
A plan to direct patients from the field to the hospital
The plan is NOT intended to serve as guidelines for scene management
EMS is to rely on their Incident Management System training for scene management.

5. Definition – Multiple Patients
Due to the variety of resources spread throughout the area, no number is attached to what defines the magnitude of an incident
Multiple patients will imply any number 2 and greater
The class to activate will be department determined
Once the first responding unit determines the Class to follow, communication to all responders must follow. Individuals may place an incident in a different Class based on personal interpretation of the situation. Everyone must know what Class the incident is so communication, transportation, and documentation will follow suit with the Class incident first declared. If different units are following a mix of Classes, confusion will be guaranteed.

6. Multiple Patient Incident
When you have more than one patient for a medical or traumatic event, you are in, at minimum, a Class 1 incident.
The actual number of victims for a Class 1 or Class 2 can change based on resources available due to time of day, day of week, or location of department
A department with multiple stations or a predetermined working response with a neighboring department may be handle an incident as a Class 1 and yet another department with less resources may declare the same incident as a Class 2. Neither department is more right or more wrong – the plan is meant to be fluid and used to fit your department needs.

7. Initial Problem Casualties outweigh resources
The objective is to be able to provide the same level of care to the 1st patient equally through to the last patient
EMS is initially overwhelmed until additional resources respond
The hospital(s) will also be overwhelmed initially until they recruit their resources
Make hospital contact as soon as possible
The sooner the hospital is pulled into the communication network, the longer they will have to gear up to accept your patients and provide appropriate care to each and every patient being transported.
An overwhelmed responding unit may need just 1 additional person to get under control or may need more – each incident is unique.

8. Universal Goal
To maximize the number and quality of survivors when presented with any number of sick or injured with the resources at hand or quickly recruited resources while respecting the limitations of the “golden period”
Golden period – the first hour after time of injury until definitive care is provided
Starts at time of insult

9. REGION X MULTIPLE PATIENT MANAGEMENT PLAN 2/13/08
CLASS 1
CLASS 2
CLASS 3
Definition
Able to meet normal level of care
Unable to meet normal level of care
Note: Box Alarms may be activated
Overwhelmingly unable to meet normal level of care
Note: May require EMS Divisions or
on-scene treatment areas
EMERGENT EVACUATION OF A HEALTHCARE FACILITY
(PATIENTS REQUIRING MEDICAL CARE)
Initial Communication
Contact closest hospital
State: “WE ARE ON THE SCENE OF A CLASS 1
MULTIPLE PATIENT INCIDENT”
Contact Resource Hospital
State: “WE ARE ON THE SCENE OF A CLASS 2
State: “WE ARE ON THE SCENE OF A CLASS 3
State: “WE ARE ON THE SCENE OF AN
EMERGENT EVACUATION OF A
HEALTHCARE FACILITY”
Initial
Information
Event description
Specific # patients
Specific patient categories
Closest appropriate hospitals
Estimate # pts.
Estimate patient acuities
(Use RED, YELLOW, GREEN)
Closest Hospitals
Closest hospitals
Possible alternative receiving
facilities
Patient
Disbursement
After conferring with closest hospital, transport agreed upon # patients to that hospital
Disburse no more than two patients to each remaining hospital
If it is determined that more than two patients should be transported to a hospital, the closest hospital will confirm with desired hospital(s) prior to transport.
Communicate remaining patients’ destinations to closest hospital
Resource Hospital coordinates transportation destination of patients
POD Hospital may be activated for assistance with communication and additional resources
Resource Hospital works in conjunction with field command and administration of affected facility to determine where patients will be transported
Triage
Tags
Triage tags not used
Triage tags MUST be used
Triage Method
Use rapid assessment to
identify patient category
START Triage
Within facility use REVERSE TRIAGE
Prior to transport use START TRIAGE
Ambulance to Hospital Communication
Every transporting ambulance contacts their receiving hospital with abbreviated report
State:
“WE ARE TRANSPORTING FROM A MULTIPLE PATIENT INCIDENT”
NO CONTACT BETWEEN TRANSPORTING AMBULANCE
AND RECEIVING HOSPITAL
NO CONTACT BETWEEN TRANSPORTING AMBULANCE / PATIENT TRANSPORTATION VEHICLE AND
RECEIVING FACILITIES
Pt Care Reports
Complete patient care reports as usual
No patient care reports
(Triage Tags serve as written report)
Copy is in the handouts.

