Region X
Multiple Patient Plan – Triage &
Categorization
December 2010 CE
Condell Medical Center EMS System
Site Code #107200E - 1210
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
EMS Educator
Objectives
Upon successful completion of this module,
the EMS provider will be able to:
1. Define a multiple patient incident.
2. Discuss time management at the scene of a
multiple patient incident.
3. Define the National Incident Management
System.
4. List field functions necessary at a multiple
patient incident.
Objectives cont’d
5. Describe responsibilities and duties of the
initial responding fire department unit.
6. Define triage, primary triage, and secondary
triage.
7. Describe when primary and secondary triage
techniques should be implemented.
8. List the three universal triage categories.
9. Describe the START system.
Objectives cont’d
10. Describe the JumpSTART system
11. Describe the Smart disaster tag
12. Identify criteria for Category I, Category II,
and Category III patients.
13. Discuss when to complete an After Action
Report and how to forward it.
14. Actively participate in role playing in
table top drills.
Overview Note

Region X Multiple Patient Plan undergoing
revisions




Based on in-put requested and received from
EMS providers
Revisions should be distributed Spring 2011
Some verbiage will be changing
Many actions taken during any multiple
patient incident will not

Triage, categorization not changing
Defining a Multiple Patient
Incident


Any incident that depletes available
resources at the time of the incident
Difficult to put a number of patients on
a plan or the easiest/hardest times of
day to respond to an incident

What is taxing to one department can be
handled with in-house resources by
another
Initial Problem

Casualties outweigh resources of
responding unit
Goal

Provide adequate resources to meet
the needs of the casualties to
maximize the number of survivors
Golden Period


A 60 minute time frame in which the
patient has to reach definitive care from
time of onset of injury
Odds of successful recovery diminish
once the golden period has been
reached
Time Management

What needs to be accomplished at the
scene




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
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Command structure set up
Safety observed at all times
Assessment – of situation and patient
Communication – to a wide variety of persons
Triage – right patient to right area
Treatment – red, yellow, green patients
Transportation – to definitive care
DRILL, DRILL, DRILL



Universally accepted plans
Should be understood by all responding
departments
Allows mutual aid response to function
shoulder to shoulder without the need
for detailed instructions/explanations
Resources

National Incident Management System
(NIMS)


Developed to provide a common system
utilized at local, state, and federal levels
Incorporates the Incident Management
System (IMS)

A process with procedures for organizing and
operating an on-scene management structure
practiced by emergency services agencies
Incident Command

Most important functional area of IMS




Person who runs the entire incident
Has the ultimate decision making authority
Needs to coordinate many activities
Must delegate functions and responsibilities
to others
 Based on size and type of incident and
resources being utilized
Command

In both small and large scale events,
still need “command” at the scene

Someone needs to coordinate activity



Which responding unit cares for which patient
Coordinate transportation so patients can be
spread between receiving hospitals, as
necessary
Even with 2 patients, one person needs to
have control/command of the scene and
make decisions
Who is Command Initially?


Generally, first arriving vehicle must
assume command until additional
resources arrive and take over the task
“Windshield survey” taken


Relay information to dispatch
Contact hospital


Closest for small scale
Resource for larger events – they will act as
your resource
Functions in the Field



Field tasks/jobs must be completed
Tasks in smaller scaled incidents can be
completed by a minimum of persons
Larger scaled events may involve
multiple persons needed to oversee the
different field functions that need to be
completed
Necessary Field Functions

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Command
Safety
Communications
Triage
Treatment
Staging
Transportation
Communication Links –
Everyone
needs to be on the same page
Field Personnel
Hospitals
Responding Units
General Duties

First responding unit



Begin communications early
Can’t get help to the scene unless dispatch
knows what you have and what you need
Hospital cannot prepare for increased
volume and acuity of patients unless
notified
 It takes EMS time to set up; it also takes
the hospitals time to prepare
SAFETY! SAFETY! SAFETY!



