Wesleyan University- Philippines

Mabini Extension, Cabanatuan City

NCM 106: Care of Clients with Problems in Cellular Aberrations, Acute Biologic Crisis, including Emergency & Disaster Nursing (SKILLS)

Submitted by:

Jenilyn Faye M. Orpilla

(Bsn4-4)

Submitted To:
Concept Instructor

1. Define TRIAGE:
The word triage comes from the French word trier, meaning to sort. In the daily routine of the ED, triage is used to sort patients into groups based on the severity of their health problems and theimmediacy with which these problems must be treated. Hospital EDs use various triage systems with differing terminology,but all share this characteristic of a hierarchy based on the potential for loss of life. A basic and widely used system uses three categories: emergent, urgent, and non-urgent (Berner, 2001). Emergent patients have the highest prioritytheir conditions are life threatening, and they must be seen immediately. Urgent patients have serious health problems, but not immediately lifethreatening ones; they must be seen within 1 hour. Non-urgent patients have episodic illnesses that can be addressed within 24 hours without increased morbidity

(Berner, 2001). A fourth, increasingly used class is fast-track. These patients require simple first aid or basic primary care. They may be treated in the ED or safely referred to a clinic or physicians office. Triage is an advanced skill; emergency nurses spend many hours learning to classify different illnesses and injuries to ensure that patients most in need of care do not wait to receive it. Protocols may be followed to initiate laboratory or x-ray studies from the triage area while the patient waits for a bed in the ED. Collaborative protocols are developed and used by the triage nurse based on his or her level of experience. Also, nurses in the triage area collect crucial initial data: vital signs and history, neurologic assessment findings, and diagnostic data if necessary. Routine ED triage protocols differ significantly from the triage protocols used in disasters and mass casualty incidents (field triage). Routine hospital triage directs all available resources to the patients who are most critically ill, regardless of potential outcome. In field triage (or hospital triage during a disaster), scarce resources must be used to benefit the most people possible. This distinction affects triage decisions.

and Suddarth's Textbook of Medical-Surgical Nursing 12th EditionSuzanne C. O'Connell Smeltzer, Brenda G. Bare, Janice L. Hinkle, Ph.D., Kerry H. Cheever, Ph.D.)
(Reference: Brunner

2. Updated American Heart Association 20102011Cardiopulmonary Resuscitation

American Heart Association 2010-2011 New CPR Guidelines The American Heart Association announced today new recommendations for the way CPR is performed. The small change could make a big difference in the lives of people suffering from cardiac arrest, the organization says. For nearly 40 years, CPR guidelines have trained people to follow these simple A-B-C instructionstilt the victim's head back to open the airway, then pinch their nose and do a succession of breaths into their mouth, and finally perform chest compressions. But now, the AHA says starting with the C of chest compressions will help oxygen-rich blood circulate throughout the body sooner, which is critical for people who have had a heart attack. With this shift, rescuers and responding emergency personnel should now follow a C-A-B processbegin with chest compression, then move on to address the airway and breaths. This change applies to adults, children, and babies, but does not apply to newborns. The revision is a part of the 2010 emergency cardiovascular care report published by the AHA., an organization that reviews its guidelines every five years, taking into account new science and literature. Although the changed procedure will take some time to reach what Monica Kleinman, the vice chair of the AHA's Emergency Cardiovascular Care Committee, calls "front-line people", there is a plan in place to implement the recommendations as soon as possible to their training network, medical staffs, and first-responders. "The sooner chest compressions are started, the more likely there will be a better outcome," Kleinman announced. "Studies performed in labs as well as largepopulation studies have shown that people do better if they get chest compressions within four minutes." (Reference: 184.173.230.155/~lrfpdor/PDF/AHA-2011-cpr-guidelines.pdf)
3.

Research: S.T.A.R.T. treatment (simple triage and rapid treatment)

OBJECTIVES: To correlate the simple triage and rapid treatment (START) colors to trauma injury severity scores (ISS). DESIGN: Six volunteer healthcare providers unfamiliar with START were trained to triage. Each chart was designated a START color by a volunteer healthcare provider and the "expert" trainer. The colors and corresponding ISS were recorded. SETTING: Level I trauma center at a suburban tertiary care hospital. PATIENTS, PARTICIPANTS: One hundred charts of patients at least 65 years old who appear in Christiana Hospital's Trauma Registry were randomly chosen for the study, and 98 charts with complete data were included. MAIN OUTCOME MEASURE(S): Cohen's Kappa score measures the level of agreement between the "volunteer" and "expert" reviewers. Pearson correlation determines the association between the START colors and mean ISS. RESULTS: The Cohen's Kappa score between the volunteer and expert reviewers was 0.9915, indicating a highly significant

agreement between the reviewers on the triage category of the patients. The mean ISS for each color was as follows: green = 11, yellow = 12, red = 20, black = 24. The mean ISS increases as the acuity of the triage category increases, with a Pearson correlation of 0.969. CONCLUSIONS: The START method is a simple technique used to triage quickly a large number of patients. Healthcare providers can undergo just-in-time training to learn this technique and use it effectively. The START colors also imply a correlation with the trauma ISS, with higher ISS more likely to be triaged "red" or "black." (Reference: http://www.ncbi.nlm.nih.gov/pubmed/19069030)