10. Copy is in the handouts.

11. Definition – Class 1 Incident
The department is able to provide normal level of care
“Business as usual”
This will be department specific based on internal resources and external working relationships
If your department normally has a neighboring department respond to certain calls, this is just “business as usual” and should not be construed as anything other than normal for your department
Business as usual for some departments is calling in mutual aid by a neighboring department. Some departments have multiple stations in town and may rely less on another department for that additional manpower.

12. Definition – Class 2 Incident
The department is unable to meet the normal level of care with their typical response pattern
Box alarms may be activated
This may be due to the severity of the complaint or the number of patients
Think of a bleacher collapse at a football stadium
Think of a multi-vehicle incident on the tollway involving a large number of vehicles
Think 1 large work van rollover with 14 unrestrained ejected passengers

13. Definition – Class 3 Incident
A department is overwhelmingly unable to meet normal level of care
Think of a tornado touching down in town
The department most likely requires activation of the Incident Management System with use of EMS Divisions with triage and on-scene treatment areas established

14. Definition – Category I Patient
This is an unstable patient from traumatic or medical issues
When possible:
Trauma patients should be transported to the highest level Trauma Center within 25 minutes
Medical patients are transported to the closest Emergency Department

15. Category I Trauma Patient
Unstable vital signs
Adult systolic B/P < 90 on 2 readings
Pediatric (<15 years old) systolic B/P < 80 on 2 readings
Glasgow Coma Scale < 10 or deteriorating mental status
Respiratory rate < 10 or > 29
Revised Trauma Score < 11

16. Category I Trauma Patient
Anatomical injuries
Penetrating injuries to head, neck, torso, or groin
Combination trauma with burns > 20% TBSA
2 or more proximal long bone fractures
Unstable pelvis
Flail chest
Limb paralysis &/or sensory deficits above wrist or ankle
Open & depressed skull fracture
Amputation proximal to wrist or ankle

17. Definition – Category II Trauma Patient
This is a patient with the potential to become critical / unstable due to the mechanism of injury or nature of the complaint but is relatively stable for now
These patients should be transported to the closest trauma center for traumatic injuries or to the closest Emergency Department for a medical insult

18. Category II Trauma Patient
Mechanism of injury
Ejection from automobile
Death in the same passenger compartment
Motorcycle crash > 20 mph or with separation of rider from bike
Unrestrained in a rollover
Falls > 20 feet for adults and x3 the height for pediatrics
Pedestrian thrown or run over

19. Category II Trauma cont’d
Auto vs pedestrian / bicyclist with > 5 mph impact
Extrication > 20 minutes
High speed MVC: speed > 40 mph, intrusion > 12 inches; major deformity > 20 inches
Co-morbid factors
Age < 5 without car / booster seat
Bleeding disorders or on anticoagulant
Pregnancy > 24 weeks
Anticoagulants – Consider any medication that “thins” the blood or acts to prohibit or slow slotting time
Examples: Coumadin, Aspirin, Plavix

20. Definition – Category III Trauma Patient
All other trauma that does not meet criteria for Category I or II
Typically simple trauma
Lacerations
Simple burns
One extremity fracture
Hip fracture

21. Definition – Primary Triage
The act of sorting patients based on severity of their injuries or illness
Object/goal
To do the most good for the most people
Primary triage
Performed at first contact with the patient
Provides a basic categorization
Must be reproducible results from one evaluator to another

22. Universal Triage Categories
Red
Immediate care necessary
Yellow
Treatment can be delayed
Green
Patient requires minimal to no treatment
Black
Patient is dead or is expected to die
The SMART triage process assigns “P” (priority) numbers to the colors.
Red – Priority 1 (P - 1)
Yellow – Priority 2 (P - 2)
Green - Priority 3 (P - 3)
Black – Priority 0 (P - 0)

