Creating Realistic Training Every Day -- Triage Tuesday!

Every day that passes is a missed opportunity to create positive change in one's organization. There are many ways to involve crews in training that can offer hidden benefits. In this article, I will share one department's method for involving crews to prepare them for triaging patients in a mass casualty incident (MCI). First, we need to discuss the basics.

Mass casualty incidents are a rare occurrence for any organization. When they do occur, even the simple tasks of locating triage tags and correctly triaging patients can prove to be daunting. Although training can be provided yearly, when such an incident occurs it may be difficult to recall proper use of triage tags and the START (Simple Triage and Rapid Transport) triage protocol.

Triage Tags

Triage tags are a simple tool, and this concept often leads one to underestimate the value and importance of the tags. Additionally, one needs to examine their own system to determine if one type of tag is being used or if there are multiple styles of tags. In my system, we had five uniquely different styles of triage tags. Different tags can lead to confusion on the scene. If there are different types of tags, additional training will be required to ensure minimum competency levels on all tags.

There are a wide variety of triage tags on the market. The decision on the type your agency implements should include input from all those involved in your EMS system. Some key considerations for tags should include whether the tags have prompts to help responders conduct START and whether there is a visual queue to determine if a patient is contaminated.

When considering any type of event involving hazardous materials or bioterrorism, it is critical that all providers are keenly aware of key patient signs and symptoms that would indicate such an event. The acronym to remember is SLUDGEM, which reminds us of those classic presentations of Salivation, Lacrimation, Urination, Defecation, GI Distress, Emesis, and Miosis. It is rather easy to recall these while in a training class; however it may be difficult to recall at 2 a.m. with thirty screaming patients. Having the SLUDGEM criteria printed on the triage tag with check boxes ensures the information is recorded and not overlooked.

Another consideration will depend on whether your system is set up for a bioterrorism event. If Mark 1 auto injectors are part of your EMS/Fire system, one may want to have a location on the tag to note the number of injectors that have been administered to a patient. This information is vital because these medications need to be re-administered in a timely manner. This information needs to be part of the patient's immediate record as well as their permanent medical record at the receiving facility. That critical information could be quickly retrieved from a tag.

Collaboration

It is important that both prehospital and hospital personnel understand the importance of the tags. By introducing this information to the hospital based providers, the fire service takes a proactive approach in their EMS system. This also creates a seamlessly integrated system for triaging patients.

Surprisingly, many physicians and nurses may be unaware of the START criteria and its importance in a MCI. This provides an excellent forum to offer your training and services to hospital based providers. Explaining why a one-minute triage is a vital task in a prehospital setting may shed new light on your unique role as a healthcare provider.

Involving hospital staff will also open discussions to determine how the tags should be used when patients are admitted into their facility. The tags have critical information regarding patient care, such as vital signs and the possible administration of auto injectors. The time to determine how hospitals will use the tags is before a MCI occurs. One MCI that I was personally involved in had one hospital putting the triage tags in the patient's chart while another threw them away. Their staff was unaware of the importance of the tags and this event created the need for system-wide dialogue.

Deployment

Triage tags usually end up in a wide variety of locations from trauma bags to glove compartments. With some planning, a simple kit can be developed for rapid deployment when facing a MCI. Sioux Falls Fire Rescue created fanny packs that were purchased with the word TRIAGE silkscreened on it. Stocking it with tags, markers, gloves and airways helps create an inexpensive triage kit. Rather than tucking them into a compartment, the kits hang where they are in constant view of the firefighters and in the same location on all apparatus. Since the kits are not frequently used, a universal location decreases deployment time and more importantly lessens potential confusion.

Other Ideas

One of the key benchmarks in any MCI is to remove the most critical (immediate) patients off scene as soon as possible. Identifying these patients can be difficult, especially in low light situations when flashlights are required. One method, in addition to triage tags, is specialized bumper stickers. Having bumper stickers constructed from red reflective material allows them to be put directly on the immediate patients, as long as these do not compromise the patient. These really make immediate patients stand out in critical situations.

Another potential use for the stickers is for multi-auto crashes. When several different patients in various vehicles need to be extricated, the bumper stickers may be used to identify patients requiring priority extrication. The first units can use the stickers on the door to identify patients who require rescue immediately for incoming units that will be providing extrication.

