Proper Preparation for Mass Casualty Incidents

Written by: August Grace, MD (NUEM ‘24) Edited by: Andrew Rogers, MD, MBA (NUEM ‘22)
Expert Commentary by: Andra Farcas, MD (NUEM ‘21)

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Introduction

In the setting of trauma, most hospitals are adept at treating and managing patients with a variety of injuries. However, the ability of a hospital to handle a mass casualty incident (MCI) requires a completely different approach and, most importantly, adequate triage and pre-planning. An MCI is defined as “an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time [7].” MCI events can include anything from hurricanes, earthquakes, and other natural disasters to terrorism or other man-made situations that include the use of explosive or biological weapons, mass shootings, or dysfunction in modes of transportation (car, plane, train crash) [3]. Although this is just a short list of the possibilities, each hospital must prioritize its response preparedness to match the likelihood of events that it could receive. For example, as a major urban center, Chicago is more likely to encounter events such as mass shootings, biological terrorism, or explosive injuries. Mobile, Alabama, on the other hand, must have adequate preparation for hurricanes and floods [4]. This post will discuss a brief overview of hospital planning and operational setup with key elements of a disaster response from events that cause high numbers of blunt trauma, penetrating trauma, burns or crush injuries that may be seen following explosive events, mass shootings, or large scale motor vehicle collisions, to name a few. 

Casualty Planning & Staffing Considerations

Arguably the most important step in an MCI is the planning that occurs before a single patient is even seen. In most events, hospitals have communication with EMS personnel that are on scene allowing them to have some sort of estimation of the scale of the event and type of disaster encountered. If the mechanism and scale are appropriate, a properly planned disaster response should be initiated and set in motion a sequence of coordinated events. 

In creating a disaster response plan, the first step is the designation of the Disaster Medical Officer (DMO). This person should be the most senior ED attending physician and he/she oversees available hospital medical personnel and resources [1]. This person will have no role in patient care and instead will be in charge of all ED operations, delegating tasks, and problem solving issues that arise in the future. 

The first task of the DMO is to get help and get it now. Approximately half of all casualties will arrive at the hospital within a one hour window, with 50-80% arriving within 90 minutes. Time begins after the first patient arrives at the hospital [8]. Therefore, getting the appropriate staff to the hospital as quickly as possible is vital to saving lives. How much staff is needed? This can be gauged by the type of disaster encountered and with assistance from EMS personnel at the scene. A five-car motor vehicle collision (MVC) will not require as much additional staff as a collapsed high rise building. The DMO will delegate the task of calling available staff to maximize the number of staff present in the ED and hospital. Contacting surgeons, scrub techs, anesthesiologists, and nurses to get as many ORs operational is invaluable to saving lives. 

Continuous staffing adjustments can be monitored and made by using the casualty predictor tool (Figure 2). When in doubt, it is better to have more staff available than needed. To reiterate, the most important part of any disaster situation is to GET HELP.

Triage/ED Setup

Once the process is underway for increasing the level of resources available, the next step is hospital setup and triage. The most important part of this step is creating enough space to allow for the massive influx of patients and maintaining proper flow throughout the ED. It is well known that most hospitals in large population centers already operate at or near full capacity [4]. This makes it even more challenging when presented with an acute influx of patients in a short period of time. There is not much that can be done in the acute setting about patients that are already admitted; however, the ED can be restructured to account for the increased surge. Patients currently in the ED with a condition deemed to be stable (will likely not require an acute intervention in the next 24 hours) can be moved to a different area (green triage area, discussed below). The patients who have a more acute condition can be triaged and recategorized using the same criteria as the incoming casualties. 

One current method of triaging patients is the tagging method. In this system, patients are tagged with a red, yellow, or green identification that categorizes patients based on acuity. Other things listed on tags can be a patient’s name, bar code, MRN or other tracking criteria. These patients are then able to be treated based on the level of care needed. In theory, this is a good way for patients to be tracked and accounted for. However, some experts believe that when there is a large volume of patients, this can slow the triage process and extend the amount of time it takes the patient to receive care that may be lifesaving. Another limitation is that it does not allow for a dynamic system, it provides a false sense of security, and can cause confusion. For example, a patient may have a green tag when initially triaged but could decompensate to a yellow or red tag [6]. Thus, there should be an appropriate system for re-evaluation if resources allow. 

