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Disaster Triage—Are You Ready?
TRIAGE DECISIONS
DISASTER TRIAGE—ARE YOU READY? Authors: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, and Andi L. Foley, MSN, RN, CEN, Lexington, KY, Federal Way, WA Section Editors: Andi L. Foley, MSN, RN, CEN, and Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN
s the ED charge nurse in a crowded department, you wondered if someone said “the Q word” last shift. Then the emergency medical services radio sounded; the disaster drill started as scheduled at 3 PM. At least you were aware of the planned drill and the emergency department had additional staff available to participate in the drill, to provide care to the “victims.” Routine disaster drills are essential to a successful response in the event of a true mass casualty event. The disaster response team needs to have continuous readiness to provide the greatest good to the greatest number of patients. Validation of disaster triage processes during drill procedures is critical for optimal management of patient care and utilization of resources. The after-drill debriefing and review provide important information for process improvement.
A
Scenario
A sinkhole appeared on the edge of a busy highway. The highway and a portion of a nearby 12-story office building collapsed into the sinkhole. The incident is 5 miles from the nearest hospital, and as the second closest facility, your hospital is expecting a significant number of casualties. The first patients to arrive include the following: •
•
Patient A, an adult male patient who walks in holding his arm. He tells you, “It hurts and I think it’s broken.” Capillary refill in the affected extremity is normal distal to the injury. Patient B, an adult male patient who arrives with a friend and states, “I can’t see . . . .” The patient reports that gas splashed into both eyes. He is able to distinguish the number of fingers held in his direct field of vision and has no other injuries.
Patricia Kunz Howard, Member, Kentucky State ENA, is Director, Emergency Services, UK HealthCare, Lexington, KY. Andi L. Foley, Member, Washington State ENA, is Clinical Nurse Specialist/Unit Based Educator, Emergency Services, St. Francis Hospital, Federal Way, WA. For correspondence, write: Andi L. Foley, MSN, RN, CEN; E-mail: [email protected]. J Emerg Nurs 2014;40:515-7. Available online 26 July 2014 0099-1767 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.05.010
September 2014
VOLUME 40 • ISSUE 5
•
•
•
Patient C, an adult female patient brought by friends who found her walking near the collapse site. The patient is dazed but follows commands. She has singed hair on her head and face. Her respiratory rate is 26 breaths/min. Capillary refill is normal for the patient’s age and gender. Patient D, an adult female patient who is brought by friends and arrives in a wheelchair with blistered burns to the anterior chest and abdomen, anterior arms, and lower neck. Her respiratory rate is 26 breaths/min. The capillary refill time is 3 seconds. Patient E, an adolescent male patient accompanied by adults who state that he was thrown from a bicycle when the sinkhole caught the back tire. He is alert, anxious, and holding his left arm and has an obvious deformity to the medial aspect of his left clavicle.
The Table includes a brief START (Simple Triage and Rapid Treatment) triage discussion 1 for each patient. The aforementioned scenario is not uncommon after a disaster. Many patients will not have received a field triage assessment. As a result, in many cases the ED triage sector has the first contact with ambulatory patients and must make a decision about triage categorization. Disaster triage differs from traditional ED triage in that the focus is on rapid identification of patient status and deployment to the appropriate care location based on color coding or another triage system used by the disaster responders. Traditional triage often determines more information than is consistent with triage expectations during a disaster event. Triage truly functions as sorting in a disaster.
Preparedness
Facility and department plans that are well developed and communicated across the organization are essential. The hospital incident command system is one method used by health care organizations to plan, mitigate, implement, and evaluate disaster response. 3 It is imperative that emergency nurses understand the key aspects of the disaster plan that have a direct impact on ED operations and triage. The decision to implement a “code disaster” is often made in collaboration with the ED medical director, ED nursing leadership on shift, and representatives of hospital administration. Once the plan is implemented, the command center should be activated.