23. Definition – Secondary Triage
Ongoing triage
Takes place throughout the incident
As patients are moved to the treatment area
As patients are in the treatment area
As patients are being transported
Upon arrival at the receiving facility
During their time at the receiving facility
Patient condition may change throughout the process requiring upgrading or downgrading as determined by the reassessment

24. Definition – Reverse Triage
Usually used for building evacuation
Patients that are able to exit on their own do so
Then patients that require assistance are removed
Then patients requiring intensive manpower are finally removed
At the collection center, the process is reversed: most critical are transported first
Reverse triage implies that the less critical are removed first to safety followed by the more critical. Once in a safe environment, then the most critical are tended to first.

25. EMS Operations Component of Incident Management System (IMS)
Incident Commander
Operations Section Chief
Other areas or responsibilities that need to be determined and assigned include a safety officer, communications, a staging area. There may be other divisions based on the size of the incident. At some incidents, multiple roles are performed by the same person. It is important to make sure each department knows who has what role and each department member should know how their department assigns these roles.
Triage
unit
Treatment
unit
Transport
unit

26. Communication Process – Class 1
Contact the closest hospital
Normal facility you transport to
Communication prompts
“This is ____FD”
“We are on the scene of a Class I multiple patient incident”
“The incident is a ___”
“We have ____” (state number and category of patients (ie: Category I, II, or III))
The hospital(s) need to be contacted as soon as possible to have lead time to prepare for receiving patient(s). Preferably this should be done by the first arriving crew but is often done by support personnel arriving due to the overwhelming tasks that need to be initially performed. Often, communications in any incident is the one component that almost always has issues.
Call the hospital early with a heads-up and give detail later.

27. Class 1 Initial Information
Information provided to the closest hospital:
Event description
Specific number of patients
Specific patient categories
Indicate what are the closest appropriate hospitals you might use for transport

28. Field-to-Hospital Communication
Class 1
Every transporting ambulance calls in their individual abbreviated reports
Respect the radio/phone time knowing multiple calls need to be made
State:
“We are transporting from a multiple patient incident”

29. Class 1 Patient Disposition
Confer with closest hospital
Agree on number of transports taken to the closest hospital
Disburse no more than 2 patients to each remaining hospital
The receiving hospital may request more than 2 patients based on what they can take
Inform the closest hospital where patients are being transported to
A department with large resources may be able to handle an event with a larger number of patients and therefore more ambulance resources. Just because you are using a large number of your usual crew man-power does not alone make this a Class 2 incident. Always consider what is your “business as usual”.

30. Communication Process – Class 2
Contact your Resource Hospital
Advocate Condell
Think – Class 2 is more hectic and you need more resources than usual so consider the hospital as a resource (ie: Resource Hospital)
Communication prompts:
“This is ____FD”
“We are on the scene of a Class 2 multiple patient incident”
“We estimate the following types of patients ____” (provide number and color category of patients)
“My call back number is ______”

31. Class 2 Initial Information
Information provided to the Resource Hospital (CMC)
Event description
Estimated number of patients
Estimated patient acuities
Use red, yellow, green colors
State who your closest hospitals are
Hospitals most likely to receive patients
List hospitals in order of their proximity

32. Field to Hospital Communication
Class 2
No contact is made between transporting ambulances and the receiving hospitals
Transportation officer will communicate with the Resource Hospital how many reds, yellows and greens are being transported and to where
The Resource Hospital will contact the appropriate receiving hospital with ETA
Class 2 incidents do not require a formal use of the Incident Management System but some components are exercised. With more patients being transported, there must be coordination at the scene so the patients are properly disbursed. You don’t want each ambulance working as if they are on their own independent call.

