THE EVOLUTION OF A TRIAGE SYSTEM CONCEPT SALT TRIAGE.pdf · 2012-10-22 · THE EVOLUTION OF A TRIAGE SYSTEM CONCEPT Sort Assess Lifesaving interventions SALT Treatment/transport Due

TRIAGETHE EVOLUTION OF A TRIAGE SYSTEM CONCEPT

Let’s consider real world…

MedComm dispatches you to a MVC. Based on caller information

(multiple patients) a second unit is also dispatched Echo One.

You and your partner survey the MVC scene through the windshield as

you approach. You quickly notice only one vehicle that has hit a

guardrail, what appears to be two potential patients (one sitting in car,

one leaning against hood), and no obvious hazards.

First impression?

Do you think you can manage this event?

Will you need the second ambulance?

THE EVOLUTION OF A TRIAGE SYSTEM CONCEPT

New Vocabulary: Rapid Triage

� When you quickly check each patient

in order to establish an injury estimate.

� Works for smaller number of patients.

� Depends on number of EMSP on scene.


Rapid Triage results for our example-

Patient leaning against hood has knee and elbow pain. No other

obvious injuries, no other complaint, was wearing seatbelt.

Patient sitting in car is the driver, has left clavicle pain, right wrist pain,

and abrasions on forehead from deployed airbag. No other obvious

injuries, no other complaint, was wearing seatbelt.

Impression- can you manage this event?

Can you adequately treat both patients?



So… how did you decide?

Can you manage this event?How many patients can you actually manage?

Can you adequately treat both patients?

Does it matter their “Priority” status?

Does it matter what resources you have?


How many patients can you carry?

33


Fair enough but… what if it gets crazy?


Or something more common?

Rapid Triage: 5 Patients1 Priority 1, 1 Priority 2, 3 Priority 3



5 Patients:1 Priority One1 Priority Two3 Priority Three

Can you manage this event?

How many patients can you actually manage?

Does it matter their “Priority” status?

Does it matter what resources you have?

How many patients can you carry?

Answer:

Dynamic… depends on severity of injuries.

One bad one… load and go.

One bad one, one not-so-bad one… load and go.

Two bad ones? Three bad ones?


Rapid Triage5 Patients:1 Priority One1 Priority Two3 Priority Three


Rapid Triage

Can you take all the critical and go?

Congratulations! You Stay!

You Are The Patient Management Team.

Request Supervisor.

Determined priorities.

Request additional resources.

Do it. Go.

Manage & Treat Patients.

Assign Patients To Arriving Resources.

Take The Last Critical and Transport.

Yes

No

How do you know?

Can you take all the critical and go?

Do you need additional resources?

How many resources do you need?


HEMSI AMBULANCE LOADING GUIDE

1 2 2 3 3 3


So… for our example…

How many ambulances do you need?


? ? ? ? ?

Using the…

HEMSI AMBULANCE LOADING GUIDE

You determine you need three units in total.

Since MedComm sent one Echo 1, you elevate it to Echo 3.

Due to low priority patients, the other unit can come Echo 1.

And, of course, YOU are the third ambulance.

1 2 3 3 3


As transport units arrive, you

(the patient management team)

distribute the patients according

to priority.

You will transport the last critical

or seriously injured patients.

1

3 3


First arriving transportYou

Last

arriving

transport

If all support ambulances arrive

at the same time, you will manage

loading them and then you will

transport the last patients.

1

3 3


Second Transport

You

Third transport

If a supervisor responds, an event evaluation

will be conducted to see if the supervisor will

assume triage duties or manage other duties

at the scene.

The supervisor will make that decision upon

arrival at the event.


1

23

33


The Many Event Dynamics

�Supervisor Availability

�Ambulances Availability

�Ambulances Blocked At Scene

�Responder Availability

�Weather Events

�HAZMAT

�Multiple MCI Locations

�Incident Command

It must remain clear to everyone that guidelines should be followed in most of the

events encountered on a daily basis. However, due to the many different emergency

dynamics, there will be the occasion to adjust the guidelines to better match a

particular set of circumstances. Supervisors will make most of the adjustments but

there will be times when the crew will need to act. Whenever possible, adjustments

made by the crew should be relayed to a supervisor.

Now for the freakish…


Airport Road, November 1989

At some point, we must move from using

Rapid Triage in a multiple-patient event

to a more course triage method for

handling a greater number of patients

found in a Mass Casualty Incident (MCI).

The triage system we will use is SALT.


Mass Casualty Incident (MCI)

SortAssessLifesaving interventionsTreatment/transportSALT



Due to the lack of scientific data regarding the efficacy of mass casualty triage

systems, the Centers for Disease Control (CDC) formed an advisory committee to

analyze the existing systems and recommend a national standard for disaster

triage.