One system that could be used instead is a tag zone. In this system, the ED could be set up into different zones that would correlate with the tag color and acuity of the condition. Who should triage? The second most senior ED attending physician. The zone system could be set up as follows: 

Red zone: Patients that need immediate medical or surgical attention. This includes patients presenting with an acute airway, circulatory or neurologic problem, multi-system involvement, or penetrating injuries to the head, neck, or chest. These patients are likely to need the vast majority of resources and staff. 

Orange zone: Not originally categorized in the tag system. These patients are expected to decompensate within the hour but did not need immediate resuscitation [2]. 

Yellow zone: Patients that are relatively stable that will likely not decompensate within the hour. Extremity injuries or conditions that have time to be worked up. 

Green zone: Patients with minor injuries that are unlikely to decompensate. “Walking wounded.” Will not require vast amounts of resources or staffing to be cared for. 

The different zones allow for a dynamic system. Patients in each zone will be cared for by a team of physicians and nurses with the majority of staffing located in Red and Orange zones. Patients can be moved “up” a zone (from yellow to orange) if their condition deteriorates or could be moved “down” a zone (from yellow to green) if they are able to be stabilized [1, 2, 3]. The “black tag” patients were not categorized into a zone as they were patients who were either already dead, or not likely to survive given the current staffing and resources available. Figure 3 shows a brief triaging algorithm (without the orange designation). This is one possible system to triage patients and get them to an appropriate level of care rapidly. The hospital system is now ready for the rapid influx of critical patients.

Implementation

All patients should enter through a single triage area. Multiple points of entry can cause confusion and overwhelm each area by not knowing the number of patients entering from each point [4]. As the number of patients in each zone starts to fill up, adequate communication about the space and number of resources available should be communicated to the DMO and charge nurse. Once patients are able to be stabilized in each zone, the goal is to get them to the OR for immediate surgery if needed, or to move them down a zone (yellow to green) in order to make space for additional critically injured patients.  

Who are the first patients to arrive? The “dual wave phenomenon” explains how patients usually present to the hospital following MCIs. The first wave of casualties are described as the “walking wounded” or those who are able to self-ambulate and usually only require minor care. These patients begin to arrive within 15-30 minutes of the incident depending on the distance from the scene to the hospital. It is important that these patients do not take up too many hospital resources or staff as they are likely well enough to survive with minimal therapeutic interventions. These patients can easily overwhelm the system and prevent proper care to more critical patients. The second wave includes the patients that arrive via EMS or other assistance from bystanders as they are not well enough to transport themselves. These are the patients who will require a vast majority of hospital staffing, resources, and time in order to prevent deaths [3, 4]. 

Summary

• The first step to preparing for an MCI is having a plan in place.

• GET HELP. If you only have time to do one thing it should be this. It does not matter how many resources you have or how much space is available if you do not have enough staff to use them.

• Have a triage plan. Create zones of various acuity with the majority of staff occupying the higher acuity areas. Patients can always be moved to a higher zone if they need more care or a lower zone if they have been stabilized. 

• Get patients to the proper provider. If the patient needs surgery, get them to the OR. This also creates space for new patients to be seen.

• Have one single area of entry. This allows the system to maintain consistency and flow. 

References

1. Emergency Safety Officer Management Plan For Mass Casualty. Kings County Hospital Center, www.downstate.edu/emergency_medicine/pdf/KCHCSection03.pdf. 

2. Menes, Kevin. “How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History: Emergency Physicians Monthly.” EPM, 5 Apr. 2020, epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/. 

3. Hospital Medical Surge Planning for Mass Casualty Incidents. Florida Department of Health, www.urmc.rochester.edu/MediaLibraries/URMCMedia/flrtc/documents/WNY-Hospital-Medical-Surge-Planning-For-Mass-Casualty-Incidents.pdf. 

4. Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press. https://doi.org/10.17226/11621

5. “SALT Mass Casualty Triage Algorithm - CHEMM.” U.S. National Library of Medicine, National Institutes of Health, chemm.nlm.nih.gov/salttriage.htm. 