Safety is everyone’s responsibility
Larger scaled incidents will need one
person to oversee the safety of the
scene
Process less formalized but just as
important in smaller sized incidents
Triage



Definition
 The act of sorting patients
 Based on severity of injuries or the
illness
Object/goal
 To do the most good for the most
people
Triage process influences other decision
making
Definition – Primary Triage

Primary triage

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
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Performed at first contact with the patient
Must be performed rapidly and with efficiency
Provides a basic categorization
Must be reproducible results from one
evaluator to another
Universal Triage Categories

Red

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Yellow

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Treatment can be delayed
Green


Immediate care necessary
Patient requires minimal to no treatment
Black

Patient is dead or is expected to die
Definition – Secondary Triage


An ongoing process
Takes place throughout the incident

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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
Secondary Triage


A dynamic, fluid process
Patient condition may change
throughout the process requiring
upgrading or downgrading as
determined by the reassessment
START System



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Widely used triage process in
disaster/multicasualty incidents
 JumpSTART used in the pediatric
population
 Need to accommodate physiological
differences between the adult versus
pediatric populations
START can be modified when responding to
smaller scaled incidents
Does not require a diagnosis to sort patients
Objective evaluation of signs observed
START Triage Areas


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Ability to walk
 Helpful in larger scaled incidents
Respiratory effort
 Check for open airway
 Check respiratory rate
Pulses/perfusion
 Check radial pulse
Neurological status
 Determine ability to follow commands
Smart
Triage for
Adults
Radial pulse or
capillary refill
START System Step #1–
Ability to Walk




Not necessary if your resources can
perform efficient and timely triage to
the number of victims present
Start by asking all patients, who can
walk, to get up and come to you
Initially this patient is “green” but will
need to be retriaged for appropriate
treatment area
Move onto next patient
Ability to Walk



Recognize that some of the “walking”
patients may actually be “yellow”
Recognize that some patients that cannot
walk, especially due to a leg injury, may be
eventually triaged as “green”
Remember: Triage is dynamic – always
ongoing; subject to change
Start System

Separating the walking patients



This process decreases the number of
patients who cannot leave the area
You are sorting down to a number of victims
that will be quicker to move through to
perform triage
You have moved the less critical out of the
way leaving a smaller number of patients,
those potentially more critical, to sort
through
START Step #2 –
Respiratory Effort



Begin to triage non-walking patients
Tag patient as you triage them
Treatment limited



Correct airway problem
Correct severe bleeding
Move onto next patient
START – Respiratory Effort

Patient not breathing




Manually open airway
If breathing resumes, tag as “red”
If no breathing, tag as “black”
Patient breathing

Evaluate respiratory rate
 RR > 30 tag as “red”


Move onto next patient
RR < 30 go to next assessment step
START Step #3 –
Pulse/Perfusion

Check for radial pulse – preferred
method



No radial pulse, tag as “red”
 Move onto next patient
Delayed capillary refill not reliable in adults
 Can be compromised by cold weather
and normally delayed in certain persons
Respirations < 30 and radial pulse
present, continue to next assessment
step
START System Step #4 –
Neurological Status

Ask a quick, simple question


If patient cannot follow simple
commands, tag as “red”


“grip my hands”
Move onto next patient
If patient can follow simple directions,
tag as “yellow”

Move onto next patient
Primary Triage Practice


Review the following cases
Determine the primary triage category
basing decisions on:




ability to walk
respirations
pulses
ability to follow commands
Practice Triage

Case #1

30 year-old female, walking around


Obvious injury is right arm fracture
Case #2



Unconscious male 20’s
Respirations 36
No radial pulse
Practice Triage Answers


Case #1
 Green – able to walk on own
 Reassessment will determine any conditions
that may indicate a yellow status
Case #2
 Should stop triage at unconsciousness
 Tag patient at red
 Further assessment in initial triage not
necessary to categorize this patient (and is
therefore a waste of time if many patients
need to be triaged)
Primary Triage Practice

Case #3

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
Male approximately 18
Walking around, confused
Case #4

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60 year-old female with fractured leg
Respirations 26
Radial pulse 86
Obeys commands
Practice Triage Answers

Case #3



Green – able to walk
Reassessment may reveal indications for
reassignment to yellow (or even red)
Case #4


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Unable to walk
Respirations <30
Radial pulse present
Obeys commands
Tag patient as yellow
JumpSTART Triage





A process developed in 1995 by a
pediatric emergency physician
Parallels structure of START for adults
Optimizes triage of injured children
Enhances resource allocation
Facilitates rapid decision making
eliminating subjective opinions
influencing triage decisions
JumpSTART Pediatric Triage

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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
 JumpSTART used if the patient appears to be a
child (a subjective assessment)
Pediatric triage has to satisfy the same criteria as
the adult: dynamic, fast, safe, and reproducible
PEDIATRIC
TRIAGE
JumpSTART
PRIMARY vs JumpSTART TRIAGE
Radial pulse or
capillary refill
JumpSTART Triage –
Step #1 Walking

If the patient is able to walk or be carried to
another area tag the patient as Green