WWW.JENONLINE.ORG
515
TRIAGE DECISIONS/Howard and Foley
TABLE
START triage of scenario patients Patient
Triage assessment
START triage category
A B C
Ambulatory without risk factors Vision changes; no life-threatening complications Singed hair on face and increasing respiratory rate; possible inhalation injury that could decompensate over a wait of several hours; burns—especially possible inhalation burns—are often undertriaged 2 Extensive burns could inhibit chest expansion if time to treatment is prolonged Injury to medial aspect of clavicle indicates significant force; alert mental status and absence of other injuries
Minor (green) Delayed (yellow) Immediate (red)
D E
Immediate (red) Delayed (yellow)
START, Simple Triage and Rapid Treatment.
Command
Supplies
A well-defined command structure is essential to communication within the facility and within the region during a community mass casualty event. 4 Such a structure assists with coordination and collaboration between hospital and prehospital disaster command, as well as ensures that hospital operations are managed as needed during the event.
If the disaster triage area is not in or directly adjacent to the emergency department, supplies will need to be readily available. Supplies include color-coded triage tags or tapes, personal protective equipment, and basic injury and wound care supplies. Disaster cart supplies should be checked monthly for availability and expiration dates.
Staging Area
Staff
Disaster triage may be staged in an area near the emergency department or may be staged in an alternate location, depending on the layout and geography of the facility. The staging area may also be located near the decontamination resources, should these be needed. Within the staging area itself, locations for each triage category will help maximize flow. Color-coded signage will assist with caregiver communication but should be quickly available and easy to set up in a short amount of time. Patients in the minor (green) category are typically ambulatory and may be relocated to an alternate area in the facility for treatment. 1 Patients at high risk of deterioration and requiring care within the hour for survival are categorized as immediate (red). When significant deterioration is not expected, even in the presence of serious injuries, a categorization of delayed (yellow) is appropriate. Patients categorized as expectant (black) are unlikely to survive but may need palliative care and pain management. If space allows, the location of live expectant patients should be separated from that of deceased expectant patients.
The most experienced provider available is the best candidate for disaster triage; this designation should be predetermined in the ED disaster plan. The ability to apply triage algorithms unique to disasters requires training and focus. The person accountable for triage is often a nurse but may be a physician or another provider, depending on the resources available. The triage team works collaboratively with the registration team to aid in rapid, comprehensive identification of arriving patients. Accurate identification at arrival will facilitate recovery efforts after the immediate disaster response period has passed. Runners are important to success in disaster triage. This group may be volunteers or staff reassigned from other areas of the hospital. Regardless of the source of the runner group, oversight and coordination from hospital incident command help to ensure that the right people are available when needed. Well-organized disaster plans are critical to ensuring that the patient and the correct resources are matched in a disaster event. Frequent drills and hands-on practice are important for the responders to be able to respond intuitively when the unexpected occurs.
516
JOURNAL OF EMERGENCY NURSING
VOLUME 40 • ISSUE 5
September 2014
Howard and Foley/TRIAGE DECISIONS
REFERENCES
4. Federal Emergency Management Agency. Incident Command System (ICS) overview. http://www.fema.gov/incident-command-system. Accessed May 14, 2014.
1. Emergency Nurses Association. Trauma Nursing Core Course. 7th ed. Des Plaines, IL: Emergency Nurses Association; 2014. 2. Taylor S, Jeng J, Saffle JR. Redefining the outcomes to resources ratio for burn patient triage in a mass casualty. J Burn Care Res. 2014;35(1):41-5. 3. Federal Emergency Management Agency. IS-100.HCb. Introduction to the Incident Command System (ICS 100) for healthcare/hospitals. http://emilms.fema.gov/IS100b/index.htm. Accessed July 10, 2014.
