1.23.17.triage umcb trauma conference 2014.hinchey v … annual meeting... · – triage)sieve) –...
TRANSCRIPT
Priori%zing Priority Pa%ents: Tools for MPI Triage
Paul R. Hinchey MD MBA Chief Opera%ng Officer Medical Opera%ons
Medical Director Na%onal Associa%on of EMTs
Plan
• What are the different triage systems?
• Which is the most accurate?
• Which one should we be using?
• Are these the right ques,ons?
Mul%-‐pa%ent incident is one which generates more pa%ents than
available resources can manage using rou%ne procedures. –Virginia Office of EMS
MPI: What are we talking about
• Discrete event which creates a rela%vely fixed number of pa%ents in a short period of %me
• Exceeds readily available resources and use of rou%ne procedures
• NOT an evolving event that con%nues to produce pa%ents over an extended %meframe
What are the different triage systems?
• MASS – Move-‐Assess-‐Sort-‐Send
• Sacco • START/Jump-‐START
– Triage Sieve – CareFlight
• SALT
The strength of opinion/complexity of the process seems inversely related to the likelihood that the author has ever been on the front line of managing a MPI
Perfec%on is the enemy of excellence
Airway
Breathing
Circula7on Disability
Triage Sieve
CareFlight Triage
NB: No “respiratory” component
SALT
• Retrospec%ve review 1,144 admi\ed trauma pa%ents transported to 2 trauma centers
• Ability of triage systems to detect severity (immediate) by physiologic and Baxt criteria: – Non-‐ortho opera%ve interven%on <6hrs – Fluid resuscita%on >1000mL or transfusion – Invasive CNS monitoring or posi%ve CT – Airway procedure or ven%la%on – Decompression of tension PTX
Garner et al Ann Emerg Med 2001
Conclusion: START, Modified START and CareFlight had similar
sensi%vi%es but CF had be\er specificity. Non-‐disaster pa%ent popula%on limits interpreta%on for MCI.
• 22 students triaged 25 virtual pa%ents • SALT vs SMART (START) – Ini%al SALT – 3 mos washout – START
• SALT v START – Accuracy 70% v 93% (p=0.0001) – Overtriage 6.8% v 1.8% (p=0.0015) – Undertriage 23.2% v 5.1% (p=0.0001) – Time 21m 3s v 11m 59s (p=0.0001)
European Jrnl Emerg Med 2011
• Evaluated triage aner train crash in 2003 • 148 records from 14 hospitals • Compared prehospital triage with outcome by modified Baxt criteria
Kahn et al Ann Emerg Med 2009
Triage Breakdown
• Field vs Hospital – Red 22 (14.9%) vs 2 (1.3%) – Yellow 68 45.9%) vs 26 (17.6%) – Green 58(72.9%) vs 120 (39.2%)
• Performance – Under triage 3 (2%) – Over triage 79 (53%) – Correct 66 (45%)
Conclusion: Poor agreement between START and outcome
criteria.
START ensured acceptable under triage at expense of over triage but was useful in priori%zing transport of the most cri%cally
injured first.
“Gold Standard” 23 Criteria
Lerner et al. Disaster Med Public Health Prep. 2011
What do we REALLY
need from a triage tool?
What do we need?
• Must be simple and FAST • Iden%fy and separate large numbers • Easy to recall despite infrequent use • Have objec%ve decision rules • Include means of iden%fica%on
MPI triage is NOT rou%ne triage
• ACSCOT accepts rou%ne trauma over triage between 30% and 50%
• Why do we expect MPI triage to be BETTER than our daily rou%ne?
• MPI triage is not “one and done”
• MPI triage is more than a pa%ent rou%ng tool
Ini%al triage is about making order out of chaos as quickly as possible
MPI Management Paradigm
• Our model is scene assessment with EMS distribu%on of pa%ents
• Control and containment is essen%al – Vic%ms must have a sense of purposeful ac%on • Only 54% of vic%ms arrive at the hospital having been transported by EMS
• Success is determined in the first 10 minutes
The goal of ini%al triage is….
• CONTROL… • Who to a\end to FIRST • Lifesaving interven%on • Rapid assessment – re-‐assessment • Determina7on of resource needs • Who to move and in what order
…it is NOT just accuracy
So which triage system should we be using?
“That which is not simple simply won’t be done”
-‐Magen David Adom
My Choice
• Simple and fast
• Sorts large numbers quickly
• Objec%ve decision rules
• Follows primary assessment
Familiarity alone is insufficient
• 109 EMS providers complete pre/post test – 20 ques%on test
• Educa%onal interven%on reviewing triage • Pre-‐test avg 55%; post-‐test 76% (p<0.001) • 1 mos later – EMT-‐P and PHRN – avg 74% – EMT – avg 68% (p<0.01)
A Rant: MCI “Training”
• Should be short and outcome oriented • Scenarios should be simple and based on what you are likely to see
• Test leadership and frontline decision making • Focus on basics that apply to ALL types of MPI events and prac%ce those frequently
• Large scale prac%ce has limited value
Kudos to Boston EMS
• The Boston Marathon bombing changed the landscape
• Pre-‐staging of assets was key to the success of the MCI
• Taught us all the importance of a plan
Pre-‐planning the MPI
“Victorious warriors win first and then go to war, while defeated warriors go to war first and then seek to win.”