Triage Tuesday

A simple method to increase the ability of crews to learn how to triage is to develop your own "Triage Tuesday." It allows the use of the mentioned ideas and concepts into an easy plan. The concept is simple, triage all patients every Tuesday. Some organizations use a similar idea, but possibly quarterly or biannually. However, with the uniqueness of fire departments including schedules, vacations, time-trades, and other disruptions create situations in which personnel may not use the tags for years at time. Triage Tuesday offers personnel the opportunity to use the tags regularly and become very familiar with them. It will offer crews valuable opportunities to develop their critical thinking ability. Finally, it provides the station officer a regular leadership moment to discuss MCI operations.

It may seem that one should only triage trauma patients, however in a MCI one can expect to see a wide range of patients. These patients can include elderly, middle aged patients with chest pain, respiratory distress, and even pediatrics. We often tend to focus on trauma, but including a diverse group of patients allows responders to develop their decision-making skills. With the exception of cardiac arrest and behavioral patients, every patient that is transported can be triaged. The crew can use their discretion when using tags on the patients depending on the various situations that may present on their arrival.

Triage Tuesday can not only assist prehospital providers, but also provide an excellent chance for healthcare providers in receiving hospitals to use the tags. They are also a key component of EMS and seeing the tags on a regular basis will offer the same training opportunities as those to prehospital providers. It also helps to develop a team concept and brings everyone to the table to discuss patient care.

Cost is not a major factor with such a program since many patients will not get transported and tagged. The amount spent can be well worth it since the training is system wide. It also allows for rotation of triage tag supplies as the tags may be updated.

Media

The following is an example of a media release that can be used to increase media exposure of your department. This is a tool you can use if the ideas in this article are implemented.

FIREFIGHTERS START TRIAGE TUESDAYS TO SAVE LIVES

My Home Town, USA, Oct 11, 2005:

All EMS/Fire personnel are trained to rapidly triage patients in mass casualty incidents. Patients are tagged and color-coded Green, Yellow or Red by their severity. Red patients are the most critical. "We train to triage and tag each patient in less than one minute," says EMS Chief Jim Sideras. "We practice those skills every Tuesday and we call it Triage Tuesday to ensure we can rapidly respond in a major emergency."

Our Fire Dept is now using bumper stickers to quickly identify trauma patients in mass casualty situations. "Identifying critically injured patients is a vital skill in a mass casualty incident. However it can be difficult with large numbers of patients," says Sideras. "We use the bumper stickers to ensure we don't miss any patients who need immediate transportation to a trauma center."

These special bumper stickers are made from red reflective material and say IMMEDIATE in large letters. The bumper stickers are put on trauma patients who meet trauma criteria, which identify these patients as needing immediate care and transportation.

Firefighters use specially designed Triage Fanny Packs that give them quick access to the tools they need in an emergency. This gives them the ability to triage patients in less than one minute.

This triage system is used across the country. It allows integration with departments throughout the country. In the event of a major disaster where other many departments are working together, the training allows integration between all organizations.

For more information, contact your local EMS Chief.

Conclusion

These ideas are simple, inexpensive, and offer both prehospital crews as well as hospital staff the opportunity to train on a regular basis. The time to begin to train and discuss how your department will operate in an MCI is well before such an event. These ideas offer your organization the opportunity to plan and dialog in preparation for a MCI. The public expectation is that the fire service can handle any emergency and Triage Tuesday offers another way to prepare your personnel to rise to any occasion.

For more information, please contact Jim Sideras at his email address: sideras@post.harvard.edu.

James Sideras (sa DARE us) is a Division Chief for Sioux Falls Fire Rescue. He is a 22-year veteran of SFFR and a registered nurse with a Masters of Science degree in nursing.

He received the Harvard University Fire Executive Fellowship and has also completed a Human Resources program at Cornell University. Currently in the National Fire Academy's Executive Fire Officer program, he has spoken at several national conferences on emergency medical topics.

Jim is a former intensive care burn nurse and a member of the National Association of EMS Physicians, Sigma Theta Tau International Honor Society of Nursing, the South Dakota Nurses Association and the South Dakota EMT Association.

He is also getting a Masters degree in Administration Studies through the University of South Dakota.

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