Mass Casualty Incident Procedures GRAYS HARBOR COUNTY 2018

Mass Casualty Incident Procedures GRAYS HARBOR COUNTY 2018 -04 -09/dg

OBJECTIVES Review updated GHEMS Patient Care Protocol PROC-210: Mass Casualty Incidents Review New Triage Tag System Integrate New Triage Tag System with START System REF-060: START Triage

MCI Types?

Mass Casualty Incidents GHEMS PROC-210 (MARCH, 2018)

Definitions Mass Casualty Incident (MCI): The combination of numbers of injured or ill patients that exceeds the capabilities of an agency’s normal first response. (reference FEMA Field Ops Guide 420 -1 July 2010) Triage Ribbon: Colored ribbon (i. e. Red, Yellow, Green or Black/White), attached to a patient’s arm or leg, indicating patient’s treatment and/or transport priority status. Triage Tracking Tag: Tag indicating patient’s priority status along with space for vital signs, injuries, treatment and personal information.

Definitions Triage Report: Includes the total number of patients and the number of patients triaged by color code. The triage report is a benchmark that should be relayed early by the IC at an incident to Harbor Dispatch and the receiving medical facility. National Incident Management System (NIMS): a systematic, proactive approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector to work together seamlessly and manage incidents involving all threats and hazards— regardless of cause, size, location, or complexity – in order to reduce loss of life, property and harm to the environment.

Intent Coincide with departmental polices and procedures Follow NIMS Achieve effective incident management Initiated by first arriving unit(s)

Procedure INITIAL ACTIONS 1. Scene Size-Up/Situational Assessment 2. Initiate/Establish Incident Command 3. Determine MCI – Request Additional Resources 4. Initiate START, assign Triage Officer 5. Establish Treatment Area (outside hot zone) 6. Assign Treatment Officer

Procedure INITIAL ACTIONS 7. Assign Transport Officer 8. Transport Officer Contact MEDCON = Grays Harbor Community Hospital MEDCON: Coordinates with receiving facilities for transport decisions. If transporting out of county, GHCH may escalate MEDCON to St. Peters

Incident Organization Triage: START – Simple Triage And Rapid Transport REF-060: START Triage Done in Hot Zone By first arriving unit(s) Colored ribbon to arm or leg When complete, totals reported to IC or Triage Officer

Incident Organization Treatment Area Optional, depending on complexity of the event & potential delays in transport Safe area away from hazard Under supervision of a Treatment Unit Leader Divided into areas based on patient condition Use of Triage Tags

Incident Organization Transportation Area Under direction of Transportation Unit Leader Coordinates patient movement to appropriate facilities In contact with MEDCON will communicate with receiving facilities Uses transport receipt form triage tag to track patient transportation Destination Agency Unit ID

Incident Organization STAGING Under direction of Staging Officer Area for arriving ambulances Creates an orderly flow Works with Transportation Unit Leader to ensure proper units sent to Transportation Area (ALS vs. BLS) Operates on separate frequency than ongoing incident operations If air ambulances utilized – establish separate Air Medical Group

Incident Organization

Incident Organization Red Treatment Staging Area Incident Operations Area Yellow Treatment Patient Loading Area Green Treatment Black Tagged Incident Command Post

Incident Organization – Initial Response Incident Commander Triage Unit Single Resource Immediate

Incident Organization – Multi-Group Incident Commander Safety Officer Staging Officer Triage Unit Single Resource Treatment Unit Transportation Unit Immediate Delayed Minor Communications Unit

Incident Organization – Multi-Group Incident Commander Safety Officer PIO Operations Section Staging Officer Medical Group Triage Unit Air Operations Treatment Unit Transportation Unit Single Resource Immediate Morgue Manager Delayed Minor Communications Unit

Communications Critical to successful incident mitigation Initial Triage Report “Head Count” Allows hospital(s) to gear up Should be made to MEDCON Individual Patient Reports May be handled by individual Units If Transportation or Communications Officer established, made by them rather than transport units Needs to be made clear what method is being used to transporting units Ongoing progress reports to MEDCON as needed

