LESSON 26 INCIDENT MANAGEMENT

Introduction Organized approach needed to manage scene and treat patients on priority basis National Incident Management System (NIMS), through Incident Command System (ICS), directs response Your role within NIMS may differ from your everyday role as an EMR

National Incident Management System Large-scale emergency requires personnel and resources from multiple jurisdictions NIMS created to coordinate and manage this response

Benefits of NIMS Unified approach to incident management Standardized command and management structures Emphasis on preparedness, mutual aid, resource management

Administration of NIMS Administered by United States Department of Homeland Security Includes many other agencies such as FEMA NIMS has a National Response Plan (NRP) NRP continues to be refined

Elements of NIMS Preparedness Communications and Information Management Resource Management Command and Management Ongoing Management and Maintenance

The Incident Command System Part of NIMS that focuses on response to: Acts of terrorism Wildfires and urban fires Hazardous materials spills Nuclear accidents Aircraft accidents Earthquakes, hurricanes, tornadoes, floods and other natural disasters War-related disasters Other mass-casualty incidents

EMRs in ICS All EMS personnel have crucial role Most EMRs will receive training related to their role in ICS

NIMS and ICS Training All personnel should receive training in NIMS and ICS Training is required to receive federal preparedness funding assistance Includes federal, state and local government employees Different courses required at different levels

Mass-Casualty Incidents Emergency in which multiple patients need care Mass-Casualty Incidents (MCIs) can be stressful Large MCI can strain EMS resources Different EMS systems define MCIs in different ways

Large MCIs Small MCI may be handled within single EMS system, but larger MCIs require multiple jurisdictions ICS directs and manages emergency response ICS and triage used for giving medical care in MCIs

Incident Command System for Mass-Casualty Incidents Oversees all aspects of response Organizes, coordinates, controls resources and personnel Similar functions grouped for maximum effectiveness Lines of authority clearly identified Advance planning for possible incidents prepares specific Incident Action Plans (IAP)

Incident Commander Assigned overall supervisory responsibility for workers and resources Directs the emergency response First-responding unit announces to dispatcher that MCI exists Command role is established Command may be transferred to another person Incident Commander functions from a command post

Sectors Rescuers assigned to section, or sector, with specific responsibilities Each section supervised by Section Chief who reports to Incident Commander 4 primary sections in ICS: Operations Planning Logistics Finance/Administration

Operations Sector Focuses on providing medical care and controlling immediate hazards May be further broken down into groups, each with its own leader Personnel may be organized in task forces or strike teams Common tasks for EMRs: Triage Treatment Transportation Staging

Role of EMRs in MCIs If you are first to respond, recognize emergency, report in to and request assistance First knowledgeable EMS provider on scene becomes triage officer Triage assessment performed on all patients Available personnel and equipment are first directed to highest-priority patients EMRs may be assigned to different sections with different responsibilities

On Arrival at an MCI Report to staging section or command post Identify yourself, level of training, follow directions Report immediately to assigned section and individual in charge Perform only task you are assigned If you complete assigned task, report back for new assignment Act only on direction of supervisory personnel

Differences in MCIs MCIs are stressful and may seem chaotic Accept your assignment without question unless you are inadequately trained for the task If asked to wait, be patient Some of your usual procedures will likely be suspended Perform whatever tasks you are assigned, regardless of your “normal” responsibilities

Triage

Triage Process of sorting patients by severity of injuries and documenting location and transport needs Different triage systems have been developed with varying categories START system commonly used for rapidly triaging and treating large number of patients START requires only limited medical training <60 seconds/patient to complete

Triage Categories Each patient is tagged with a colored tag indicating triage category: Priority 1  Red  Immediate care needed Priority 2  Yellow  Delayed care Priority 3  Green  Minor care (hold) Priority 4  Black  No care needed

Triage Process Quickly size up scene With few patients, triage can proceed quickly and tags may not be needed When there are many patients, tags are generally used Triage officer designated In scene with many patients, patients with minor injuries asked to walk to designated area, if they can walk without assistance

Triage Process (continued)

Triage Process (continued) Remaining patients are triaged, each in <60 seconds START system evaluates each patient’s breathing, perfusion or circulation, and mental status to assign triage category Triage a patient and move immediately to next When all patients triaged, personnel begin providing care for Priority 1 patients first

Acronym RPM for Steps of START Assessment R = Respiration P = Perfusion M = Mental status

Step 1  Assess Breathing/Respiration

Step 2  Assess Perfusion For patient breathing without opening airway, next check pulse or capillary refill If pulse is present or capillary refill is under 2 seconds, assess mental status If pulse is weak or irregular, tag Priority 1 (red tag) If pulse is absent or capillary refill time is over 2 seconds, tag Priority 1 (red tag) – if patient is bleeding severely, apply pressure dressing

Step 3  Assess Mental Status For patient who is breathing and has adequate circulation or perfusion, give simple command such as “Open your eyes” or “Squeeze my hand” Patients who follow command are considered alert/responsive and tagged Priority 2 (yellow tag) Patients who cannot follow command are considered unresponsive and are tagged Priority 1 (red tag)

After Triage Re-evaluation is ongoing Observe or check status of patients originally categorized as Priority 2 or 3 Priority 2 may become unresponsive, making patient Priority 1

National Trauma Triage Protocol Use the National Trauma Triage Protocol to determine where Priority 1 patients tagged red and Priority 2 patients tagged yellow should be transported

Pediatric Triage

Pediatric Triage START system criteria less effective for infants and children: Respiratory rate >30 breaths/minute may not be a problem in infant or child Child who has just stopped breathing may have a pulse Young child may not respond to command for other reasons or be too young to respond as expected

JumpSTART Triage for Pediatric Patients Assess same characteristics; follow different criteria and take somewhat modified steps First ask children who can walk to move to one side and tag them as green (Priority 3)

JumpSTART Pediatric Triage Process Assess breathing Assess circulation Assess mental status

Step 1  Assess Breathing Check whether child is breathing If breathing at rate of 15-45 breaths/minute, move on to assess circulation If breathing <15 or >45 breaths/minute or if breathing is irregular, tag Priority 1 (red tag) If not breathing, open airway

Step 1  Assess Breathing (continued) If still not breathing, look in mouth for foreign body obstruction and remove If now breathing, tag child Priority 1 (red tag) If not breathing, check for a pulse If no pulse, tag patient Priority 4 (black tag) Give child with a pulse 5 ventilations; if breathing begins, tag red and move on If no breathing, tag black

Step 2  Assess Circulation For child breathing 15-45 breaths/minute without opening airway, check pulse in an uninjured extremity If you feel a pulse, assess mental status If no pulse, tag patient Priority 1 (red tag)

Step 3  Assess Mental Status For child who is breathing and has pulse, assess mental status with AVPU assessment A child alert and responding is tagged Priority 2 (yellow tag) A child not responding or responding inappropriately to pain is considered unresponsive and tagged Priority 1 (red tag)