33. Class 2 Patient Disposition
The Resource Hospital (ie: CMC) coordinates transportation destinations for your patients
Condell will notify the closest hospitals to determine the bed availability in the ED
Condell will notify the contact at the scene as to how many and what category patients the different facilities can take
Scene to inform Condell which ambulance is taking which patient(s) to where
Condell to contact the receiving hospital with ETA

34. Communication Process – Class 3
Contact your Resource Hospital
Advocate Condell
Think – Class 3 you are overwhelmed and need lots of resources (ie: use your Resource Hospital)
You will most likely be setting up EMS divisions to help at the scene
Communication prompts:
“This is ___FD”
“We are on the scene of a Class 3 multiple patient incident”
“We estimate the following types of patients ____ “ (provide number and color category of patients)
“My call back number is ____”

35. Class 3 Initial Information
Information provided to the Resource Hospital (CMC)
Event description
Estimated number of patients
Estimated patient acuities
Use red, yellow, green colors
State who your closest hospitals are
Hospitals most likely to receive patients

36. Field to Hospital Communication
Class 3
No contact is made between transporting ambulances and the receiving hospitals
Field communication will be between one designated person at the scene and the Resource Hospital
Call back number must be provided from the scene to the hospital

37. Class 3 Patient Disposition
Resource Hospital coordinates transportation destination of patients
Resource Hospital to communicate to the one contact at the scene how many of what type of patients go to which facilities
The Resource Hospital will contact the appropriate receiving hospital(s) with ETA after obtaining this information from the scene (ie: Transportation)

38. Declaring a Multiple Patient Incident
“Business as usual” is defined differently by every department
It must be clear to all responding personnel what level of plan is being declared so response is uniform
Declare the Class type and follow that plan
Unless all responding personnel are aware of the class type declared, individuals will be following what they feel is proper, not necessarily what has been declared
If initial responders declare a Class I type of call, triage tags and not used, individual report is called to the hospital, and all patients have a written report. If some responders feel this should be a Class 2 incident, some of the responders will be using triage tags, report will not be called to the hospital but the ambulance will just show up, and reports will be written for each individual.
Chaos will be magnified unless everyone is functioning under the same guidelines.

39. Field Provider Log Form
Use this form as a voice prompt to cover all initial information important to provide to the hospital
The form is a worksheet and NOT part of the patient record
All departments have been provided with this form
Form should be forwarded to the Resource Hospital along with the After Action Report
Used for critique and PI purposes

40. Sample provided in handout packet

41. Field Provider Log Form – Class 1 Communication Prompt
EMS to call the closest appropriate hospital
Class 1: “Business as usual”
“Hello. This is ____FD. We are on the scene of a Class 1 multiple patient incident. The incident is a __(describe the event to the ECRN)___. Our total number of patients is ___. We have (fill in the number of Category I, II, III trauma or medical patients).
“How many patients can you take?”

42. Field Provider Log Form
Space is provided in a table format for the field provider to record which hospital will take what number of patients
Table information will assist in patient distribution
Return this form with the After Action Report to the EMS office at CMC

43. Field Provider Log Form – Class 2 or 3 Incident
EMS to call their Resource Hospital
Class 2 – unable to meet normal level of care
Class 3 – overwhelmingly unable to meet normal level of care
“Hello.” This is ____FD. We are on the scene of a Class __ multiple patient incident. The incident is a _(describe event to the ECRN)_

44. Field Provider Log Form cont’d– Class 2 or 3 Incident
“We estimate we have the following types of patients (number of red, yellow, green, deceased patients is given)”
“Our closest hospitals are ____”
Provide the ECRN with a call back number
Use SMART command board to record hospital availability and patient destinations
Return this form with the After Action Report to the EMS office

45. Documentation – Class 1 Plan
Triage tags NOT used
Complete patient care reports as usual
Class 1 is business as usual after-all
The anticipation is that you will make only one transport run to the hospital

46. Documentation – Class 2 Plan
Use triage tags
Fold appropriate color to show
Use tags to make “notes”
Complete patient care reports as usual
The anticipation is to transport only once from the scene
If you are needed to return to the scene, do so as soon as possible and then write reports
Use the tags to write notes for the last person to use when they must write the report but may not have been the only care giver for this one patient.

47. Documentation – Class 3 Plan
Use triage tags
NO patient care reports are completed
Triage tags serve as the written report
The anticipation is that you will be making several runs back and forth between the scene and receiving hospitals
Every person caring for the patient can add notes to the tags. The tag will be the only doucmentation from the scene for this patient.