START (Simple Triage and Rapid Treatment)

First Responders, Emergency Medical Technicians and Paramedics are trained to handle emergencies. You know how to quickly assess a patient and intervene. But even the best emergency provider is easily overwhelmed when there are multiple patients who all need emergency care. The START system, developed by Hoag Hospital and the Newport Beach Fire Department (Newport Beach, CA), helps prepare emergency personnel to quickly organize their resources to handle multi-casualty emergencies. Using START, various agencies and individuals assume predetermined roles in managing the emergency, onscene personnel quickly evaluate the situation and call in the appropriate extra resources and assign them specific tasks. Because of the planning and training that are the core of the START system, agencies and individuals know what they are expected to do when they arrive at the scene. The triage portion of START, which is the focus of this training program, relies on making a rapid assessment (taking less than a minute) of every patient, determining which of four categories patients should be in, and visibly identifying the categories for rescuers who will treat the patients.

Triage
The concept of triage is simply a method of quickly identifying victims who have immediately life-threatening injuries AND who have the best chance of surviving so that when additional rescuers arrive on scene, they are directed first to those patients.

Golden hour
The Golden hour refers to a concept that a trauma patient has the best chance for recovery if he or she can get to Advanced Trauma Life Support within one hour from the time of the injury. Obviously, those who are most seriously injured have the least time. When there are multiple victims, the Golden Hour can slip away because there arent enough rescuers for each victim. The START triage system relies on making a rapid assessment (taking less than a minute) of every patient, determining which of four categories patients should be in, and visibly identifying the categories for rescuers who will treat the patients. If you are the initial START rescuer, you DO NOT stop to do other than the most basic intervention. If you attempt to treat every patient before completing the triage, you cannot assess the rest of the patients and identify the top priorities. Remember that in a serious disaster, it is unlikely that you can save all the victims. The important thing is to work together with the other rescuers to save as many patients as

you can. START gives you the best chance of doing that.

The Tags...
Managing a scene with multiple patients can be frustrating and difficult. These steps will help you systematically triage and treat each patient. They also will give you information to help you determine the number and types of additional rescue personnel, equipment and transport vehicles you need to manage the crisis. It is important to recognize that you are not abandoning patients by assigning them the Delayed or Minor categories. They are being directed to the rescuers or facilities that have been assigned to handle those patients. The rescuers who are managing the Minor and Delayed patients will be reassessing them and will re-assign them to the Immediate category if they deteriorate.

Red - Immediate
When you arrive at an emergency where someone has used the START triage system, your first priority is to find and treat the IMMEDIATE patients. These patients are at risk for early death - usually due to shock or a severe head injury. They should be stabilized and transported as soon as possible.

Yellow - Delayed
Patients who have been categorized as DELAYED are still injured and these injuries may be serious. They were placed in the DELAYED category because their respirations were under 30 per minute, capillary refill was under 2 seconds and they could follow simple commands. But they could deteriorate. They should be reassessed when possible and those with the most serious injuries or any who have deteriorated should be top priorities for transport. Also, there may be vast differences between the conditions of these patients. Consider, for example, the difference between a patient with a broken leg and one with multiple internal injuries who is compensating initially. The second patient will need much more frequent re-assessment.

Green - Minor
Patients with MINOR injuries are still patients. Some of them may be frightened and in pain. Reassure them as much as you can that they will get help and transport as soon as the more severely injured patients have been transported. Any of these patients also could deteriorate if they had more serious injuries than originally suspected. They should be reassessed when possible.

Navy - Deceased
Those patients determined nonviable should be left in place unless this hampers the efforts of caring for others

The Principle...
The START flowchart is a quick way to learn the system. As you move through the patient assessment, sequentially evaluate the current status for RESPIRATIONS, PERFUSION, and MENTAL STATUS (RPM). You either assign the victim a classification or you move to the next level of the flowchart.

The chart above can be simplified to this...

