This exercise program was developed and made
available by the Missouri Hospital Association
through funds from the ASPR Hospital
Preparedness Program CFDA 93.889, through a
subcontract from the Missouri Department of
Health and Senior Services for the purposes of
individual hospital preparedness and exercise.
Sources used in the development of these materials
are noted in the Notes Section except where
general knowledge.
Patient Surge Tabletop
Exercise
Focus: Patient Triage
Exercise Purpose and Goal
 The goal and purpose of this exercise is to orient
hospital triage staff to the process of disaster
patient triage and to triage simulated patients.
 This exercise will utilize the START triage system to
triage simulated patients.
 This system can be used to sort simulated
patients, according to their injuries and level of
acuity, into categories allowing the most critical
patients to receive treatment more quickly than
patients who may be able to have delayed
treatment.
Exercise Objectives
 Provide an orientation to Surge Capacity and the
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Care Continuum
Discuss the need for triage
Review various decision tools for triage
Discuss the activation process for our Mass
Casualty or Patient Surge Plan
Discuss the key components for the response
Develop response objectives for a mass casualty
event
Triage simulated patients using the START triage
system (or substitute your triage methodology)
Surge Capacity and the Care Continuum
 Hospitals must prepare for surges of patients
due to a variety of causes: natural disasters,
man-made events causing injury and/or illness,
and disease outbreaks.
 Numbers of patient surge capabilities will vary,
hospitals should plan for a 20% surge.
 Response will span the continuum from
Conventional, Contingency, to Crisis care
Care Continuum
 Conventional Capacity: The spaces, stuff, and supplies
used are consistent with daily practices within the institution.
These spaces and practices are used during a major mass
casualty incident that triggers activation of the facility
emergency operations plan.
 Contingency Capacity: The spaces, staff, and supplies used
are not consistent with daily practices but provide care that is
functionally equivalent to usual patient care. These spaces or
practices may be used temporarily during a major mass
casualty incident or on a more sustained basis during a
disaster (when the demands of the incident exceed
community resources.)
Source: Hick et al., 2009.
Care Continuum
 Crisis Capacity: Adaptive spaces, staff, and
supplies are not consistent with usual standards
of care, but provide sufficiency of care in the
context of a disaster (i.e., provide the best
possible care to patients given the circumstances
and resources available). Crisis capacity
activation constitutes a significant adjustment to
standards of care.
Source: Hick et al., 2009.
What is disaster triage?
 Triage is used to classify patients for care based
on the severity of their illness or injury in
context of the resources available with the goal
of doing the most good for the greatest number
of people.
When do we go to disaster triage?
 When a large number of patients present that
overwhelm normal resources for treatment.
Triage helps to ensure best use of the limited
resources.
 The triage process should be ongoing; in the
field, when patients present, when arriving at
their treatment area, after initial treatment is
given…..
Types of triage
 Primary triage – takes place early in an incident
either in the field by EMS or when patients
present to the hospital.
 Secondary triage – performed after additional
assessments and initial interventions
 Tertiary triage – performed after or during the
provision of definitive diagnostics and medical
care
Decision Tools for the Triage Process
 Decision tools provide:
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Common criteria that can be applied in a relatively
uniform fashion by multiple providers
Objective indicators by which to determine
prognosis
Improved consistency of decisions across multiple
providers and facilities
Prognostic value that is evidence based
A degree of protection from legal action if the
provider is following published guidelines or
facility plans in good faith
Type of triage decision tools
 Limited resource allocation algorithms (i.e.
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ventilators)
SOFA (Sequential Organ Failure Assessment)
ESI (Emergency Severity Index)
START (Simple Triage and Rapid Transport)
JumpSTART – Pediatric version of START
SOFA
Emergency Severity Index
 Decision Criteria
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Immediate life
saving intervention
required
Mental status
Level of pain
Vitals; HR, RR, O2
sat
Number of
resources needed
Why tag at the hospital?
 Re-triage patients who arrive
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via EMS as status may have
changed.
Triage disaster patients at the
Hospital Triage Area as soon
as possible after their arrival.
Triage tag communicates
priority of treatment.
Easily identifiable as to
category and therefore hospital
treatment area destination.
Avoids the need to repeatedly
re-triage the patient. (periodic
reassessment is still needed)
START
 Triage criteria
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Walk?
Breath?
Respiratory Rate?
Perfusion?
Capillary refill or
radial pulse?
Mental status?
