Pre-ED Triage Development Committee
Members
*Warren Billett
Connie Blaau
Todd Chassee, MD
Lance Corey
Joe DeFors, AD, BS, MPA
Sherry Closson
Jerry Evans, MD
Cheryl Klima, MA, LLPC
Tim Ladd
Mike May
Deb Paul-Cheadle
Sheila Rettig, RN, MSN
Kevin Throop, RN
Lynn Zabler
*Committee chair
NOCH
Mason-Oceana 911
Kent County EMS
Oceana County EMS
CEMA
MMPC
Muskegon County MCA
Michigan Department of Community Health
Mecosta County EMS
Grandville Fire Department
Metro Health Hospitals
Interpreter Network
Spectrum Health
Metro Health Hospital
Objectives
•
Develop pre-ED screening process and recommendations for care of patients
who do not meet adjusted ED admissions criteria.
•
Create a plan to transfer patients to sites less affected by the disaster (i.e.,
influenza pandemic).
•
Develop a plan for offsite and remote triage (e.g., telephone or pre-hospital visit).
•
Provide a translation plan that meets regional language needs.
•
Provide a template for pre-event education needs to ensure proper use of previsit triage methods.
Assumptions
1)
2)
3)
4)
5)
6)
7)
8)
Recognize onset of outbreak is early enough to be proactive.
Lack of local control/empowerment will threaten local response efforts.
We will be operating at different levels of response for extended periods of time.
Primary care offices will be functioning.
ER/Hospitals will be overwhelmed.
We will have a functioning 911 system.
At some point, we will need to triage patients as expectant (black tag) by phone
evaluations.
Appropriate pre-hospital real-time decision-making by EMS medical directors, as
it applies to alternate treatment standards, will be supported retroactively by
State authorities.
Caring for the Community | preparing for an influenza pandemic 1 Background
The task of this committee was to develop guidelines that will direct the “medical community’s” response
during times of pandemic outbreak. The term “medical community” was interpreted in the broadest sense
possible to include any provider or clinic or source of medical information in the community. The goal is to
provide information and care in the community setting to minimize the demand on the First Response,
Emergency Medical Services (EMS) and hospital systems. This can be accomplished through early
education of the public as to what they can expect from a health care system that is going to be taxed by
an overwhelming number of patients requiring unavailable human assets, equipment and space.
Health care providers all want to believe that, given the opportunity, all patients would receive the best
possible care. In the beginning, the committee struggled with the fact that not all patients in a pandemic
would receive optimal care. The committee agreed that guidelines must be developed to help identify those
individuals that will benefit the most from the limited assets. More directly stated, in the time of a pandemic
it will be necessary to make decisions that will ultimately determine who may live or die.
The following were members of the committee:
Sherry Closson
MMPC
Connie Blaauw – 12-year veteran Dispatcher for Mason-Oceana 911. Previous experience includes seven
years managing a residential Alternative Immediate Service facility for clients with mental and physical
disabilities.
Warren Billett EMT-P/IC – Manager EMS Department of North Ottawa Community Health System; Chair,
Region 6 Bio-Defense Network Coalition.
Dr. Todd Chassee – Medical Director Kent County EMS, Assistant Professor in the Emergency Medicine
Program Michigan State College of Human Medicine, Emergency Physician Spectrum Health Butterworth
Hospital.
Lance Corey
Oceana County EMS
Joe DeFors, AD, BS, MPA – Co-founder and principal officer of Comprehensive Emergency Management
Associates, a full service emergency planning, training and exercise firm. Joe works in a variety of
capacities on projects and holds the position of corporate finance officer. Joe is retired from the Lansing
Fire Department where he was a Firefighter/Paramedic.
Dr. Jerry Evans
Muskegon County MCA
Cheryl A. Klima, MA, – Bioterrorism Coordinator, MDCH-EMS and Trauma Systems Section, experience
in disaster mental health and emergency preparedness.
Tim Ladd – Director of Mecosta County Emergency Medical Service. Tim has a Bachelor Degree in Health
Care Administration and has been a paramedic since 1991.
Michael May – Lieutenant, Grandville Fire Department, Grandville, MI. Mike has 28 years of EMS
experience and is currently responsible for managing Grandville’s EMS program. He is also involved in
local planning and sits on the governing board of the Kent County Medical Control Authority.
Caring for the Community | preparing for an influenza pandemic 2 Sheila Rettig, RN, MSN – President/CEO Interpreter Network, LLC, Master’s-prepared nurse entrepreneur
experienced in cultural community issues. Interpreter Network is a service that unites language and culture
in health care, legal, business and education arenas.
Kevin Throop – Supervisor of Emergency services at Spectrum Health's Butterworth campus.
Lynn Zabler, RN, FCN, RN – Twenty years experience as Trauma Nurse Specialist, ED Supervisor, and
House Supervisor, 12 years experience in Outpatient nursing, Oncology, and Day Surgery. Has worked
extensively in a management capacity. Most recently working in Employee Health/Safety/ Disaster
Preparedness. Certifications include: Trauma Nurse Specialist, PALS, ACLS, Pediatric Trauma Nurse
Specialist, Faith Community Nurse, RISEN, Oncology, and multiple other certifications throughout the
years.
Process
Utilizing the above assumptions, it became apparent that there would need to be a graduated response
depending on the situation in any given region. Many sources were reviewed and information assessed.