48. After Action Report Form used to critique the process
Submit the After Action Report with the Field Provider Log Form to your Resource Hospital EMS office
The form requires a description of the incident and asks for a check-off of the type of incident with the total number of patients involved
The form can be completed while at the hospital or can be done at the station. The form can be completed by 1 person or as a group effort by all on the call. The important thing is that the form is completed.

49. After Action Report Questions
Which hospital was contacted?
Mode of communication used?
Difficulties with communication?
Difficulties in declaring which incident to declare?
Difficulties with triage?
Difficulties with patient disbursement?
What references or forms were used?
How effective was the plan in patient disbursement?
The After Action Report is your format to report satisfaction or displeasure with the current patient management plan. If something is not working, be specific regarding why it did not work and be prepared to offer a suggestion for change.

50. START Triage Simple Triage and Rapid Transport
A color coding system used in triage to communicate priorities
Smart tag used to communicate by sight the triage color
Red – immediate priority
Yellow – urgent priority
Green – delayed priority
Black – deceased or soon to be

51. Primary Triage - Adults
Primary triage must be:
Dynamic providing the ability to reassess
Some patients get better, some worse
Safe
Fast
Reproducible
Every person who assesses the same patient needs to be making a decision based on identical criteria
Need the ability to upgrade and downgrade injured people throughout the process
Primary triage starts at time of first patient contact. If the patient can walk to another area, do not waste time tagging that patient – they may not remain green when they are reassessed at the next location even though you may be thinking of them as a “green” patient because they got up and walked to another area.

52. Primary Triage -  Walking
There is NO time for head-to-toe assessments in this first evaluation
First step
“Can you walk?”
People who are walking have an airway and adequate respiratory and circulatory systems to be upright and walking
These patients have a wide range of injuries and some could be potentially life-threatening
If the patient can walk to another area, consider them as Priority 3 – GREEN for now
All patients deserve constant reassessment and may need to be moved to another triage level
Just because the patient can walk to another area does not mean they are a green. The retriage may indicate them to be a red, yellow, OR green. The first tag given to the walking patient should be in this area they have walked to.
Constantly reassess patients; even a “green” can deteriorate and need to be reassigned a new color. The SMART triage tags allow for a change in the patient condition by being refolded.

53. Primary Triage -  Respirations
If the patient cannot walk to another area, then move on to evaluation of respirations
If the airway needs to be opened, provide chin lift with jaw thrust.
If the patient does not breathe with this maneuver, they are BLACK / dead
If the airway needs to be maintained with the maneuver, try to recruit a bystander / other less injured person
If respirations can be maintained, patient tagged Priority 1 - RED

54. Primary Triage -  Respirations
For patients who can breath, assess for the rate of respirations
Respiratory rate >30 tagged Priority 1 – RED
Respiratory rate < 30 move on to circulation assessment
Once the patient is determined to be any priority / color, the triage process is done for now and move onto the next patient
You may not move through all of the primary triage assessment process to determine a color category. As soon as you can assign a color, stop the primary triage (you have already determined what color they are) for this patient and move onto the next person. For some patients, you may move all the way through primary triage if they cannot walk, their respirations are adequate, they have capillary refill < 2 seconds and you need then to determine their level of consciousness to verify a yellow or red status. Once the patient is reassessed and found to be okay, they may even move up to a green status (ie: perhaps they could not walk away from the initial scene due to fractured leg; if this is their only injury they may be downgraded to green from yellow at the next assessment process).

55. Primary Triage -  Circulation
Assess capillary refill
If capillary refill is over 2 seconds, tag the patient as Priority 1 – RED
If capillary refill is difficult due to adverse field conditions, check the presence of radial pulse
If radial pulse is absent, tag the patient Priority 1 – RED
Manage any life-threatening bleeding at this stage
If the patient has a capillary refill <2 seconds or a radial pulse, then move on to level of consciousness

56. Primary Triage –  Level of Consciousness
If the patient cannot obey simple commands, they are tagged as Priority 1 – Red
Simple command could be response to “what is your name” or “raise your arm”
If the patient can obey simple commands, they are tagged Priority 2 – Yellow
Patients will/should be retriaged with the secondary triage to again determine the category they will be in
Again, the patient should be retriaged when they are in the treatment sector and may be downgraded from yellow to green.