JumpSTART
 Utilizes same
assessment criteria
as START.
 Algorithm adjusted
for pediatric
patients.
START triage tag training video
 http://www.triagetags.com/index.php?route=inf
ormation/information&information_id=9
Types of triage tags
 DMS
 others
Triage Tag Common Elements
 Color based categories:
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Red – need immediate care
Yellow – delayed
Green – minor, walking wounded
Black – deceased or not expected to survive
 May have bar codes
 May have place for patient information
Other times to triage
 Evacuation – triage patients for order to evacuate the
facility
 Based on type of event: no notice vs. advanced
warning
 Time available to evacuate
 Resources available to evacuate
 Reverse triage may be used: evacuate the largest
number of patients in the shortest amount of time
– Greens and those in immediate danger 1st
– Yellows – require additional resources to move
– Reds – critical care and/or require the most resources to
move
Other times to triage
 Large influx of patients expected
Triage existing ED and inpatients to determine
who can be discharged or released to a lower
level of care
 There is a shortage of a critical resource. Triage
criteria must be developed for allocation of that
resource.
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Critical Plan Components
 Alerting – receive notice of a significant event
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from local and/or regional partners
Notification – internal responders as well as
relevant external partners
Command – HICS, scaled, flexible. Incident
action planning.
Control – departmental specific response
Communications – ability to communicate
between critical areas and responders
Critical Plan Components
 Coordination – within the hospital as well as to
external local and regional partners
 Public Information - internally to patients, staff,
families, and visitors. External to the public and
news media.
 Operations – triage and clinical teams. Develops
the strategy and tactics to meet the incident
objectives. Expansion of clinical care areas,
patient triage and treatment.
Critical Plan Components
 Logistics – acquisition of resources to support
the operation
 Planning – gathers incident related data,
analyses, and forecasts. Conducts planning
meetings and prepares the Incident Action Plan.
Material, personnel, patient, and bed tracking.
Patient Surge (Mass Casualty) Plan
Review
 Review the key components of your plan here
Triage Exercise
 Exercise objectives
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Discuss the need for activation of the hospital
patient surge plan
Discuss the need for establishment of triage
and treatment areas
Utilize patient cards to triage patients for
transport to treatment areas using START
triage system
Scenario Part 1
 Monday evening, 9pm
 Your ED is at normal staffing, supply, and
patient levels
 You receive a call in the ED from Public Safety
Dispatch that there has been a transportation
accident (insert most likely scenario, bus, train,
plane, etc. for your area) in your community
 EMS and Fire are enroute. They anticipate at
least 30 (can modify to stress your facility)
casualties from initial reports.
Discussion Break
 Would this cause an activation of your
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Emergency Plan?
Who would you contact?
What level of activation?
What are the critical components (priorities) of
the response to this situation?
What are your incident objectives at this time?
Who is in charge?
Scenario Part 2
 An update is received by Incident Command on
the scene. There are an estimated 100
casualties with 40 estimated as being critical.
 The other hospital in the community can accept
20 of the non-critical casualties as they are
currently under construction in their ED.
 Modify this slide to stress your facility and cause
an adequate level of required response.
Discussion Break
 Does this new information cause any of your
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previous decisions to change?
Additional notifications?
Level of activation?
Areas to set up/activate? (Command Center,
Triage Area, Treatment Areas, Labor Pool, etc.)
Where are they located?
Who is the hospital Incident Commander?
What hospital incident command system (HICS)
positions would you activate?
Have your objectives changed?
Scenario Part 3
 Your first patient arrives by helicopter with
serious injuries.
 A bus load of green patients arrive from the
scene. They have triage tags on them from EMS.
 A passenger van arrives with 10 people they
have brought in from the scene.
Triage Exercise
 You are working the Triage Area.
 Triage the paper patients with the information
listed on their card.
 Tear off the appropriate portion of the triage tag
and attach the tag prior to movement of the
patient to the appropriate Treatment Area.
What have we learned?
 What went well?
 What did not go well?
 Any gaps in our knowledge, skills, resources, or
planning that need to be enhanced to be more
prepared for this type of a situation in the
future?
Questions?
Thank you for your participation!
Please complete your Participant Evaluation Form
prior to leaving
References
 IOM (Institute of Medicine). 2012. Crisis
Standards of Care: A Systems Framework for
Catastrophic Disaster Response. Washington DC:
The National Academic Press
 HICS Guidebook, 2014: California Medical
Services Authority.