Disasters and Triage Management

Aziz Ullah
Nursing Lecturer
KMU.IHS-Swat
Objectives
• Discuss the concept of triage and priority setting in
emergency setting and during disaster management
• Describe and anticipate various types of disasters i.e.,
Natural and Manmade.
• Identify the chain of communication and need for
multidisciplinary interventions during a disaster.
• Describe the role of an in-charge nurse, triage nurse and
other Emergency Room nurses in ensuring a non-panic,
well-coordinated management during a disaster (pre-
hospital and hospital setting).
• Discuss the post disaster effect of patient in their quality of
life
• Discuss the role of rehabilitation
 DISASTER
Definition:
A disaster is a sudden, hazardous event that
seriously disrupts the functioning of a
community or society and causes human,
material, and economic or environmental
losses that exceed the community’s or
society’s ability to cope using its own
resources.

(International Federation of Red Cross and Red

Crescent Societies, 2015)
 TYPES OF DISASTERS
Natural disasters Man-made disasters
• Cyclones, typhoons, • Accidents
Hurricanes,
snowstorms, heat waves • Fires
• landslides, floods, • Civil disturbances
earthquakes, volcanic Riots and demonstrations
eruptions,
• Communicable diseases, • Warfare
epidemics • Refugees
Forced movements of
large number of people
 Cont.
• Meteorological disasters: (Cyclones ‫ طوفان‬,
typhoons ‫آندھی‬, hurricanes ‫سمندری طوفان‬,
snowstorms ‫)برفانی طوفان‬, heat waves
• Topological disasters (landslides, floods ‫سیلاب‬,
earthquakes, volcanic eruptions).
• Biological disasters: (communicable diseases,
epidemics)
 Elements of Disaster Management
The spectrum of disaster management involves:
•Disaster prevention-(The formulations and implementation of
long‐ range policies and programs)
•Mitigation- Measures aimed at reducing the impact of a disaster
(natural or man‐made disaster)
•Preparedness- Organizing, planning, coordinating, resources
planning and training are its major concerns
•Response and Recovery -Process by which communities and
the nations are assisted in returning to their proper level of functioning
following a disaster.
 DISASTER MANAGEMENT PRINCIPLES

• A concise, clear disaster plan

• Clearly defined roles
• Community education
• Prevent occurrence
• Minimize casualties
• Prevent further casualties
• Rescue the injured
• Provide first aid
• Provide definitive care
• Facilitate reconstruction and recovery
 The DISASTER Paradigm/Model

• D detect
• I incident command (Knowledge)
• S scene safety and security
• A assess hazards
• S support needed
• T triage/treatment
• E evacuation
• R recovery
 ROLES OF NURSES IN DISASTER
• Carrying out their own responsibilities
• Allowing others to carry out their own
responsibilities
• Adequate observer
• Check availability of all supplies
• Moving patients
• Staff assignment
• Communication with supporting teams,
management
• Knowledge of intradepartmental policies
ROLES OF NURSES IN DISASTER (cont.)

• Proper triage (proper distribution of patients)

• Accurate assessment
• Appropriate care methods
• Able to make rapid and sound decisions
• Cautious acceptance of roles (excess non-clinical
personnel to carry out other tasks)
• Regular relief periods such as breaks and meal times
 Effects of Disaster
• Social reactions:
– Generalized panic, widespread Plundering, Rumors,
population displacements
• Food and Nutrition:
– Food stock destruction, Disruption of distribution
• Communicable Diseases:
– Pre-existing Diseases in the Population
– Diseases resulting Ecological Changes
– Diseases due to Population Movements
– Diseases caused by Interruption in Public Health Services
• Psychological Aspects
 Conclusion

• Disaster plans , should never be considered

complete.
• Plans needs to be practiced and updated on a
regular basis.
• A plan that is not revised at periodic intervals
may create a false sense of security and may
actually be counter productive in a real
emergency.
 Triage
Waiting room

Team leader

Aziz Ullah
Nursing Lecturer
Acknowledgment: Qaisar Khan
 EMERGENCY

 An Emergency is any sudden illness or injury that

poses an immediate risk to a person's life or long-
term health and requires immediate intervention.

 Serious, unexpected, and often dangerous situation

requiring immediate action.
 Types of Emergency

1) Medical Emergencies:
Acute Physiologic crises that are not directly
caused by traumatic impact to the body.

2) Traumatic Emergencies:
It is Physiologic crises that are caused by blunt
or penetrating impact to the body
Roles of Emergency Nurse

Roles of emergency Nurse includes:

Patient care CREAM
• Patient Care
• Consultation
• Research
• Educator
• Advocacy
• Manager
 TRIAGE
It is defined as:

 Triage is the term derived from the French verb

“trier” meaning to sort or to choose

 It is quick sorting of patients who come to ER for

care.

