Wesleyan University- PhilippinesMabini Extension, Cabanatuan City

NCM 106: Care of Clients with Problems in CellularAberrations, 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 routineof the ED, triage is used to sort patients into groups based on the severity of their healthproblems and theimmediacy with which these problems must be treated. Hospital EDs use various triage systems with differing terminology,but all share thischaracteristic of a hierarchy based on the potential for loss of life. A basic and widelyused system uses three categories: emergent, urgent, and non-urgent (Berner, 2001).Emergent patients have the highest priority—their conditions are life threatening, and theymust be seen immediately. Urgent patients have serious health problems, but notimmediately lifethreatening ones; they must be seen within 1 hour. Non-urgent patientshave episodic illnesses that can be addressed within 24 hours without increased morbidity

(Berner, 2001). A fourth, increasingly used class is “fast-track.” These patients requiresimple first aid or basic primary care. They may be treated in the ED or safely referred toa clinic or physician’s office. Triage is an advanced skill; emergency nurses spend many hours learning to classifydifferent illnesses and injuries to ensure that patients most in need of care do not wait toreceive it. Protocols may be followed to initiate laboratory or x-ray studies fromthe triage area while the patient waits for a bed in the ED. Collaborative protocols aredeveloped 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, neurologicassessment findings, and diagnostic data if necessary. Routine ED triage protocols differ significantly from the triage protocols used in disastersand mass casualty incidents (field triage). Routine hospital triage directs all availableresourcesto 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 mostpeople possible. This distinction affects triage decisions.

(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.)

2. Updated American Heart Association 2010-2011Cardiopulmonary ResuscitationAmerican Heart Association 2010-2011 New CPR GuidelinesThe American Heart Association announced today new recommendations for the wayCPR is performed. The small change could make a big difference in the lives of peoplesuffering from cardiac arrest, the organization says. For nearly 40 years, CPR guidelineshave trained people to follow these simple A-B-C instructions—tilt the victim's head backto 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 ofchest 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 andresponding emergency personnel should now follow a C-A-B process—begin with chestcompression, then move on to address the airway and breaths. This change applies toadults, children, and babies, but does not apply to newborns. The revision is a part of the 2010 emergency cardiovascular care report published by theAHA., an organization that reviews its guidelines every five years, taking into account newscience and literature. Although the changed procedure will take some time to reach whatMonica 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 assoon as possible to their training network, medical staffs, and first-responders. "Thesooner chest compressions are started, the more likely there will be a betteroutcome," Kleinman announced. "Studies performed in labs as well as largepopulationstudies have shown that people do better if they get chest compressions within fourminutes."(Reference: 184.173.230.155/~lrfpdor/PDF/AHA-2011-cpr-guidelines.pdf)

3. Research: S.T.A.R.T. treatment (simple triage and rapidtreatment)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 STARTcolor 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 randomlychosen 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. Pearsoncorrelation 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, witha Pearson correlation of 0.969.CONCLUSIONS:The START method is a simple technique used to triage quickly a large number of patients. Healthcare providers canundergo just-in-time training to learn this technique and use it effectively. The START colors also imply a correlation withthe 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 handleemergencies. You know how to quickly assess a patient and intervene. But even the bestemergency provider is easily overwhelmed when there are multiple patients who all needemergency care.The START system, developed by Hoag Hospital and the Newport Beach FireDepartment (Newport Beach, CA), helps prepare emergency personnel to quicklyorganize their resources to handle multi-casualty emergencies. Using START, variousagencies and individuals assume predetermined roles in managing the emergency, on-scene personnel quickly evaluate the situation and call in the appropriate extra resourcesand assign them specific tasks. Because of the planning and training that are the core ofthe START system, agencies and individuals know what they are expected to do whenthey arrive at the scene.The triage portion of START, which is the focus of this training program, relies on makinga rapid assessment (taking less than a minute) of every patient, determining which of fourcategories patients should be in, and visibly identifying the categories for rescuers whowill treat the patients.

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

Golden hourThe Golden hour refers to a concept that a trauma patient has the best chance forrecovery if he or she can get to Advanced Trauma Life Support within one hour from thetime 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 aren’tenough rescuers for each victim. The START triage system relies on making a rapid assessment (taking less than aminute) of every patient, determining which of four categories patients should be in, andvisibly 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 basicintervention. If you attempt to treat every patient before completing the triage, you cannotassess 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. Theimportant 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 willhelp you systematically triage and treat each patient. They also will give you informationto help you determine the number and types of additional rescue personnel, equipmentand transport vehicles you need to manage the crisis.It is important to recognize that you are not abandoning patients by assigning them theDelayed or Minor categories. They are being directed to the rescuers or facilities thathave been assigned to handle those patients. The rescuers who are managing the Minorand Delayed patients will be reassessing them and will re-assign them to the Immediatecategory if they deteriorate.