57. PRIMARY TRIAGE Used for the adult patient
AIM
To teach the flow chart on primary triage
Teaching points
Patients whose circulation is normal should be assessed for level of consciousness.
If they cannot obey simple commands we tag the patient as priority one.
Summarize primary triage.
Primary triage allows you to identify the most seriously injured patients so they can be treated / transported using time and resources effectively.

58. JumpSTART Pediatric Triage
Children are not small adults
An adult system will not be accurate for children
A child’s length is proportional to their physiology
A child at 8 years-old becomes physiologically similar to the adult
Pediatric triage has to satisfy the same criteria as the adult: dynamic, fast, safe, and reproducible
JumpSTART takes into consideration the differences in airway and circulation from the adult to the child.

59. PEDIATRIC TRIAGE JumpSTART
AIM
To understand criteria for Pediatric Triage.

60. PRIMARY vs JumpSTART TRIAGE
These triage forms are full sized in the handouts.

61. JumpSTART Triage -  Walking
If the patient is able to walk to another area tag the patient as Priority 3 – Green
You will retriage this patient for appropriateness of category/priority using the Secondary Triage process
We know some people who can walk may have potentially life threatening injuries
If the patient cannot walk, evaluate breathing
For infants not walking yet, remove them from the site & evaluate them in the secondary triage area using the JumpSTART process
Obviously infants cannot walk but can be carried away from the scene to the next stage. Infants should be first evaluated in secondary triage using the entire JumpSTART algorithm starting with breathing.

62. JumpSTART Triage -  Breathing
If the patient is NOT breathing, open the airway
If the patient begins to breath, tag them Priority 1 – RED
If the patient is apneic, check for a palpable pulse
If no pulse, tag them BLACK – dead
If they have a palpable pulse, give 5 rescue breaths
If no breathing, tag the patient BLACK

63. JumpSTART Triage –  Respiratory Rate
If the patient is breathing, check the rate
If the rate is < 15 or > 45, tag them Priority 1 – RED
If the rate is between 15 and 45, check for a palpable pulse

64. JumpSTART Triage -  Pulses
If there is no palpable pulse with the breathing patient, tag them Priority 1 – RED
If there is a palpable pulse with the breathing patient, evaluate their level of consciousness (ie: AVPU)

65. JumpSTART Triage –  Level of Consciousness
If the patient is breathing and has a palpable pulse, check their AVPU
If the patient is “P” (inappropriate response to pain like posturing) or “U” (unresponsive), tag them Priority 1 – RED
If the patient is “A” (awake, alert), “V” (responding to voice) or “P” (appropriately responding to pain) tag them Priority 2- Yellow

66. Secondary Triage
Used to assist in getting the patient to the right place in the right time
Secondary triage refines the initial clinical picture of patient sorting
Primary triage just started segregating patients into groups
Getting those that can to walk to another area lessens that amount of patients your staff has to walk through while looking for the most serious injuries
Performed to place patient in correct treatment zone (ie: RED, YELLOW, GREEN, BLACK)

67. Secondary Triage
Uses a refined physiological scoring system and anatomical examination
Glasgow coma scale
Best eye opening
Best verbal response
Best motor response
Vital signs
Respiratory rate
Systolic blood pressure
The secondary triage process does NOT take into consideration that the normal ranges for respiratory rate or systolic blood pressure are not the same for adults and children.

68. SECONDARY TRIAGE
To familiarise students with the trauma score module. The secondary triage process does NOT take into consideration that the normal ranges for respiratory rate or systolic blood pressure are not the same for adults and children.