6. “Report: Mass Casualty Trauma Triage Paradigms and Pitfalls .” Journal of Emergency Medical Services , Office of the United States Assistant Secretary for Preparedness and Disaster Response. 

7. DeNolf, Renee L. “EMS Mass Casualty Management.” StatPearls [Internet]., U.S. National Library of Medicine, 15 Oct. 2020, www.ncbi.nlm.nih.gov/books/NBK482373/. 

8. “Mass Casualty Predictor .” Homeland Security Digital Library , Centers for Disease Control and Prevention . 

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Expert Commentary

This is a great review of MCI management in the Emergency Department by Drs. Grace and Rogers. Although the past few years of the COVID-19 pandemic have felt like we’ve been working in a perpetual MCI, these are important principles to review on a regular basis, as they are not something we necessarily practice every day in the emergency department.

The authors do a good job of emphasizing the importance of preparing for an MCI ahead of time. Another important aspect of preparation is decontamination. An ED disaster response plan should incorporate how to effectively put patients (both walk-ins and EMS arrivals) through decontamination if the disaster at hand requires it. The authors emphasize the importance of having patients enter through a single triage area, and the decontamination station should be similarly set up nearby allowing for one-directional flow of patients through the decontamination process. This is not only vital to patient treatment but also to ensuring staff safety. Additionally, it is necessary to ensure that the ED has sufficient and adequate level Personal Protective Equipment and that the appropriate staff are trained on donning/doffing procedures. 

In addition to gathering the staffing resources, there should also be an emphasis on gathering disaster-specific supplies: alerting the blood bank if it is a traumatic MCI, amassing antidotes if it is toxicological in nature, compiling medical equipment (such as ventilators) as applicable, etc. Additionally, alerting other EDs in the system as to the impending influx of patients as well as reaching out to disaster-specific specialty centers (ie, hyperbarics facility for a structure fire for carbon monoxide treatment) can also help take pressure off and allocate more resources. 

Finally, the importance of a hotwash or after-action review cannot be emphasized enough. This is a process by which participants can have an open and honest professional discussion about what went well and what can be improved in the future. It centers around four main questions (What was supposed to happen? What did happen? What caused the difference? What can we learn from this?) and is vital for building an ED’s capacity for conducting an adequate emergency response to an MCI. 

References

1. Blackwell, T.H., DeAtley, C., Yee, A. (2021). Medical support for hazardous materials response. Cone, D.C. (ed). Emergency Medical Services Clinical Practice and Systems Oversight; Volume 2: Medical Oversight of EMS. (3rd edition, p339-351). UK: John Wiley and Sons, Ltd. 

2. Greenberg, T., Adini, B., Eden, F., Chen, T., Ankri, T., Aharonson-Daniel, L. An after-action review tool for EDs: learning from mass casualty incidents. Am J Emerg Med. May 2013;31(5):798-802. Doi 10.1016/j.ajem.2013.01.025. Epub 2013 Mar 6. PMID: 23481154.

3. Metz, T. How to Facilitate an After-Action Review (AAR or Hot Wash): Agenda and Tips. MG Rush Facilitation Training & Meeting Design. https://mgrush.com/blog/after-action-review/. 

4. Salem-Schatz, S., Ordin, D., Mittman, B. Guide to the after action review. Center for Evidence-Based Management. Oct 2010.  https://www.cebma.org/wp-content/uploads/Guide-to-the-after_action_review.pdf.

Andra Farcas, MD

Emergency Medicine & EMS Physician

CU Department of Emergency Medicine

University of Colorado School of Medicine

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Grace, A. Rogers, A. (2021, Apr 26). Proper Preparation for Mass Casualty Incidents. [NUEM Blog. Expert Commentary by Farcas, A]. Retrieved from http://www.nuemblog.com/blog/mass-casualty-incident-preparation

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Mobile Integrated Health

Written by: Ezekiel Richardson, MD (NUEM ‘23) Edited by: Alex Herndon, MD (NUEM ‘21) Expert Commentary by: Hashim Zaidi, MD

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Introduction

Community Paramedicine, also known as Mobile Integrated Health (MIH), is a developing field in which paramedics and emergency medical technicians assist under-resourced areas in the provision of public health, primary healthcare, and preventive services. The express goal of these services is to “improve access to care and avoid duplicating existing services.” [1] While community paramedicine was pioneered in rural settings in which distance significantly limited the patients’ access to primary care and public health, it has continued to expand from rural areas that are underserved into underserved suburban and urban centers.