September 2014
VOLUME 40 • ISSUE 5
Submissions to this column are encouraged and may be sent to Andi L. Foley, MSN, RN, CEN [email protected] or Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN [email protected]
WWW.JENONLINE.ORG
517
DISASTER TRIAGE—ARE YOU READY? Authors: Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, and Andi L. Foley, MSN, RN, CEN, Lexington, KY, Federal Way, WA Section Editors: Andi L. Foley, MSN, RN, CEN, and Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN
s the ED charge nurse in a crowded department, you wondered if someone said “the Q word” last shift. Then the emergency medical services radio sounded; the disaster drill started as scheduled at 3 PM. At least you were aware of the planned drill and the emergency department had additional staff available to participate in the drill, to provide care to the “victims.” Routine disaster drills are essential to a successful response in the event of a true mass casualty event. The disaster response team needs to have continuous readiness to provide the greatest good to the greatest number of patients. Validation of disaster triage processes during drill procedures is critical for optimal management of patient care and utilization of resources. The after-drill debriefing and review provide important information for process improvement.
A
Scenario
A sinkhole appeared on the edge of a busy highway. The highway and a portion of a nearby 12-story office building collapsed into the sinkhole. The incident is 5 miles from the nearest hospital, and as the second closest facility, your hospital is expecting a significant number of casualties. The first patients to arrive include the following: •
•
Patient A, an adult male patient who walks in holding his arm. He tells you, “It hurts and I think it’s broken.” Capillary refill in the affected extremity is normal distal to the injury. Patient B, an adult male patient who arrives with a friend and states, “I can’t see . . . .” The patient reports that gas splashed into both eyes. He is able to distinguish the number of fingers held in his direct field of vision and has no other injuries.
Patricia Kunz Howard, Member, Kentucky State ENA, is Director, Emergency Services, UK HealthCare, Lexington, KY. Andi L. Foley, Member, Washington State ENA, is Clinical Nurse Specialist/Unit Based Educator, Emergency Services, St. Francis Hospital, Federal Way, WA. For correspondence, write: Andi L. Foley, MSN, RN, CEN; E-mail: [email protected]. J Emerg Nurs 2014;40:515-7. Available online 26 July 2014 0099-1767 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.05.010
September 2014
VOLUME 40 • ISSUE 5
•
•
•
Patient C, an adult female patient brought by friends who found her walking near the collapse site. The patient is dazed but follows commands. She has singed hair on her head and face. Her respiratory rate is 26 breaths/min. Capillary refill is normal for the patient’s age and gender. Patient D, an adult female patient who is brought by friends and arrives in a wheelchair with blistered burns to the anterior chest and abdomen, anterior arms, and lower neck. Her respiratory rate is 26 breaths/min. The capillary refill time is 3 seconds. Patient E, an adolescent male patient accompanied by adults who state that he was thrown from a bicycle when the sinkhole caught the back tire. He is alert, anxious, and holding his left arm and has an obvious deformity to the medial aspect of his left clavicle.
The Table includes a brief START (Simple Triage and Rapid Treatment) triage discussion 1 for each patient. The aforementioned scenario is not uncommon after a disaster. Many patients will not have received a field triage assessment. As a result, in many cases the ED triage sector has the first contact with ambulatory patients and must make a decision about triage categorization. Disaster triage differs from traditional ED triage in that the focus is on rapid identification of patient status and deployment to the appropriate care location based on color coding or another triage system used by the disaster responders. Traditional triage often determines more information than is consistent with triage expectations during a disaster event. Triage truly functions as sorting in a disaster.
Preparedness
Facility and department plans that are well developed and communicated across the organization are essential. The hospital incident command system is one method used by health care organizations to plan, mitigate, implement, and evaluate disaster response. 3 It is imperative that emergency nurses understand the key aspects of the disaster plan that have a direct impact on ED operations and triage. The decision to implement a “code disaster” is often made in collaboration with the ED medical director, ED nursing leadership on shift, and representatives of hospital administration. Once the plan is implemented, the command center should be activated.