START Triage Assess, Treat, (use bystanders) When you have a color STOP - TAG - MOVE ON Move Walking Wounded NO RESPIRATIONS after head tilt Breathing UNCONSCIOUS but

Respirations - over 30

M I N O R

D E C E A S E D

I M M E D I A T E

Perfusion Capillary refill >2 or NO RADIAL PULSE Control bleeding Mental Status Unable to follow simple commands D E L A Y E D Otherwise REMEMBER: Respirations - 30 Perfusion - 2 Mental Status - Can Do

The How To...

Remember this simple formula to guide your START assessment. RPM stands for RESPIRATION PERFUSION MENTAL STATUS Sequentially use this assessment system for every patient.

Entering the scene

As always, make sure the scene is safe for you to enter. If it is not, wait until it has be made safe. Next, ask those who are not injured or who have only minor injuries to identify themselves. Tag those with minor injuries as MINOR.

Minor Injuries - Tag MINOR

Ask several uninjured victims to stay close to assist you, direct the others to a designated spot away from the immediate scene to wait for additional personnel. Respiration First, determine if the patient is breathing. If yes, immediately check the respiration rate. If not, reposition the patient. If the patient does not start breathing spontaneously, DO NOT start CPR.

Patient not breathing after repositioning head- Tag DECEASED

Move on to the next victim. (Not starting CPR may be the hardest thing you must do at a multiple casualty scene, but if you perform CPR on one patient, many others may die.) C-spine injury You will have to position the airway without manually stabilizing the cervical spine. This is counter to what you have been taught and may result in worsening a cervical spine injury. But if you dont reposition the victim immediately, the person will die in the field. You wont have the personnel to carefully stabilize the C-spine and you cant afford to let other victims die while you take time to do it yourself. If the patient begins breathing spontaneously after repositioning, tag the person IMMEDIATE and move on. If necessary, ask an uninjured victim to help maintain the open-airway position.

Patient begins breathing after repositioning the head - Tag IMMEDIATE

If the victim is breathing when you approach, but has a respiratory rate of more than 30, tag IMMEDIATE and move on. Dont take time to formally count the respirations. If the rate seems too fast, tag the victim IMMEDIATE and move on.

Respiratory rate greater than 30 - Tag IMMEDIATE

Perfusion If you can feel a radial pulse, move on to the Mental Status assessment. If you cant feel it, tag the patient IMMEDIATE, have an uninjured victim put direct pressure on any visible, serious bleeding and move on to the next patient.

No Radial Pulse - Tag IMMEDIATE

Next check for capillary refill. If capillary refill is more than 2 seconds, tag the patient IMMEDIATE, have an uninjured victim put direct pressure on any visible, serious bleeding and move on to the next patient.

Capillary refill greater than 2 seconds - Tag IMMEDIATE

If capillary refill is less than 2 seconds, move to MENTAL STATUS. M ental Status If the victim is unconscious or cant follow simple commands, tag them IMMEDIATE and move on to the next victim.

Unconcious or cannot follow commands - Tag IMMEDIATE

If the victim can follow simple commands, tag them DELAYED and move on to the next victim.

Can't follow simple commands - Tag DELAYED

Those who are responsible for organizing the operations of a multi-casualty incident are probably familiar with the Incident Command System (ICS). START was designed to work within the ICS. While it is not our intent to teach the Multi-Casualty Branch of the Incident Command system in these few pages, we did want to give you an overview and share some of our philosophies with you. Every area has its unique situations, resources and operational procedures that need to be considered when developing a plan. We hope this will help you to see what needs to be done to mange a successful multi-casualty incident.

A Management Philosophy
When the first units arrive at a multi-casualty incident, they are certainly going to be overwhelmed. There is a temptation to set up the management levels of the organization first, so the operational levels will have supervision when they are assigned. To do this, most organizations have to use personnel from the first or second wave of responding resources. This removes them from the triage / transportation / treatment provider role, creating a delay in getting patients to the hospital. After 10 to 20 minutes, its a sad sight to see many rescuers in ICS vests, setting up their operations and no one attending to the victims. Remember that it is not necessary to assign mid-management positions until the maximum span of control is exceeded. An incident commander can easily handle 5 to 7 direct reporting positions before an Operations Chief or medical group supervisor is needed. Assigning your first arriving operational units to hands-on functions as much as possible will speed up your ability to triage, transport and treat your patients. This is referred to as the bottom up approach to ICS. If you think about the things that need to be done before you can transport a patient, it becomes clear where you need to assign your initial resources. Before you can send a patient to a hospital, you must have an ambulance available and get a destination from an area coordinator. Before you can get a destination, you need to know how many of what category of patients are loaded in the ambulance. Before you can identify what category a patient is in, they must be tagged and carried to the ambulance loading area. Before they can be tagged, they must be triaged.

1. 2. 3. 4.