Although several models were found, many of them lacked clinical guidelines for making these critical
decisions and none of them addressed the increase of stress on the healthcare system at the community
level. Based on work done by Dr. Mark Hall, a matrix was developed with five levels of response.
Guidelines were written for dispatch centers, pre-hospital providers (first responders and EMS) and
transporting agencies for both flu-like illnesses and non-flu-like illnesses. The ethics and legal committees
were consulted when making the decisions on this matrix.
Education of the public and providers is essential to minimize the stress on the medical care system. This
must be kept as simple and objective as possible. Education must be done prior to onset of significant
spread of influenza.
Medical equipment and personnel will need to be rationed based on the local situation and availability.
Resources must be used to benefit the most people to provide the greatest number of positive outcomes.
Objectives Report
This committee developed a pre-ED triage and treatment matrix to be utilized by pre-hospital personnel for
determining disposition of patients in a pandemic situation. This matrix utilizes standards of care during a
pandemic that reduces the stress on hospitals and EMS systems in an overwhelming medical crisis.
The triage and treatment matrix can be utilized at any pre-hospital triage site to include Neighborhood
Emergency Help Centers, physician offices, nursing homes, medi-centers, ambulatory care sites, dispatch
centers, etc.
The committee worked with Interpreter Network to develop internet-based educational videos in multiple
languages. The committee strongly encourages further development of educational videos.
The committee developed a template for education on the triage and treatment matrix (Figure 1).
Caring for the Community | preparing for an influenza pandemic 3 Figure 1
This matrix takes into account the progression of the pandemic in relationship to the impact that it is having
on the local medical community and allows the local medical community the flexibility to adapt to the needs
of the system.
In Figure 2, Level A through Level E represents the impact the outbreak may have on the local medical
community. At Level A, the local community would begin awareness education for the medical community
as well as for the public. This would begin an awareness that should this pandemic reach the local area,
changes in the way medical services are delivered may/will change. However, at this level, there has not
been an increase of patients in the medical system and therefore there would be no change in how
healthcare is delivered. The education for the public would include media and internet-based video
messages targeted to specific groups (ethnicities). More on the actual communications will be covered
later in this report.
Caring for the Community | preparing for an influenza pandemic 4 Figure 2
Caring for the Community | preparing for an influenza pandemic 5 For each level detailed in Figure 2, in Figure 3 shows changes in the expected response from different
parts of the system (Dispatch, Treatment or Transport) as we move from Level A to Level E. Figure 3 Caring for the Community | preparing for an influenza pandemic 6 Then, within each of the three areas, we took into account that not only will the medical community need to
address the patients afflicted with the pandemic illness, we will need to continue caring for the patients that
we would routinely be seeing as well. In Figure 4 we accommodate patients with non-flu-like complaints. Figure 4 Caring for the Community | preparing for an influenza pandemic 7 In Figure 5 we are looking at the transition from Level A and Level B. This turning point triggers awareness,
signaling that it’s time to begin looking at each agency’s response planning, staffing, and asset/resource
availability. Because there is no increase in patient care there are no changes in the response.
Figure 5 Caring for the Community | preparing for an influenza pandemic 8 In Figure 6, we now have seen a significant increase in the numbers of patients and we need to begin to
limit the response of the medical system in order to provide the greatest amount of care for the largest
number of patients.
Figure 6 Caring for the Community | preparing for an influenza pandemic 9 Figure 7
Caring for the Community | preparing for an influenza pandemic 10 In the Dispatch area we are no longer responding to priority 3 calls.
Figure 8
Caring for the Community | preparing for an influenza pandemic 11 Figure 9
Caring for the Community | preparing for an influenza pandemic 12 Figure 10 Caring for the Community | preparing for an influenza pandemic 13 Figure 11
Caring for the Community | preparing for an influenza pandemic 14 Figure 12 Caring for the Community | preparing for an influenza pandemic 15 Figure 13 Caring for the Community | preparing for an influenza pandemic 16 TRANSLATION PLAN
OBJECTIVE


Provide a translation plan that meets regional language needs.
Provide a template for pre-event education to ensure proper use of pre-visit triage methods.
There are three essential components to providing effective communication to Limited English Proficient
(LEP) population and cultural groups.
1) ACCESS – How will LEP populations access information?
2) ACKNOWLEDGEMENT – How will LEP populations understand a clear and correct message?
3) ACCEPTANCE – What factors can influence levels of acceptance of a state plan, to support
implementation and success?
It is important to understand communication trends in LEP cultural groups. The results of an informal study
among several cultural groups in West Michigan revealed that there are two categories to study.
1) Communication patterns with a high frequency use are:
a. Messages from school age children and family
b. Neighbors
c. Community meeting places
d. Community leaders/Spiritual leaders
PROBLEM: Information many times is incorrect or at least flawed.
2) Communication patterns with a low frequency use are:
a. TV
b. Newspaper
c. Radio
d. Written notices
PROBLEM:


Commonly used standard media sources are primarily communicated in English and do not
address emergency messaging for multiple languages.
Low literacy levels limit effectiveness, even when messages are provided in native languages.
SUGGESTED SOLUTIONS
1) Create a universal symbol for ALL people to become familiar with and recognize alternate care
sites or information.
Caring for the Community | preparing for an influenza pandemic 17 2) Create access to information via video conferencing/internet sources for multiple languages and
for Deaf and Hard of Hearing.
3) Identify potential champions within various cultural groups to support state recommendations.
4) Education preparedness for pre-triage situations.
Caring for the Community | preparing for an influenza pandemic 18