MCI Tag System PATENT ACCOUNTABILITY WITHIN A MULTI-CASUALTY INCIDENT

MCI Tags/System Components Ribbon Dispenser Initial Triage Count Card Triage Count Worksheet Incident Command Worksheet Triage Tags Triage Tag Receipt Holder Transportation Receipt Holder Staging Resource Status Sheet Treatment Unit Leader Count Worksheet

Triage Tag

Front Triage Tag Features Contaminated Receipt Personal Property Receipt Ambulance Receipt Back

Front Triage Tag Features Transportation Receipt Destination/Via/Chief Complaint/Time Patient Information Personal Information Entry Patient Information Back

Front Triage Tag Features Haz. Mat Entry If contaminated Decon info If suspected nerve agent – Injector information on back Injury Indicator Back

Front Triage Tag Features Vitals Entry Re-Triage/Entry/Category Receipts Back

Front Triage Tag Features Treatment Entry START Algorithm Back

Front Triage Tag Features Card Numbering Each tag has a unique ID number/barcode Used as a patient tracking number throughout the incident Abbreviated number on transport receipt Back

Integrating New Triage Tag System with START Triage

START Triage GHEMS Patient Care Protocol REF-060 No change to actual protocol Change to MCI supplies/tags and corresponding system

START Triage Rapid approach to triaging large numbers of patients Initial rapid assessment and treatment: < 30 seconds 4 factors Ability to walk Respiration: > or < than 30/min Pulse: Radial pulse/Cap refill < or > 2 seconds Mental Status: able/unable to follow simple command No detailed treatment done Correct airway blockage Stop uncontrolled bleeding RP M

START Triage

START Triage – Simplified Move the Walking Wounded MINOR No Respirations after Head Tilt MORGE Respirations – Over 30 IMMEDIATE Perfusion – Radial Pulse Absent IMMEDIATE Mental Status – Unable to Follow Simple Commands IMMEDIATE All Others DELAYED

START Triage – Primary Triage Call the walking wounded Direct them to treatment area for assessment These are your MINOR patients

START Triage – Primary Triage Start where you are Triage patient as you find them Assess RPM Tie appropriate color ribbon to wrist or ankle (Approx. 2’) For initial patient counts: Mark on Initial Triage Count Card (preferred) Take piece of same color ribbon with you Advise Triage Unit Leader (IC if not established)

START Triage – Primary Triage

START Triage – Primary Triage Count Worksheet Used by Triage Unit Leader Tally's triage numbers as reported When complete, report numbers to Incident Command Could use Triage Count Cards

Patient Movement – Incident to Treatment Red Treatment Incident Operations Area Yellow Treatment Patients movement from incident area to treatment area After initial/primary triage As additional resources arrive Litter Teams Secondary Triage – Tags Applied Green Treatment Black Tagged Incident Command Post

Secondary Triage – Entry to Treatment Area

Patient Treatment – Treatment Area

Patient Treatment – Treatment Area Triage Tag Receipt Holder Slide receipt into provided slot Used to track patients in respective treatment area(s) by Treatment Officer Area for notes Note when patient transported Note if patient condition changes Transferred to different treatment area

Treatment Area Patient Count Treatment Unit Leader Count Worksheet Used to reconcile patient counts Should match the remaining patient counts in each category

Transportation – Ambulance Loading Area Destination decision in conjunction with MEDCON Consider transporting of multiple patients Ensure proper level of care for transport (ALS/BLS) Red Treatment Staging Area Yellow Treatment Patient Loading Area Green Treatment Incident Command Post

Transportation – Ambulance Loading Area

Patient Transportation Receipt Holder Slide transport receipt into provided slot Used to track patients being transported from the scene Destination Unit Time Triage level ETA Chief complaint

Transportation – Ambulance Loading Area Ambulance Transport Receipt Given to transporting unit Ensures proper delivery to proper destination Should be included as part of EMS report

Incident Command Worksheet For use by Incident Commander Prompts for incident benchmarks and position staffing

Staging Ambulance Staging Resource Status ▪ For use by Staging Officer ▪ Tracts units in and out of the staging area

Putting it all together… Victims Treatment Area Patient Loading Area Staging Area Incident Command Post

Active Shooter – Patient Tracking Victims Casualty Collection Point Patient Loading Area Staging Area