Across the nation, community paramedicine has taken on may roles, from providing primary prevention and onsite triage in Minneapolis, targeting emergency medicine “hot spots” for prevention of 911 calls in Ontario, to leveraging telemedicine to allow a physician to triage 911 dispatches, paramedic assessment, and diverting patients to primary care in Houston. [2,3,4]

In the United States we have seen a slow and steady migration of low-income individuals out of cities. Nearly 60% of all low-income individuals live outside the city limits of the nearest metropolitan area. [5] Suburban poverty has increased by half in most major metropolitan cities including Chicago. [6] Notably, a significant amount of literature suggests that wealthy and middle class suburbs (whose health infrastructure was built to support individuals with income and agency) are now facing a massive migration of low-income citizens. [7, 8] Accordingly, new healthcare solutions like MIH will be of paramount importance as trends in American migration continue as they have over the last 50 years.

In places like Houston, Minneapolis, and Ohio City where a single healthcare system captures a large share of the patient population and sees a significant amount of the costs from ambulance runs, those healthcare systems have funded community paramedics to assess high-volume patients and if medically appropriate, divert them triggering an ambulance run to the Emergency Department. [2, 4, 9]

In Minneapolis, this was done by staffing a community paramedic at a homeless shelter and community shelter that saw frequent ambulance calls and transports after clients left for the night and may have forgotten medications, developed asthma exacerbations, or minor injuries. [2]

In Houston, telemedicine equipment and a part time emergency medicine physician allowed remote evaluation in a patient’s home with a walk around tour a referral for certain home care services, medication refills, and primary care appointments.4 Houston’s program showed significant improvement in efficiency. Of the 5,570 patients participated, 18% received ambulance transport as opposed to 74% and EMS crews returned to service 44 minutes faster than prior. [10]

In Ohio City, frequent fliers who have called and been transported to the emergency department more than 10 times in 24 months will be given the option to have community paramedics perform a home assessment and ensure that they have the equipment and primary care to avoid emergency department visits. [7]

In Ontario, a community paramedic was stationed in a random apartment building selected for high volume and proportion of elderly individuals and a high frequency of EMS calls. There the paramedic was able to assess the health of residents, answer questions, and provide basic health education, as well as had the ability to activate emergency transport and provide basic primary care. The intervention showed evidence of an increase in the amount of Quality Adjusted Life Years, a decrease in blood pressure among study participants, as well as a significant decrease in EMS calls, thus making a difference in both patient health outcomes and proper utilization of emergency health systems. [11]

Conclusions

While community paramedicine is a promising new intervention as populations age and migrate out from urban centers, there is still sparse data on its success. Even the data that does exist raises serious questions about reproducibility from both a clinical results standpoint and an intervention oversight. However, community paramedicine’s strength may be in its flexibility and the freedom of enterprising EMS directors, public health, and city safety officials to tailor a program to a city’s needs and available budget.

Limitations

In Minneapolis, the community paramedicine program was not renewed because of difficulty quantifying cost savings and proving financial feasibility. Ohio City’s program is too early to yield results. Houston’s program and Ontario’s program have produced literature supports the notion that paramedicine can reduce EMS calls and costs spent on transportation and emergency evaluation.

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Expert Commentary

Thank you to the authors for touching on a critical subject that has only become even more important during a global pandemic. Mobile Integrated Healthcare (MIH) – also known as Community Paramedicine – shows significant promise in providing resources to those disenfranchised from healthcare.

The 1996 EMS Agenda for the Future calls for EMS to one day serve as “community-based health management that is fully integrated with the overall health care system…integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net.” Nearly a quarter of a century later we are getting the necessary footholds to move this vision from fantasy to reality while still recognizing the need for EMS as the public’s emergency medical safety net. The Center for Medicare & Medicaid Services (CMS) has recognized the value of leveraging existing EMS resources to further the mission of community-based health management.