You will retriage this patient in treatment for
appropriateness of category/priority using the
Secondary Triage process
We know some people who can walk may have
potentially life threatening injuries
 Retriage/secondary triage in treatment should
be performed to validate the appropriate
category
JumpSTART Step #1 cont’d


Modifications for nonambulatory children
 May not be walking due to chronological
age, developmental delay, acute injury
preventing walking before incident, chronic
disability
For infants not walking yet, remove them
from the site & evaluate them in the
secondary triage area using the JumpSTART
process
 Start assessment at the “breathing”
evaluation step
JumpSTART Step #2 Breathing


Spontaneous, move onto next
assessment step
Apneic or irregular breathing, open
airway
 If breathing resumes, tag as “red”
 If not breathing, check for pulse
 If no pulse, tag as “black”
 If pulse, give 5 breaths

If breathing resumes, tag as ”red”
JumpSTART Step #2 Breathing Assessment cont’d

If pulse difficult to assess (ie: cold
weather)




Give trial of 5 breaths unless clear signs of
death
If breathing resumes, tag as “red”
If no spontaneous breathing, tag as “black”
Move onto next patient
JunpSTART Step #3 Perfusion



Evaluate in least injured extremity
Palpable pulse, move to next step
No peripheral pulse, tag as “red”
 Move onto next patient
Practice JumpSTART


Case #1
 2 year-old female standing while being held
 Moving arms and kicking legs
 Respirations 28
 Radial pulse present (126)
Case #2
 5 year-old unconscious, withdraws from pain
 Respirations 38
 No radial pulse
Practice Answers


Case #1
 Green – able to walk
 Respirations >15 and <45 adequate
 Palpable pulses present
Case #2
 Red – unconscious
 Enough information has been obtained to categorize
the patient at this point
 Absence of radial pulse also a category red criteria
but triage beyond unconsciousness was not
necessary and a waste of time – patient already
known to be a red
Practice JumpSTART


Case #3
 8 year-old boy unable to walk but follows
commands
 Respirations 28
 Radial pulse present
Case #4
 9 year-old male standing, supporting a
fractured arm; able to follow commands
 Respirations 24
 Radial pulse present
Answer Key JumpSTART


Case #3
 Yellow – unable to walk but follows
commands
 Respirations >15 and <45
 Radial pulse present
Case #4
 Green – able to walk; following commands
 Respirations >15 and <45
 Radial pulse present
Smart Disaster Tags




Universally used color-coded tag for
easy communication
Once tagged, prevents inappropriate
retriage of same patient
Can be used as a tracking system
during treatment and/or transportation
With SMART tags, severity level can be
quickly revised by refolding the tag
Smart
Triage
Tags
One tag
– three
levels of
priority
Smart Tag System

Areas provided for documentation
 Patient details/demographics
 Past medical history
 Patient assessment
 Treatment/interventions/vital signs
 Secondary triage
 GCS
 Respiratory rate
 Systolic blood pressure
 Tracking system
Treatment Area


Patients retriaged upon arrival into
treatment area
Patients separated into areas based on
color category
 Red for critical patients
 Yellow for noncritical
 Green for those patients requiring
very little care
Secondary Triage





Ongoing
Occurs when patients moved into
treatment areas
Occurs during stay in treatment area
Continues during transportation
Continues at the receiving hospital
Secondary Triage



Includes evaluation of GCS
Converted points of GCS added to
respiratory rate and systolic B/P
Secondary triage also known as the
“Triage Score”
Secondary
Triage
Combining
GCS with
RR and
systolic B/P
Practice Secondary Triage


Review the following cases
Determine secondary triage level based
on adding 3 factors:

GCS



Convert GCS score of 3-15 to equivalent 0-4
Respiratory rate (0 - 4 points)
Systolic blood pressure (0 – 4 points)
Secondary Triage Practice


Case #1
 20 year old female, eyes open but not able
to walk
 Follows commands
 Obvious injury is a fractured left leg
 Respirations 22
 Radial pulse present (96); B/P 124/76
 Capillary refill 1 second
Triage category = Green (12 points)
 GCS (15) 4 + RR 4 + B/P 4 = 12
Secondary Triage Practice


Case #2
 36 year-old male lying on ground; eyes
open and moving spontaneously
 Soot around face; voice is croaky
 Respirations 34
 Radial pulse present; B/P 150/110
Triage category = Yellow (11 points)
 GCS (15) 4 + RR 3 + B/P 4 = 11
Secondary Triage Practice


