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Education/Training

Review Protocols and Tagging on Triage Thursdays

Perhaps you’ve heard of “Taco Tuesdays” or “Wacky Wednesdays.” For your training needs perhaps consider “Triage Thursdays.” This review of triage tags and procedures will help your personnel and crews practice their protocols in less stressful environments than a true MCI.

Background

The etymology of the word triage means to break into three pieces. Napoleon’s military surgeon, Dominique Jean Larrey, created the idea of an ambulance transport system, and the sorting was designed to decide who got evacuated from the battlefield fastest. The START triage method was developed by providers at Hoag Hospital and the Newport Beach Fire Department in California in the 1980s and has become widely adopted across the U.S. and parts of the world. START has EMS providers perform rapid assessment of patients, determining which of four categories patients should be in and identifying them by tag color for treatment.

There are many versions of triage used in the field: START, SALT, and Careflight, to name a few. Regardless of the system you use, a triage system should be employed when the patient count exceeds the ability of your unit to treat and/or transport with the personnel and resources on hand. Incident command should be established, and one provider should be designated as the triage officer and, using a triage tag (such as the START tag, pictured), conduct a rapid assessment of every patient based upon their respirations, perfusion, and mental status (RPM).

If the patient can follow commands and walk, they should be tagged green and asked to move to a designated area for later evaluation.

Respirations—If a patient has no respirations, the triage officer should reposition the head. If the patient does not spontaneously start to breathe, they should be tagged black. If the patient is breathing more than 30 or fewer than 8 times a minute, they should be tagged red.

Perfusion—If capillary refill on the patient takes more than two seconds, they should be tagged red.

Mental status—If the patient cannot follow commands, they should be tagged red. Christopher Strattner, EMT-P, an instructor for the National Center for Security and Preparedness in New York, suggests you ask the patient a simple math problem, such as, “What is 5+3?”, as the answers to typical questions such as “What is your name?” often cannot be quickly verified. If the person cannot follow commands or answer simple questions, they should be tagged red.

If a patient cannot move under their own power but has effective respirations, perfusion, and mental status, they should be tagged yellow and delayed.

Triage Thursdays Drill

Supplies needed—An adequate supply of triage tags that match your typical call volume for the shift; a pen or Sharpie marker.

Instructions—No doubt your agency uses a PCR or ePCR to document its calls and treatments. For the Triage Thursday drill, designate every Thursday (or any day of your choosing) as “triage day.” Every patient encounter will have you and your crew utilize the RPM triage assessment system and tag patients. You’ll continue your assessment and treatment as you usually do, but with the addition of the tag. When time and treatment permit, complete the triage tag areas along with your regular PCR/ePCR.

After the call review with your partners/crew/supervisor what your RPM results were, why you triaged the color you did, and discuss if others have different perspectives.

As an option, if local protocols and your dispatch center allow it, establish “EMS Command” on the radio (with prior notice and training) for each of the Triage Thursday calls and practice giving patient counts, probabilities of patient count escalation, numbers of red, yellow, green, and black tags, and transport decisions as you would at an actual MCI.

Final Thoughts

MCIs are generally a low-frequency, high-stress event. The more your team practices with triage protocols and tags, the more efficient and accurate they will be for the real thing.

While the article refers to “Triage Thursdays,” this truly can be done during any predetermined shift.

Use the calls as an opportunity to discuss other facets of effective MCI management, such as multiagency coordination, communications, command and division vests, color-coded tarps, ICS principles, and local hospital capacity.

References

Garner A, Lee A, Harrison K, et al. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med, 2001; 38(5): 541–8.

Khan K. Tabletop Exercise on Mass Casualty Incident Triage, Does It Work? Health Science Journal, 2018; (12)3: 566; http://www.hsj.gr/medicine/tabletop-exercise-on-mass-casualty-incident-triage-does-it-work.pdf.

Lee CW, McLeod SL, Van Aarsen K, et al. First responder accuracy using SALT during mass-casualty incident simulation. Prehosp Disaster Med, 2016 Apr; 31(2): 150–4.

Nakao H, Ukai I, Kotani J. A review of the history of the origin of triage from a disaster medicine perspective. Acute Med Surg, 2017 Jul 14; 4(4): 379–84.

Risavi BL, Salen PN, Heller MB, Arcona S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care, 2001 Apr–Jun; 5(2): 197–9.

Barry A. Bachenheimer, EdD, FF/EMT, is a frequent contributor to EMS World. He is a career educator and university professor, as well as a firefighter and member of the technical-rescue team with the Roseland (N.J.) Fire Department and an EMT with the South Orange (N.J.) Rescue Squad. He is also co-owner of Jump Bag Training Company, LLC. Reach him at barry@jumpbagtraining.com.

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