The ET3 model unveiled earlier this year by CMS describes a 5-year payment model that will pay participating EMS services for 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination partner (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care partner, either on the scene or connected using telehealth. This shows the promise of incentives to reduce unnecessary transports but also to reimburse for services rendered by EMS. This applies in novel interventions such as mobile integrated healthcare but also in more common scenarios. Imagine what a model such as this could do with those who are quarantined at home or in shelters with COVID but require regular telehealth check ups for chronic disease management. Or even more simply, community members who need someone to help ensure they have food and running water.

MIH is a promising field that builds on the foundation of EMS being a community-based healthcare entity as opposed to a patient transportation service. MIH, particularly for the most vulnerable populations frequently served by EMS and the ED, stand to benefit the most with models such as this. EMS has come a long way from “you call, we haul” and initiatives such as MIH should be supported and financially fostered in communities by local and state agencies.

Hashim Zaidi, MD

McGovern Medical School

Assistant Professor

Harris Health System

Medical Director

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Richardson, Ezekiel. (2021, Jan 4). Mobile Integrated Health [NUEM Blog. Expert Commentary by Zaidi, H]. Retrieved from http://www.nuemblog.com/blog/mobile-integrated-health

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References

1. https://www.cdc.gov/dhdsp/pubs/docs/SIB_Feb2019-508.pdf. (2020) Retrieved January 7, 2020

2. “Community Paramedicine: A Simple Approach To Increasing Access To Care, With Tangible Results, " Health Affairs Blog, October 31, 2017. DOI: 10.1377/hblog20171027.424417

3. Dainty, K. N., Seaton, M. B., Drennan, I. R., & Morrison, L. J. (2018). Home visit‐based community paramedicine and its potential role in improving patient‐centered primary care: a grounded theory study and framework. Health services research, 53(5), 3455-3470.

4. Langabeer, J. R., II, M. G., Alqusairi, D., Champagne-Langabeer, T., Jackson, A., Mikhail, J., & Persse, D. (2016). Telehealth-enabled emergency medical services program reduces ambulance transport to urban emergency departments. Western journal of emergency medicine, 17(6), 713.

5. Kneebone, Elizabeth, and Garr, Emily. 2010. “The Suburbanization of Poverty: Trends in Metropolitan America, 2000 to 2008.” Metropolitan Opportunity Series. Brookings Institution, Metropolitan Policy Program. http://www.brookings.edu/~/media/research/files/papers/2010/1/20-poverty-kneebone/0120_poverty_paper.pdf.

6. Kneebone, Elizabeth, and Holmes, Natalie. 2015. “The Growing Distance Between People and Jobs in Metropolitan America.” Brookings Institution, Metropolitan Policy Program. http://www.brookings.edu/~/media/research/files/reports/2015/03/24-job-proximity/srvy_jobsproximity.pdf.

7. Allard, Scott W., and Sarah Charnes Paisner. "The rise of suburban poverty." (2016).

8. Kneebone, E. (2014). The growth and spread of concentrated poverty, 2000 to 2008-2012. The Brookings.

9. Frolik, C., & Tribune News Service. (2019, December 30). Ohio City to Launch MIH-CP Program to Cut Down on Frequent Flyers. Retrieved from https://www.emsworld.com/news/1223715/ohio-city-launch-mih-cp-program-cut-down-frequent-flyers.

10. JEMS. (2020). The Impact of Telehealth-Enabled EMS on Ambulance Transports - JEMS. [online] Available at: https://www.jems.com/2017/08/01/the-impact-of-telehealth-enabled-ems-on-ambulance-transports/ [Accessed 11 Jan. 2020].

11. Agarwal, G., Angeles, R., Pirrie, M., McLeod, B., Marzanek, F., Parascandalo, J., & Thabane, L. (2019). Reducing 9-1-1 emergency medical service calls by implementing a community paramedicine program for vulnerable older adults in public housing in Canada: a multi-site cluster randomized controlled trial. Prehospital Emergency Care, 1-12.