69. Example - SECONDARY TRIAGE4
Example - SECONDARY TRIAGE 4
An adult brought into the treatment area as a priority two lying on back board and holding abdomen 5 13
Eyes open spontaneously 4
Confused
AIM
To familiarise students with the trauma score module.
Teaching point
Using the triage cards that were issued earlier, ask the delegates to look at the trauma scoring module
Explain the three elements
1. Glasgow Coma Scale
2. Respiratory rate
3. Systolic BP
Explain how scoring is used to determine priority using the example on the slide.
Run the practical on secondary triage (details are in the workbook).
Localizes to pain – pushes you away or grabs for you or equipment 3 2
Respiratory rate 32
Systolic BP 70 9

70. Secondary Triage Practice
Review the following cases and using your handout, score these patients.
First step is to calculate the Glasgow coma scale
Then convert the 3-15 score to 0-4 points
Score the respiratory rate
Score the systolic blood pressure
Add the converted GCS, RR, and systolic B/P to get the secondary triage score

71. Secondary Triage Practice
Pt #1 - adult looking around, confused, grabbing at equipment. RR 26; B/P 108/60
Pt #2 - adult; eyes open when their name is called; yells out occasional words but not appropriate to the situation, withdraws/pulls back extremities when touched. RR 18; B/P 114/72
Pt #3 - adult; eyelids flicker when earlobe is pinched; mumbles incomprehensibly; withdraws to pain. RR 6; B/P 84/54
GCS calculations:
Pt #1 – eyes – 4; verbal – 4; motor 5 = total 13
Pt #2 – eyes - 3; verbal – 3; motor 4 = total 10
Pt #3 – eyes – 2; verbal – 2; motor – 4 = total 8

72. Secondary Triage cont’d
Pt #4 – child; looking around; answers all questions, moves all extremities and assists with care provided. RR 24; B/P 92/68.
Pt #5 – infant; watching those around them, crying for their mother, moves all extremities and tries to pull away when you provide care (normal response) RR 28, B/P 88/50
GSC scores calculated:
Pt #4 – eyes – 4; verbal – 5; motor 6 = total 15
Pt #5 – eyes – 4; verbal – 5; motor 6 = total 15

73. Secondary Triage Scores
Patient #
GCS converted RR
Systolic B/P
Total
Priority #1
(T-13) 4 4 12
green #2
(T-10) 3 11
yellow #3
(T-8) 2 2 3 7
red #4
(T-15) 4 #5
Young children may be appropriate but their normal respiratory rate or lower systolic B/P may cause them to lose a point and therefore lower their total score. For now, there is only one secondary triage scoring device to use for all.

74. SMART MCI BAG™
Purpose
To assist the operational management personnel on the scene
Compact and mobile
Provides a command
board for fluid documentation
The command board is a write and wipe surface and can be upgraded and changed as the situation progresses.

75. All ambulances in Illinois have received a SMART® Triage Pack
Components of the Triage
Pack:
Folding SMART® Triage Tags
Mini-light sticks to identify
RED patients at night
DEAD tags
Triage prompt card
(to prioritize adults)
Dynamic record of casualties
already triaged
Pencil
All ambulances in Illinois have received a SMART® Triage Pack
Every ambulance in Illinois (both fire department and private ambulance company ambulances) have received one SMART® triage pack.
Components of the Triage Pack:
Folding smart triage tags
Mini-light sticks to identify RED patients at night
Dead tags
Smart tape (to prioritize injured or sick children up to 32 kg)
Triage prompt card (to prioritize adults)
Dynamic record of casualties already triaged
Pencil

76. The State of Illinois has adopted the START triage method in partnership with the SMART® Incident Command System as a state-wide standard
SMART® Tags
to be used when
doing START Triage
Use SMART tags for
Class 2 and Class 3
Incidents
Refold tags as
needed if the
patient condition
changes
Region X has adopted the SMART Incident Command System® as a standard for the process of triage which includes the use of specific triage tags. The SMART tag is designed to show just one color at a time but can be refolded to reflect any change in status.
The triage process should be repeated at each link of the incident management chain. The primary (first) triage method will be used to sort victims into groups and is based upon vital signs and level of consciousness. The secondary triage method is utilized to prioritize treatment and transport goals and is based upon anatomic and physiologic criteria.
Though the SMART Triage System uses the words “Priority 1”, “Priority 2” and “Priority 3”, Region X uses the coordinating terms Red, Yellow and Green (not the word ‘priority’).