Red - ImmediateWhen 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 riskfor early death - usually due to shock or a severe head injury. They should be stabilizedand transported as soon as possible.

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

Green - MinorPatients with MINOR injuries are still patients. Some of them may be frightened and inpain. Reassure them as much as you can that they will get help and transport as soon asthe more severely injured patients have been transported. Any of these patients alsocould deteriorate if they had more serious injuries than originally suspected. They shouldbe reassessed when possible.

Navy - DeceasedThose patients determined nonviable should be left in place unless this hampers theefforts of caring for others

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

MINOR

Move Walking Wounded

DECEASED

NO RESPIRATIONS after head tilt

IMMEDIATE

Breathing butUNCONSCIOUS

Respirations - over 30

Perfusion Capillary refill> 2or NO RADIAL PULSEControl bleeding

Mental Status Unable tofollow simplecommands

DELAYED

Otherwise

REMEMBER:Respirations- 30Perfusion - 2Mental Status- Can Do

The How To...

Remember this simple formula to guide your START assessment. RPM stands for RESPIRATIONPERFUSIONMENTAL STATUSSequentially use this assessment system for every patient.

Entering the sceneAs always, make sure the scene is safe for you to enter. If it is not, wait until it has bemade 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 MINORAsk several uninjured victims to stay close to assist you, direct the others to a designatedspot away from the immediate scene to wait for additional personnel. RespirationFirst, 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, DONOT start CPR.

Patient not breathing after repositioning head- Tag DECEASEDMove on to the next victim.(Not starting CPR may be the hardest thing you must do at a multiple casualty scene, butif you perform CPR on one patient, many others may die.) C-spine injuryYou will have to position the airway without manually stabilizing the cervical spine. This iscounter to what you have been taught and may result in worsening a cervical spine injury.But if you don’t reposition the victim immediately, the person will die in the field. You won’thave the personnel to carefully stabilize the C-spine and you can’t afford to let othervictims die while you take time to do it yourself.If the patient begins breathing spontaneously after repositioning, tag the personIMMEDIATE and move on. If necessary, ask an uninjured victim to help maintain theopen-airway position.

Patient begins breathing after repositioning the head - TagIMMEDIATEIf the victim is breathing when you approach, but has a respiratory rate of more than 30,tag IMMEDIATE and move on. Don’t take time to formally count the respirations. If therate seems too fast, tag the victim IMMEDIATE and move on.

Respiratory rate greater than 30 - Tag IMMEDIATEPerfusionIf you can feel a radial pulse, move on to the Mental Status assessment.If you can’t feel it, tag the patient IMMEDIATE, have an uninjured victim put directpressure on any visible, serious bleeding and move on to the next patient.

No Radial Pulse - Tag IMMEDIATENext check for capillary refill. If capillary refill is more than 2 seconds, tag the patientIMMEDIATE, have an uninjured victim put direct pressure on any visible, serious bleedingand move on to the next patient.Capillary refill greater than 2 seconds - Tag IMMEDIATEIf capillary refill is less than 2 seconds, move to MENTAL STATUS.Mental StatusIf the victim is unconscious or can’t follow simple commands, tag them IMMEDIATE andmove on to the next victim.Unconcious or cannot follow commands - Tag IMMEDIATEIf the victim can follow simple commands, tag them DELAYED and move on to the nextvictim.Can't follow simple commands - Tag DELAYEDThose who are responsible for organizing the operations of a multi-casualty incident areprobably familiar with the Incident Command System (ICS). START was designed to workwithin the ICS. While it is not our intent to teach the Multi-Casualty Branch of the IncidentCommand system in these few pages, we did want to give you an overview and sharesome of our philosophies with you. Every area has its unique situations, resources andoperational procedures that need to be considered when developing a plan. We hope thiswill 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 beoverwhelmed. There is a temptation to set up the management levels of the organizationfirst, 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 respondingresources. This removes them from the triage / transportation / treatment provider role,creating a delay in getting patients to the hospital. After 10 to 20 minutes, it’s a sad sightto see many rescuers in ICS vests, setting up their operations and no one attending to thevictims.Remember that it is not necessary to assign mid-management positions until the maximumspan of control is exceeded. An incident commander can easily handle 5 to 7 directreporting positions before an Operations Chief or medical group supervisor is needed.Assigning your first arriving operational units to hands-on functions as much as possiblewill speed up your ability to triage, transport and treat your patients. This is referred to asthe bottom up approach to ICS. If you think about the things that need to be done before you can transport a patient, itbecomes clear where you need to assign your initial resources.