WWW.JENONLINE.ORG
515
TRIAGE DECISIONS/Howard and Foley
TABLE
START triage of scenario patients Patient
Triage assessment
START triage category
A B C
Ambulatory without risk factors Vision changes; no life-threatening complications Singed hair on face and increasing respiratory rate; possible inhalation injury that could decompensate over a wait of several hours; burns—especially possible inhalation burns—are often undertriaged 2 Extensive burns could inhibit chest expansion if time to treatment is prolonged Injury to medial aspect of clavicle indicates significant force; alert mental status and absence of other injuries
Minor (green) Delayed (yellow) Immediate (red)
D E
Immediate (red) Delayed (yellow)
START, Simple Triage and Rapid Treatment.
Command
Supplies
A well-defined command structure is essential to communication within the facility and within the region during a community mass casualty event. 4 Such a structure assists with coordination and collaboration between hospital and prehospital disaster command, as well as ensures that hospital operations are managed as needed during the event.
If the disaster triage area is not in or directly adjacent to the emergency department, supplies will need to be readily available. Supplies include color-coded triage tags or tapes, personal protective equipment, and basic injury and wound care supplies. Disaster cart supplies should be checked monthly for availability and expiration dates.
Staging Area
Staff
Disaster triage may be staged in an area near the emergency department or may be staged in an alternate location, depending on the layout and geography of the facility. The staging area may also be located near the decontamination resources, should these be needed. Within the staging area itself, locations for each triage category will help maximize flow. Color-coded signage will assist with caregiver communication but should be quickly available and easy to set up in a short amount of time. Patients in the minor (green) category are typically ambulatory and may be relocated to an alternate area in the facility for treatment. 1 Patients at high risk of deterioration and requiring care within the hour for survival are categorized as immediate (red). When significant deterioration is not expected, even in the presence of serious injuries, a categorization of delayed (yellow) is appropriate. Patients categorized as expectant (black) are unlikely to survive but may need palliative care and pain management. If space allows, the location of live expectant patients should be separated from that of deceased expectant patients.
The most experienced provider available is the best candidate for disaster triage; this designation should be predetermined in the ED disaster plan. The ability to apply triage algorithms unique to disasters requires training and focus. The person accountable for triage is often a nurse but may be a physician or another provider, depending on the resources available. The triage team works collaboratively with the registration team to aid in rapid, comprehensive identification of arriving patients. Accurate identification at arrival will facilitate recovery efforts after the immediate disaster response period has passed. Runners are important to success in disaster triage. This group may be volunteers or staff reassigned from other areas of the hospital. Regardless of the source of the runner group, oversight and coordination from hospital incident command help to ensure that the right people are available when needed. Well-organized disaster plans are critical to ensuring that the patient and the correct resources are matched in a disaster event. Frequent drills and hands-on practice are important for the responders to be able to respond intuitively when the unexpected occurs.
516
JOURNAL OF EMERGENCY NURSING
VOLUME 40 • ISSUE 5
September 2014
Howard and Foley/TRIAGE DECISIONS
REFERENCES
4. Federal Emergency Management Agency. Incident Command System (ICS) overview. http://www.fema.gov/incident-command-system. Accessed May 14, 2014.
1. Emergency Nurses Association. Trauma Nursing Core Course. 7th ed. Des Plaines, IL: Emergency Nurses Association; 2014. 2. Taylor S, Jeng J, Saffle JR. Redefining the outcomes to resources ratio for burn patient triage in a mass casualty. J Burn Care Res. 2014;35(1):41-5. 3. Federal Emergency Management Agency. IS-100.HCb. Introduction to the Incident Command System (ICS 100) for healthcare/hospitals. http://emilms.fema.gov/IS100b/index.htm. Accessed July 10, 2014.
September 2014
VOLUME 40 • ISSUE 5
Submissions to this column are encouraged and may be sent to Andi L. Foley, MSN, RN, CEN [email protected] or Patricia Kunz Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN [email protected]
WWW.JENONLINE.ORG
517