77. Forms During the incident use the “Field Provider Log Form”
Provides prompts for hospital communication
After the incident, individually or as a group, complete the “After Action Report”
Provides a critique opportunity
Return both forms to the EMS Resource Hospital as soon as possible

78. CISM We all need to monitor our peers for evidence of traumatic stress
One event stressful for one person may not be stressful for another responder
Purpose of CISM
To provide psychological first aid and management of traumatic stress for those affected by the event
Signs and symptoms of traumatic stress may not develop for up to 2 months after the event
Staff may need to be rotated through rehabilitation periodically throughout a long term response

79. Components of Psychological First Aid
Listening
Conveying compassion
Assessing needs
Making sure basic needs are met
Not forcing persons to talk
Providing support to family/significant others
Encouraging, not forcing, social support
Protecting from additional harm

80. CISD Activation 1-800-225-2473 For CISD, contact
Any member of the Condell Medical Center EMS System is authorized to contact CISM resources
For CISD, contact

81. Scenario Practice
For the following scenarios, run the call as you would normally respond from your station
All members of the department should be involved
The 2-3 responding personnel will need to initiate a plan of action
When others respond from the station to take over command, everyone needs to function with the same guidelines and definitions
The presenter needs to be able to flow with the process. One shift may consider a call a Class 1 and the next shift may consider the same incident a Class 2. Go with the decision of the crew in charge. The critique should include why decisions were made as they were.
Allow folks to use the paper prompts that are on the ambulances to build familiarity with the tools. These paper prompts are in the handouts. Responders should use the “Field Provider Log Form” and complete it. The responders should use the 2 sided form with classes 1 -3 on one side and Class 1 on the other side.

82. Which hospital do you contact? What do you say?
Two autos have been involved in a head-on crash. Each auto
was traveling in excess of 60 mph. Three people have
been thrown from the wreckage and are unconscious.
Four others are trapped inside with various types of severe injuries.
Answers to the questions may change based on the department and on the individual making the decisions. Use the answers as points of discussion and for learning various approaches to similar situations.
What Class?
What Category trauma?
Which hospital do you contact?
What do you say?
How does this affect the transporting
ambulances?

83. The administrator at a private school calls 911 to report
that a strange odor in the building has caused several
students to collapse. Someone has pulled the fire
alarm to evacuate the building.
As you arrive, students are running towards you.
The presenter can change this scenario to a local mall, a movie theatre, an office building or any other venue in their respective town/city/village.
What Class?
What Category medical?
Which hospital do you contact?
What do you say?
How does this affect the transporting
ambulances?

84. Two patients were in this car. One patient is in traumatic arrest.
One patient is unresponsive
but
breathing.
What Class?
What Category trauma?
Which hospital do you contact?
What do you say?
How does this affect the transporting
ambulances?

85. Four teenagers have stolen this vehicle and hit the building
at a moderate rate of speed.
Upon your arrival,
all victims are sitting
on the curb with minor
injuries and in police custody.
What Class?
What Category trauma?
Which hospital do you contact?
What do you say?
How does this affect the transporting
ambulances?

86. Five members of a family were rescued from this home.
All five are exhibiting signs of
severe smoke inhalation.
What Class?
What Category medical?
Which hospital do you contact?
What do you say?
How does this affect the transporting
ambulances?

87. This accident involves a total of five patients:
2 Category I Trauma Patients
3 Category II Trauma Patients
What Class?
Which hospital do you contact?
What do you say?
How does this affect the transporting
ambulances?

88. This crash involves four vehicles. Category I = 3 patients
Category II = 1
Category III = 2
What Class?
Which hospital do you contact?
What do you say?
How does this affect the transporting
ambulances?

89. bicycle riders. The bikes were traveling at a high rate of speed.
A car traveling at 60 mph
has hit a group of seven
bicycle riders. The bikes were
traveling at a high rate of speed.
The victims include:
6 Category One Trauma Patients
1 Category Two Trauma Patient
What Class?
Which hospital do you contact?
What do you say?
How does this affect the transporting
ambulances?

90. Bibliography
Bledsoe, B. Porter, R., Cherry, R. Paramedic Care Principles and Practices.
Region X Multiple Patient Management Plan, 2009.
Region X SOP’s. March 2007, Amended January 1, 2008
Smartmci.com (TSG Associates Ltd )