1. Before you can send a patient to a hospital, you must have an ambulance available andget a destination from an area coordinator.

2. Before you can get a destination, you need to know how many of what category ofpatients are loaded in the ambulance.

3. Before you can identify what category a patient is in, they must be tagged and carried tothe ambulance loading area.

4. Before they can be tagged, they must be triaged.

Take It From The TopLet’s 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, we’llassume there are no other life threatening factors such as fire, heavy rescue or hazardousmaterial 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 thefirst 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 areperforming START triage. Something is immediately happening. The first rescuers on thescene are taking an action that must precede all others.How many rescuers need to be assigned to triage? Of course, that depends on howmany patients you have, but keep this in mind. It will take no longer than one minute totriage each patient, and probably less time. That means two rescuers will triage twopatients per minute. In ten minutes, 20 patients will have been triaged. The question foryou is, how fast can I move these patients to waiting ambulances and can my triage teamstay ahead of the litter bearers? It does little good to have a lot of patients tagged if thereis no one to move, transport or treat them.

The Movement of PatientsThe next major consideration is how to move your patients to either ambulances, or ifnone are available, to treatment areas. This will require methods to carry them (flats,stretchers, backboards) and personnel (litter bearers). Litter bearers are grouped asLitter Teams and report to the Triage Unit Leader for assignments. The preferred numberof people for a litter team is four, however it can be done by three in most cases. Plan toassign 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 astash of equipment somewhere that may not arrive until later will have a devastating effecton the speed of your operation. As the equipment gets used, it must be replaced. Have aplan that will keep you in carrying devices, such as, having the ambulance leavebackboards to replace the ones they are taking with patients.

Transportation Transportation will have to be organized early if you don’t want to end up with a mess thatcan’t be straightened out. An ambulance staging and loading area has to be establishedand personnel assigned to keep it organized. This function is managed by the GroundAmbulance Coordinator. The additional staff required should include someone to manageambulance staging and another assist with documentation.

Patient Destination Coordinator Coordinating patient destination is one of the more complicated functions. In areas wherethere are more than one hospital, it’s imperative that we not relocate the disaster to theclosest hospital. A system for the distribution of patients to area hospitals must beestablished in advanced and utilized properly by emergency personnel. The MedicalCommunications Coordinator performs this function by notifying the Area Coordinator ofthe 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 areavailable when the first patient is ready for transport.

Keep Things MovingSomeone needs to direct the litter teams where to go with their patients. This is the job ofthe Treatment Dispatch Manager, the traffic cop for the movement of patients. In thebeginning, patients can be moved directly out of triage and into waiting ambulances, ifavailable. Once the litter teams can move patients faster than they can be loaded, theywill have to go to treatment areas and be sent from there to loading. It’s the TreatmentDispatch Manager who keeps this organized and moving.

In SummaryThere are whole courses devoted to this subject. It will take a lot of planning, training, andmulti-agency coordination if you want it to go well. Although multi-casualty incidents arenot that frequent, it is well worth the energy to prepare for them. These principles can beapplied on a smaller scale to the more frequent multiple patient (3-12) incidents. The morethese concepts are used in the routine setting, the better they will be applied to the largerincidents.

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

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

3

START 4(Simple Triage and Rapid Treatment) 4(Untitled) 4Triage 4(Untitled) 4Golden hour 4(Untitled) 4

The Tags... 5(Untitled) 5Red - Immediate 5(Untitled) 5Yellow - Delayed 5(Untitled) 5Green - Minor 5(Untitled) 5Navy - Deceased 5The Principle... 5The How To... 6(Untitled) 7Entering the scene 7(Untitled) 7Minor Injuries - Tag MINOR 7(Untitled) 7Patient not breathing after repositioning head- Tag DECEASED 7(Untitled) 7Patient begins breathing after repositioning the head - Tag IMMEDIATE 7(Untitled) 7Respiratory rate greater than 30 - Tag IMMEDIATE 7No Radial Pulse - Tag IMMEDIATE 8Capillary refill greater than 2 seconds - Tag IMMEDIATE 8Unconcious or cannot follow commands - Tag IMMEDIATE 8Can't follow simple commands - Tag DELAYED 8(Untitled) 8A Management Philosophy 8

(Untitled) 8Take It From The Top 9(Untitled) 9Triage 9(Untitled) 9The Movement of Patients 9(Untitled) 9Transportation 9(Untitled) 9Patient Destination Coordinator 9(Untitled) 10Keep Things Moving 10(Untitled) 10In Summary 10