Disaster Triage Overview


What is a Disaster?

  • Definition: An event where illness or injuries surpass the resource capabilities of a healthcare facility or community due to destruction and devastation.

  • Types of Disasters:

    • Internal Disaster: Occurs within a healthcare facility or campus.

    • Examples include:

      • Fire or explosion

      • Loss of critical utilities

      • Workplace violence

    • External Disaster: Occurs outside a healthcare facility or campus.

    • Examples include:

      • Natural disasters: hurricanes, earthquakes, tornadoes

      • Technological failures, pandemics

Multi-Casualty vs. Mass Casualty Incidents

  • Multi-Casualty Incident (MCI):

    • Can be managed by a single hospital using local resources.

    • Example: A crash involving 10 people that exceeds the handling capacity of one ambulance.

  • Mass Casualty Incident (MCI):

    • Overwhelms local medical capabilities and requires collaboration of multiple agencies and facilities.

    • Example: Shooting or explosion requiring police, fire, EMS, and multiple hospitals to coordinate efforts.

Sources of Potential Disasters

  • Natural Events:

    • Superstorms & hurricanes, earthquakes, tsunamis

  • Biological Threats:

    • Pandemics (e.g., COVID-19, 2020; MERS — Middle Eastern Respiratory Syndrome)

  • Human-Made Events:

    • Terrorist attacks, industrial accidents

  • Historical Impact: Hurricane Katrina and September 11, 2001 have significantly influenced disaster planning in the U.S.

Terrorism Events

  • CBRNE Categories:

    • Chemical

    • Biological

    • Radiological

    • Nuclear

    • Explosive

  • Response Protocols: Each category requires its own unique response protocol. Nurses must be aware of signs, symptoms, and decontamination procedures associated with each type.

Mass Decontamination

  • Definition: Systematic process of removing or neutralizing hazardous substances from victims to prevent further harm and protect responders.

5 Steps for Mass Decontamination

  1. Post Decon: Follow through on decontamination procedures.

  2. Decon Execution: Carry out the planned decontamination process.

  3. Initial Size-up: Assess the situation at the start of the decontamination process.

  4. Victim Control: Manage how victims will be treated and decontaminated.

  5. Decon Setup: Establish the decontamination area properly to ensure effective procedures.

  • Importance: Proper sequencing ensures responder safety, victim throughput, and effective contaminant removal before patients enter the medical system.

Triage in Disasters

Step 2: Symptomatic vs. Asymptomatic Patients

  • Decontamination Triage: Directs victims into two categories based on symptoms:

    • Immediate Decontamination: For symptomatic patients showing signs of exposure; prioritized for rapid decontamination.

    • Observe for Symptoms: Asymptomatic, ambulatory patients monitored and directed through a secondary lane.

  • Outcome: Separation reduces cross-contamination and allows for efficient resource allocation.

Step 3: Decontamination Setup

  • Setup Importance: Creates clearly defined zones (hot and cold zones) and movement corridors for victims.

  • Implementation: Fire department trucks help establish a decon corridor using water spray systems.

Step 4: Mass Decontamination Execution

  • Key Fact: Removal of outer garments alone can eliminate 80–90% of physical contamination.

  • Procedure: Victims walk through a rinsing corridor managed by responders. Clothing is bagged and removed from the scene.

  • Significance: This step is critical for reducing secondary contamination to medical staff.

Levels of Prevention in Disaster Response

  1. Primary Prevention: Plans in place before emergencies occur.

    • Example: Evacuation routes posted, emergency drills conducted.

  2. Secondary Prevention: Actions taken during the event.

    • Activities include triage, emergency treatment, shelter supervision, and immediate medical care.

  3. Tertiary Prevention: Follow-up and recovery after the event.

    • Policy changes, mental health follow-up, food storage regulations, etc.

Role of the Nurse in Disasters

  • Before the Event:

    • Develop internal and external emergency response plans.

    • Participate in drills and training exercises.

  • During the Event:

    • Collaborate with medical command to organize services and meet patient needs: triage, first aid, emergency care, shelter assistance.

Locations of Nurses During a Disaster

  • Potential Locations:

    • Hospital emergency departments and inpatient units receiving surge patients.

