Region X Multiple Patient Management Plan

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

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

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

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

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 PLAN2/13/08

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

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

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 • 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

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

25. EMS Operations Component of Incident Management System (IMS) Incident Commander Operations Section Chief 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))

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

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

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

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

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

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

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?

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