 Triage is the prioritization of patient care (or

victims during a disaster) based on illness/injury,
severity, prognosis and resource availability.
 Purpose of Triage
The purpose of triage is to:
₋ Identify patients needing immediate resuscitation; to
assign patients to a pre-designated patient care area,
thereby prioritizing their care.
₋ To initiate diagnostic/therapeutic measures as
appropriate.
₋ To separate the patients requiring immediate medical
attention from those who could wait.
 History of Triage
• French word “TRIER” means “to pick, to choose or to
sort”.
• The term was first originated during the Napoleonic
Wars (1803–1815).
• During World War I, French military used the word
“Triage” for categorizing wounded soldiers.

• Today’s triage system is introduce in 1960’s when

demand of emergency service surpass available
resources.
 Why triage is needed in Hospital Setting

• Triage means nursing judgment is made within a

group of patients to choose the sickest ones for
earliest.

• With increasing numbers of patients seeking

emergency care, correct sorting allows the proper
resource to be provided for each level of patient.

Paula ,2008 Journal of Emergency nursing

Resources require for Triage

SC-STEM : mnemonic
•Space
•Communication system
•Supplies
•Treatment area
•Experienced professional
•Multidisciplinary team.
Why we as nurses need to learn triage
What is Triage Nursing

Prioritizing patients based on:

A short history of the illness
Vital signs
Documents triage assessment
Designates treatment areas

Triage Nurse Qualifications

They are Gate Keepers to the ER,
Must be knowledgeable, experience, temperament, and
qualifications necessary to function in a high stress roll
Most facilities require at least 6 month- 1year of ER
experience before allowing nurses to triage
Three Rights of TRIAGE
• Putting the patient in the Right place.
• At the Right time.
• To receive the Right level of care.

Facilitates allocation of appropriate

resources to meet the patient’s medical needs.
 Goals of Triage Nursing
PRIMARY GOAL:

• Rapid identification of patients with urgent life

threatening conditions.

COMPLEMENTARY GOALS:

• Prioritizing care needs for all patients

• Regulating patients flow
• Determining the most appropriate area
Triage Categories

• Non disaster (Hospital Triage): To provide

the best care for each individual patient.

• Disaster Triage: To provide the most

effective care for the greatest number of
patients.
Non disaster or E.D triage

The primary objectives of an ED triage are to:

1. Identify patients requiring immediate care.
2. Determine the appropriate area for treatment
3. Facilitate patient flow through the ED and
avoid unnecessary congestion.
4. Provide continued assessment and
reassessment of arriving and waiting patients.

5. Provide information and referrals to

patients and families.

6. Alleviate patient and family anxiety and

enhance public relations.
 START SYSTEM
(Used for Disaster Triage)
• Allows rapid assessment of victims
• It should not take more than 15 sec/Pt.
• Once victim is in treatment area more detailed
assessment should be made
Overview of three category triage acuity systems
category acuity Recommended Examples
reassessment

Class 1 Emergent continuous Cardiopulmonary

arrest, severe
Immediately life or limb
respiratory distress,
threatening
major burns, major
trauma, massive
uncontrolled bleeding
Coma, status epil..
Abdominal pain,
Class 2 Urgent Every 30 multiple fractures,
Requires prompt care, but
will not cause loss of life or minutes lacerations, renal calculi,

limb if left untreated for

several hours.
Rash, chronic headache,
Class 3 Non urgent Every 1-2 sprains, cold symptoms
And treatment but time is
not a critical factor hrs
The Canadian E.D. Triage and Acuity Scale
 Disaster Triage Color Codes

RED Hyper acute ; 1st priority

E.g. life threatening problem, severe blood
loss, shock, unconsciousness
YELLOW Serious ;2nd priority
E.g. moderate blood loss, conscious head
injury, spinal cord injury.
GREEN Walking injured, 3rd priority
E.g. minor laceration, # , burns.

BLACK Deceased , cardiopulmonary arrest

 ED Triage and Acuity Scale (see word file)
Triage category Condition examples

 Cardiac Arrest , Major Trauma

Life-threating condition which
Level 1 require immediate intervention.


Air way compromise, Shock state
Near death Asthma, Sever respiratory
High risk condition, including
(Red)
distress
 Unconscious , Seizure , Anaphylactic
immediate life/organ threat and
shock
high liability risk which require
Immediate high resource intensity.



Pneumothorax traumatic/tension
Spinal cord injuries ,CVA
Head injury, decrease conscious level
 Acute myocardial infarction
 Head injury, alert vomiting
Level 2 Condition that have the potential for  Moderate trauma
implication or increase in severity,
Yellow which require medium resource


Mild/Moderate Asthma
Chest pain with no complication
15-30min intensity.


Renal colic
Overdose
(time to physical assessment May be associated with significant  GI bleeding with normal vital sign
 Pain scale above 7
discomfort or affect ability to function  Abdominal pain with stable vital
or do activities of daily living  sepsis

 Minor Trauma
Level 3(Green) Condition that have low potential  Pain scale 4-7
30-60 min for deterioration or complication,  ENT pain
 Psychiatric condition
(time to physical assessment ) which require low resource  Chest pain stable condition
intensity. 