The committee could not conclusively identify any existing triage system as

optimal so they developed SALT by combining the best features of the existing

systems.

SALT is endorsed by several national organizations, including the American

College of Emergency Physicians, the American College of Surgeons Committee on

Trauma, the American Trauma Society, and the National Association of EMS

Physicians.





In many other triage systems, sorting patients began with tagging

patients who could walk as minor or Green. However, this group

may still have injuries that need immediate or delayed treatment.

So instead, patients that can walk should be prioritized as third for

individual assessment, and not simply assigned to a minimally

injured category without further evaluation.

Simple voice commands are used to prioritize patients for

individual assessment and to give those who can walk clear

instructions regarding where to go for help.



The wave command is used to further prioritize when to assess

patients. Incorporating a wave command into the global sorting

process allows the provider to distinguish those patients who are

not able to follow a command from those who are not physically

able to walk but can still follow a command.

By assessing those patients who are not waving or making

purposeful movements first (ie, those not able to follow

commands), the provider is likely to approach those patients who

may require lifesaving interventions first.



So, those patients who can wave or are making purposeful

movements should be individually assessed second.

However, because a patient with uncontrolled hemorrhage

who can follow commands may be prioritized second and

exsanguinate while awaiting attention, those patients

with obvious uncontrolled hemorrhage move into the group that

should be assessed first.



Individually assess first:

� Patients who not making purposeful movements

� Patients who are still

� Patients who have an obvious life threat





Providing Lifesaving Interventions (LSI) is a formal

process that is done with every individual assessment

and is completed before assigning a triage category.



LSI includes:

� Control of major hemorrhage,

� Opening the airway

� 2 rescue breaths for children

� Decompression of tension pneumothorax

� Autoinjector antidotes

LSI are provided quickly and only if supplies are readily available. These

interventions were selected because they can be applied rapidly and can have

a profound impact on survival, although data regarding actual application in

mass casualty settings are lacking.











EXPECTANT



SALT includes an expectant category.

The expectant category is intended to be resource based and the

definition could and should change depending on the magnitude

of the incident, available resources, and the provider's level of

training and comfort with using the category.

The expectant category will be needed only if there are not

enough resources available in the field to meet demand. This

methodology allows providers to focus resources on potentially

salvageable patients rather than applying resuscitation resources

to those who are unlikely to survive.

EXPECTANT



The expectant category is intended to be flexible and dynamic to

ensure that should additional resources become available, it will

be easy to find dying patients so that they can receive resuscitation

or comfort care.

Patients categorized as expectant should be readily identified,

reevaluated frequently as resources become available, and have

their triage categorization changed as appropriate.

EXPECTANT



Answer:

Dynamic again. Depends on...

Number of critical or serious patients (3 critical? 6 combined?)

Number of responders on scene

Number of paramedics on scene


When do you switch from Rapid Triage for a

multiple-patient event to the SALT Triage for a

mass casualty incident (MCI)?

SortAssessLifesaving interventionsTreatment/transportSALTRapid Triage


When you feel that you cannot manage your

critical patients adequately, including keeping

track of patient priorities, you should switch

from Rapid Triage to SALT Triage.

Provide MedComm a description of the event

and an estimated of number of patients.

SortAssessLifesaving interventionsTreatment/transportSALTRapid Triage


TRIAGE TAGSAll tags have RED, YELLOW, GREEN, and

BLACK. Some tags use GREY for expectant

while others may use another color or label.

One transition that needs to occur is from

using the somewhat nebulous “Priority 1”

in Rapid Triage to RED, “Priority 2” to YELLOW,

and “Priority 3” to Green.

The priorities are used for dealing with logistics such as describing

the event to MedComm or a supervisor. However, when giving your

patient report, concentrate on providing an accurate and efficient

patient and do not use a priority.


TRIAGE TAGS- APRIL 2012Each ambulance will carry 10 triage tags and

a notepad in the LDB lock box.

Remember, you SORT first (no tags) and only

tag after you do your individual assessment.

Each supervisor carries additional triage tags.

Once an incident command is established, you will need to regularly

provide a report as you triage. Give an update each time you use all

of your 10 tags.

See a supervisor if you have any operational questions concerning

rapid triage or SALT triage.

Documents

THE EVOLUTION OF A TRIAGE SYSTEM CONCEPT SALT TRIAGE.pdf · 2012-10-22 · THE EVOLUTION OF A TRIAGE SYSTEM CONCEPT Sort Assess Lifesaving interventions SALT Treatment/transport Due