-‐ Sun Tzu
Special Events in the ATX
Major Events • Aus%n City Limits Music
Fes%val • Aus%n Marathon • Formula One • ESPN X Games • South by Southwest
6th Street District • Halloween • New Year’s Eve • Texas Relays • Mardi Gras • ROT Rally • UT Football • Every Thurs-‐Sat Night
Pre-‐planning the Event
• Mini-‐City Communica%ons “Geo-‐Fencing”
• Staging of Resources
• Access Routes
• Table Top Exercises
Table Top Exercise
• Performed threat analysis • Chose two most likely • Created table top scenarios • Prac%ced with command staff – Timed inserts for realism – Simulated decision making
JIT Training: Daily Event Briefing
• Review – highest risk events – rou%ng and closures
• Assign MCI roles • Review START triage
– Triage packs – Team leads with SMART Command Boards
• Evacua%on Route
40
Desired Outcomes
Control – Establish scene command/presence Ini%al assessment (head count) Resource request Triage and life saving interven%ons Staging/hospital resources Des%na%on decision
On March 13th 2014 pre-‐event planning was put to the test….
Incident Map
Pa,ent Triage Categories and Disposi,on Pt Age Gender Primary Complaint Pt Disposition Unit RCSQL_tdate Transport Code Facility Name
20 Female Death on Scene Dead on Scene DC05 2014-03-13 Black DOS
25 Male Death on Scene Dead on Scene DC05 2014-03-13 Black DOS
24 Female Injury - Multiple Sites Treated-Transported by EMS DM08s 2014-03-13 DELTA Code-3 UMC- Brackenridge
21 Female Cardiac Arrest Treated-Transported by EMS M17 2014-03-13 ECHO Code 3 UMC- Brackenridge
29 Male Unspecified Condition Treated-Transported by EMS M06b 2014-03-13 DELTA Code-3 UMC- Brackenridge
26 Male Injury - Multiple Sites Treated-Transported by EMS DM09s N/A DELTA Code-3 UMC- Brackenridge
~20 Male Injury - Multiple Sites Treated-Transported by EMS DM09s N/A DELTA Code-3 UMC- Brackenridge
18 Female Injury - Multiple Sites Treated-Transported by EMS M03 2014-03-13 DELTA Code-1 St David's Hospital
18 Female Injury - Multiple Sites Treated-Transported by EMS M03 2014-03-13 CHARLIE St David's Hospital
19 Male Injury - Multiple Sites Treated-Transported by EMS M06B N/A CHARLIE South Austin Hospital
29 Female Injury - Extremity Lower Treated-Transported by EMS M06b 2014-03-13 CHARLIE South Austin Hospital
20 Male Injury - Head Treated-Transported by EMS DM08s 2014-03-13 CHARLIE St David's Hospital
39 Male Unspecified Condition Treated-Transported by EMS M33 2014-03-13 BRAVO St David's Hospital
20 Female Injury - Head Treated-Transported by EMS M03 2014-03-13 BRAVO South Austin Hospital
19 Female Injury - Extremity Lower Treated-Transported by EMS M13 2014-03-13 BRAVO South Austin Hospital
29 Male Injury - Extremity Lower Treated-Transported by EMS M03 2014-03-13 BRAVO South Austin Hospital
20 Female Injury - Extremity Lower Treated-Transported by EMS M33 2014-03-13 ALPHA South Austin Hospital
20 Male Injury - Multiple Sites Treated-Transported by EMS M13 2014-03-13 BRAVO South Austin Hospital
18 Female Injury - Extremity Lower Treated-Transported by EMS M13 2014-03-13 BRAVO South Austin Hospital
19 Female Injury - Extremity Lower Treated-Transported by EMS M03 2014-03-13 BRAVO South Austin Hospital
24 Female Injury - Multiple Sites Treated-Transported by EMS M12 2014-03-13 BRAVO South Austin Hospital
29 Male Injury - Extremity Lower Treated-Transported by EMS M33 2014-03-13 ALPHA South Austin Hospital
20 Male Injury - Extremity Upper Treated-Transported by EMS M33 2014-03-13 ALPHA South Austin Hospital
21 Female Injury - Multiple Sites Treated-Transported by EMS M12 2014-03-13 BRAVO South Austin Hospital
17 Female Injury - Extremity Lower Treated-Transported by EMS M13 2014-03-13 BRAVO South Austin Hospital
Final Disposi,on of Vic,ms
• 23 total pa)ents were transported – 5 Red – UMC Brackenridge Hospital – 4 Yellow – St. David’s Hospital – 1 Yellow – South Aus7n Hospital – 13 Green – South Aus7n Hospital – 2 Black – DOS on scene (11th/Red River Intersec7on)
• All reds were off the scene in 15:20 • All yellows were off the scene in 21:27
Take Away
• Accurate predic%on of severity is not the sole purpose of MPI triage tools so expecta%ons should not be based on rou%ne prac%ce
• To be effec%ve a triage system should be simple, fast, and based on the familiar
• Performance is likely similar so cri%cal element is frequent PRACTICE and PLANNING targeted at likely events