Take It From The Top

Lets work from the beginning and assign our resources in a sequential order. For the purpose of focusing on the medical aspects of a multi-casualty incident, well assume there are no other life threatening factors such as fire, heavy rescue or hazardous material releases. If there are, of course they must be considered.

Triage
Since nothing much can happen until patients get tagged, it makes sense to assign the first company to triage. The company officer can assume the role of triage unit leader, assess the situation and order the necessary resources while the other members are performing START triage. Something is immediately happening. The first rescuers on the scene are taking an action that must precede all others. How many rescuers need to be assigned to triage? Of course, that depends on how many patients you have, but keep this in mind. It will take no longer than one minute to triage each patient, and probably less time. That means two rescuers will triage two patients per minute. In ten minutes, 20 patients will have been triaged. The question for you is, how fast can I move these patients to waiting ambulances and can my triage team stay ahead of the litter bearers? It does little good to have a lot of patients tagged if there is no one to move, transport or treat them.

The Movement of Patients

The next major consideration is how to move your patients to either ambulances, or if none are available, to treatment areas. This will require methods to carry them (flats, stretchers, backboards) and personnel (litter bearers). Litter bearers are grouped as Litter Teams and report to the Triage Unit Leader for assignments. The preferred number of people for a litter team is four, however it can be done by three in most cases. Plan to assign many of your initial resources to this function or you will get way behind the curve. Be sure the equipment you use to carry patients arrives with the personnel. Having a stash of equipment somewhere that may not arrive until later will have a devastating effect on the speed of your operation. As the equipment gets used, it must be replaced. Have a plan that will keep you in carrying devices, such as, having the ambulance leave backboards to replace the ones they are taking with patients.

Transportation
Transportation will have to be organized early if you dont want to end up with a mess that cant be straightened out. An ambulance staging and loading area has to be established and personnel assigned to keep it organized. This function is managed by the Ground Ambulance Coordinator. The additional staff required should include someone to manage ambulance staging and another assist with documentation.

Patient Destination Coordinator

Coordinating patient destination is one of the more complicated functions. In areas where there are more than one hospital, its imperative that we not relocate the disaster to the closest hospital. A system for the distribution of patients to area hospitals must be established in advanced and utilized properly by emergency personnel. The Medical Communications Coordinator performs this function by notifying the Area Coordinator of the incident and setting the system into action. Since most systems of this nature take

time to get organized, notification should be given as soon as possible so destinations are available when the first patient is ready for transport.

Keep Things Moving

Someone needs to direct the litter teams where to go with their patients. This is the job of the Treatment Dispatch Manager, the traffic cop for the movement of patients. In the beginning, patients can be moved directly out of triage and into waiting ambulances, if available. Once the litter teams can move patients faster than they can be loaded, they will have to go to treatment areas and be sent from there to loading. Its the Treatment Dispatch Manager who keeps this organized and moving.

In Summary
There are whole courses devoted to this subject. It will take a lot of planning, training, and multi-agency coordination if you want it to go well. Although multi-casualty incidents are not that frequent, it is well worth the energy to prepare for them. These principles can be applied on a smaller scale to the more frequent multiple patient (3-12) incidents. The more these concepts are used in the routine setting, the better they will be applied to the larger incidents.

(Refrence: http://emsstaff.buncombecounty.org/inhousetraining/start/start_overview1.htm)

Table of Contents
(Reference: Brunner and Suddarth's Textbook of Medical-Surgical Nursing 12th Edition- Suzanne C. O'Connell Smeltzer, Brenda G. Bare, Janice L. Hinkle, Ph.D., Kerry H. Cheever, Ph.D.) START
(Simple Triage and Rapid Treatment) (Untitled) Triage (Untitled) Golden hour (Untitled) The Tags... (Untitled) Red - Immediate (Untitled) Yellow - Delayed (Untitled) Green - Minor (Untitled) Navy - Deceased The Principle... The How To... (Untitled) Entering the scene (Untitled) Minor Injuries - Tag MINOR (Untitled) Patient not breathing after repositioning head- Tag DECEASED (Untitled) Patient begins breathing after repositioning the head - Tag IMMEDIATE (Untitled) Respiratory rate greater than 30 - Tag IMMEDIATE No Radial Pulse - Tag IMMEDIATE Capillary refill greater than 2 seconds - Tag IMMEDIATE Unconcious or cannot follow commands - Tag IMMEDIATE Can't follow simple commands - Tag DELAYED (Untitled) A Management Philosophy

3 4
4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 8

(Untitled) Take It From The Top (Untitled) Triage (Untitled) The Movement of Patients (Untitled) Transportation (Untitled) Patient Destination Coordinator (Untitled) Keep Things Moving (Untitled) In Summary

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