    • Military combat and field medical support.

    • Disaster Medical Assistance Teams (DMAT) deployed to disaster sites.

    • Community/public health volunteers.

  • Drill Requirement: The Joint Commission (JC) mandates hospitals conduct a minimum of 2 emergency drills per year.

Scene Safety Assessment — SEPIA

  • SEPIA Acronym Breakdown:

    • S: Structural Damage? Is the building compromised?

    • E: Exposure Risk? Hazards present?

    • P: Perpetrators? Any active threats?

    • I: Items of Suspicion? Any suspicious packages or substances?

    • A: Abilities? Do responders have proper training and equipment?

  • Safety Note: No scene is ever 100% safe, but SEPIA helps assess risk before entry.

How to Assist in a Disaster

  • Entry Protocol: Do NOT enter a scene without clearance from officials.

  • Consequences of Untrained Response: Untrained responders may become casualties, burdening the response system.

  • Authorization Procedures:

    • Wait for official order to enter disaster zones.

    • Identify oneself to incident command for assignment.

    • Follow the chain of command.

Triage Principles in Disasters

  • Core Principle: Greatest good for the greatest number.

  • Color Coding System: Used to categorize patients based on the severity of their condition.

  • Incident Command System: Activated during triage with defined roles.

    • Roles include:

    • Scene Command

    • Staging

    • Transport

    • Triage

    • Treatment

    • Logistics

Anticipated Challenges at a Disaster Scene

  • Challenges:

    • Chaos & Noise: Overwhelming sensory input complicates communication and decision-making.

    • Physical Dangers: Unstable structures and hazardous materials require constant situational awareness.

    • Blood & Body Fluids: Standard precautions (gloves, eye protection, masks) are non-negotiable.

Communication and Notification

  • How Hospitals Are Notified:

    • Communication through radio, cellular, or electronic methods from EMS to ED.

    • Notifications from state or regional emergency management agencies.

    • Each hospital has its own activation policy.

  • Key Response Teams:

    • MRC: Medical Reserve Corps

    • DMAT: Disaster Medical Assistance Team

    • DMORT: Disaster Mortuary Operational Response Team

    • IMSURT: International Medical/Surgical Response Teams

Hospital Incident Command System (HICS)

  • HICS Definition: A facility-level organizational model for disaster management.

  • Structured Roles:

    • Hospital incident commander: Overall authority.

    • Medical command physician: Clinical oversight.

    • Triage officer: Manages patient sorting and flow.

  • Emergency Operations Center (EOC): Central hub for coordination.

START Triage System

  • Definition: QUICK assessment method used for mass casualty events.

  • Acronym: Simple Triage and Rapid Treatment

START Color Coding System

  • Categories of Injuries:

    • Red (Immediate/Class I): Life-threatening injuries requiring prompt care.

    • Yellow (Delayed/Class II): Serious injuries that can wait for care.

    • Green (Minor/Class III): Non-urgent, "walking wounded" patients.

    • Black (Expectant/Class IV): Expected to die or already deceased; resources diverted to salvable victims.

Triage and Communication Procedures

  • Identification of Ambulatory Victims:

    • Walking wounded should be triaged as Green/Minor.

    • Direct them to a designated area with clear instructions.

  • Communication Protocols: Ensure clarity in instructions and monitor ambulatory victims to prevent them leaving the scene.

RPM — The Three Assessment Parameters

  • Order of Assessment for Non-Ambulatory Victims:

    1. Respiratory Rate (R): Is breathing present?

    2. Perfusion (P): Assess capillary refill or radial pulse.

    3. Mental Status (M): Ability to follow commands.

  • Outcome Focus: Assess based on the outcomes of R, P, and M to prioritize care.

RPM Step 1: Respiratory Rate

  • Outcomes:

    • Not present (After repositioning airway): BLACK (Dead/Expectant).

    • Respirations > 30/min: RED (Immediate).

    • Respirations < 30/min: Continue to perfusion assessment.

RPM Step 2: Perfusion Assessment

  • Methods: Acceptable to assess via capillary refill or radial pulse.

  • Outcomes:

    • Capillary Refill > 2 seconds: RED (Immediate).