Case #3
 30 year-old male sitting next to the
previous patient; eyes open
 Some dried blood noted on face and arms
 Respiratory rate 20
 Radial pulse present; B/P 130/80
Triage category – Green (12 points)
 GCS (15) 4+ RR 4+ B/P 4 = 12
Secondary Triage Practice


Case #4
 27 year-old female walking around with
burns to their arms; eyes open
 Crying out in pain
 Respiratory rate 32
 B/P 120/80
Triage category = Yellow (11)
 GCS (15) 4 + RR 3 + B/P 4 = 11
Smaller Scaled Incidents



Some principles of SMART triage can be
applied regardless of size of incident
For smaller sized incidents, patients meet
criteria as a Category I, II, or III trauma
patient
 Hospital report can include physiological
assessment and the ECRN can even
categorize the patient
Hospital report can include categorization
from the field (“We have a Category I trauma
patient”)
Category I Patient


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
Category I Patient Criteria

Unstable vital signs




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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
Category I Patient Criteria

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
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
Category II Trauma Patient

Mechanism of injury





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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
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
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
After Action Report



Form to be completed at end of every call
involving 2 or more traumatically injured
patients
This is a PI tool to evaluate the current
process
 Allows for review of
systems/processes/procedures/operations
to determine what works and what needs
revision
Fax (or leave form) to Resource Hospital for
PI review
Scenario Practice



Review the scenario
Place the incident somewhere in your
town/village/city
Determine how you would respond to the call
and how you would handle the call



What roles are necessary?
What additional resources are necessary?
When and how is report called to the hospital?
Case Scenario Practice




Use the following scenarios as a base
Can add/delete patients to meet your
needs
Add physiological findings based on
how you want to use the scenario
Best if all at the department drill
together
 Need to appreciate the roles taken by
every person at the scene
Well person check turned bad!

Newspaper delivery boy called 911


Newspapers not picked up for 2 days
The weather is chilly and furnaces have
been turned on in homes
Case Scenario #1





Upon entry into the home, you find one adult
victim lying on the floor inside the front door
Another adult victim is collapsed on the stairs
Another adult victim is collapsed in the
kitchen
3 children are found unresponsive in their
beds
One adult is triple zero; all other victims have
poor respirations and weak pulses
Case Scenario #1


What are your first thoughts and considerations?
 Safety is number one
 What would make entry into the scene safer?
 Evaluate what kind of additional resources are
necessary
 Are you thinking CO exposure?
 Contact closest hospital to coordinate transportation
What category are these patients?


You have one dead
You have 5 critical patients
 Category I patients for medical reasons
Multiple vehicle crash



At least 10 vehicles involved
At least 18 victims
As first responding unit, what do you do?
Case Scenario #2


Do a windshield survey
Need to activate additional help
immediately



What would you request?
Remember an early phone call to alert
the hospital
What scene safety issues must be
considered?
Case Scenario #3


1 vehicle rolled, 5
teenager passengers
All patients with
unstable vital signs
and altered level of
consciousness
Case Scenario #3






With first responding unit, what needs
to happen?
What resources are necessary?
Who and when are you notifying the
hospital?
How do you assign triage?
How do you coordinate transportation?
How do you communicate with the
hospital?
Case Scenario #3


High speed MVC
4 occupants – 1 ejected; driver DOA
Case Scenario #3



As a responding unit with 2(3) crew,
how do you begin triage?
What additional resources do you need
to request?
How do you coordinate this scene?




Communication
Triage
Treatment
Transportation
Multiple Vehicle Incident >40mph

5 patients between the 3 cars
Case Scenario #4

2 patients in first car



1 patient in middle vehicle



Driver wants to sign a release
Passenger complains of back pain
Asking repetitive questions; unable to follow
commands
Moves only right extremities
2 patients in truck


Driver wants to sign a release
Passenger complains of knee and hip pain
Case Scenario #4





Start with 1 responding unit
Can add additional help per department
guidelines
Discuss assessment provided
Can any of these patients sign a release?
 Any patient awake and oriented can sign a
release
Do any of these patients meet criteria for
withholding full spinal immobilization?
 MVC >40mph so all patients require spinal
immobilization based on mechanism of
injury
Bibliography




Bledsoe, B., Porter, R., Cherry, R. Paramedic
Care Principles and Practices. Prentice Hall.
2009.
Region X Multiple Patient Management Plan,
2009.
Region X SOP’s March 2007, Amended
Version May 1, 1008.
Smartmci.com (TSG Associates Ltd 2004 –
2008)