    • Capillary Refill < 2 seconds: Proceed to assess mental status.

    • Absent radial pulse: RED (Immediate).

RPM Step 3: Mental Status Assessment

  • Outcomes:

    • Unable to respond appropriately: RED (Immediate).

    • Responds appropriately: YELLOW (Delayed).

  • Significant Distinction: Mental status is key in differentiating between Immediate and Delayed categories.

Systematic Movement through the Scene

  1. Organized Approach: Work through the scene systematically without skipping assessments. All victims receive a 30-sec evaluation.

  2. Track Color Counts: Maintain a tally of Red, Yellow, Green, and Black tags, informing command of resource needs in real time.

  3. Resource Delegation: Delegate simple tasks (e.g., pressure on wounds) to bystanders; focus on assessment and tagging.

Triage Scenarios

Scenario 1: Triage Category

  • Assessment:

    • Cannot move or feel legs.

    • Respirations: 26/min

    • Radial Pulse: 110 (present)

    • Mental Status: Awake and oriented

  • Classification:

    • Applying START: RR < 30, Radial pulse present, Oriented → Category: YELLOW (Delayed)

Scenario 2: Triage Category

  • Assessment:

    • Soaked with blood, no obvious critical bleed.

    • Respirations: 38/min

    • Weak pulse, no radial pulse.

    • Mental Status: Awake

  • Classification:

    • Applying START: RR > 30 → Category: RED (Immediate)

Scenario 3: Triage Category

  • Assessment:

    • Walks over with a broken arm.

    • Respirations: 22/min

    • Radial Pulse: 124 (present)

    • Mental Status: Awake, alert, crying

  • Classification:

    • Applying START: RR < 30, Radial present, Alert → Category: GREEN (Minor)

Scenario 4: Triage Category

  • Assessment:

    • Gurgles, cannot maintain airway, not breathing.

    • Weak carotid pulse (no radial).

    • Mental Status: Unresponsive

  • Classification:

    • Airway repositioned and remains unresponsive → Category: BLACK (Expectant)

Scenario 5: Triage Category

  • Assessment:

    • Open head wound with controlled bleeding.

    • Respirations: 16/min

    • Radial Pulse: 88 (present)

    • Mental Status: Unconscious, unresponsive

  • Classification:

    • Applying START: RR < 30, Radial present, Cannot respond → Category: RED (Immediate)

Pediatric Triage Considerations

  • Note: Adult triage tools are inappropriate for pediatric patients due to anatomical and physiological differences.

  • System: The JumpSTART pediatric triage system applicable for children ages 1–8 years.

    • Infants (<1 year): Automatically categorized as Minor (Green) if no visible injuries.

Differences from START

  • Normal pediatric vital signs differ from adults; respiratory and pulse norms are age-adjusted.

JumpSTART Triage System

  • Key Assessment Parameters:

    • Respirations: Absent requires airway intervention; breaths may follow trial ventilation for apneic children.

    • Perfusion: Brachial pulse preferred; absence indicates critical compromise.

    • Mental Status (AVPU): Determines categorization into Immediate or Delayed.

Hospital Protocols and Self-Referrals

  • Self-Referral Expectation: Victims may arrive before hospital activation is complete.

  • Decontamination Assessment: Every patient should be assessed for potential exposures before entering the ED.

  • Protocol Familiarity: Triage according to hospital policies; clarity on MCI protocol before disaster occurs is crucial.

Psychosocial Response of Survivors

  • Impact of Disasters:

    • Immediate and long-term psychological effects on survivors.

    • Lifestyle, roles, and routines are altered.

    • Coping abilities are challenged.

  • Nursing Interventions:

    • Monitor for Acute Stress Disorder (ASD).

    • Monitor for Post-Traumatic Stress Disorder (PTSD) using IES-R Questionnaire for trauma response.

Example Questions

  1. Classification of an Explosion:

    • ED nurse's answer: 4 — External Disaster

  2. Assigning a Black Tag:

    • Correct answer: 4 — Full-thickness extremity burns.

  3. Response to PTSD Symptoms:

    • Correct answer: 4 — Referral to occupational nurse for feelings exploration.

  • Note: Dismissing symptoms can allow ASD or PTSD to go unaddressed.