Allergic condition
Headache(non Migraine/not sudden
 UTI
 Skin condition
 GERDS
 Prognosis mortality
Level 4(blue) Condition in which the  90 % or above burns
outcome will always going to  Visible brain matter outside the skull in
head injury
Triage levels

1- Immediate/Resuscitation
2- Emergent
3- urgent
4- Semi-urgent
5- Non-urgent

ATS” (Australian Triage Scale)

 TRIAGE LEVELS
1- Resuscitation: -- Immediate Threat to life
Time to nurse assessment: IMMEDIATE
Time to physician assessment: IMMEDIATE
• Cardiac and respiratory arrest
• Major trauma
• Active seizure
• Shock
• Severe Bleeding
• Status Asthmatics
• Mnemonic : CR MASSS
2- Emergent Triage levels
 Potential threat to life, limb or function
 Patients with acute medical conditions (critical) do not
require resuscitation.
 Nurse Immediate , Physician <15 minutes
– Decreased level of consciousness
– major limb fracture/dislocation
– Kidney stone
– Severe respiratory distress
– Chest pain with cardiac suspicion
– Severe abdominal pain
– G.I. Bleed with abnormal vital signs
– Chemical exposure to eye
Triage levels

3- Urgent
 Acute symptoms who are in a stable condition
but with Significant distress
 Time Nurse < 20 min, physician < 30 min
– Head injury without decrease of LOC and
having vomiting
– Mild to moderate respiratory distress
– G.I. Bleed not actively bleed
– Acute psychosis (Such as Depression)
– Non Cardiac Chest Pain
4- Semi/Non-urgent 60-120 minutes :
 Stable Conditions
 Time for Nurse assessment: 1 to 2 hours
 Time for physician assessment: 1 to 2 hours
 Head injury, alert, no vomiting
 Chest pain, no distress, no cardiac suspicion.
 Depression with no suicidal attempt
 Earache, Toothache, Sore Throat, Suture
removal and others.
Nausea, vomiting, without signs of dehydration.
Such patients may be asked to visit the family
physicians (OPD) during the day hours.
 Assessment of Triage Patient
PRIMARY SURVEY:

• Rapid identification of patients with urgent

life threatening conditions.
• A= Airway
• B= Breathing
• C= Circulation.
• D= Disability
 PQRST for Pain Assessment
P (Provokes) what provokes the symptoms?
Q (quality) What does it feel like?
what makes it better?
What makes it worse?

R (radiation) where is it?

Where does it go?
Is it in one or more spots?

S (severity) If we gave it a number from 0-10, what is your

rating?
T (time) When did it start (Onset)?
How long did it last (Duration)?
Does it come and go?
OLD CART Assessment For Chief
Complain
O Onset of symptoms
L Location of problem
D Duration of symptoms
C Characteristic of the symptoms described
A Aggravating factors
R Reliving Factor

T Treatment administered before arrival

40
Principles of Disaster Triage

• Do the greatest good for the greatest number of

people
• Employ the most efficient use of available resources
• Treat as many as possible who have a chance of
survival.
• Base treatment on exclusion criteria
 References
• Newberry, L. (2003). Sheehy’s Emergency Nursing: Principles
and practice.(5th ed.). St.Louis: Mosby.
• Lewis, S. M., Collier, I. C., & Heitkemper, M. M. (2004). Medical
Surgical Nursing. (5th ed.). St Louis: Mosby.
• Cone, K, J, & Murray, R. (2002). Haracteristics, insights,
decision making and preparation of ED triage nurses. Journal
of emergency nursing online.
www.wellmedmedicalgroup.com/.../staffbios.php
• Andrew Harding, Triage, Diagnose, Treatment and Disposition,
Journal of Emergency Nursing, In Press, Corrected Proof,
Available online 3 June 2009.
• Montejano.C.Anna, What is Triage Nursing. Journal of
Emergency Nursing, In Press, Corrected Proof. Available online
2009.
• Kelly Jo Cone & Murray Ruth Oct 2002, Characteristics,
insights, decision making and preparation of ED triage. Journal
of Emergency Nursing, In Press, Corrected Proof, Available
online 2009.
• Paula Funderburke (April2008).Exploring best practice for
Triage .Journal of Emergency Nursing vol 34 -2. p.p 180-181
http://intranet/akulibrary/JournalSearchNew.asp?alphabet=A
References
• Garcia, M. L. (1985). Disaster nursing: Planning,
assessment and intervention. Maryland: an Aspen
Publications
• Lewis, S. M., Collier, I. C., & Heitkemper, M. M.
(2010). Medical-Surgical Nursing (5th. ed.). St. Louis:
Mosby
• Newberry, L. (2003). Sheehy’s emergency nursing:
Principles and practice (5th ed.). Emergency nurses
association. St. Louis: Mosby.
•
 Cont.
 Suzane, C., & Hinkle, J. (2009). Medical
Surgical Nursing (10th ed.). Brunner &
Suddarth's .
 Brown, A, F., & Cadogan, M, D. (2010).
Emergency Medicine (6th ed.). UK: Hodder
Arnold
 Retrieved from
http://www.pitt.edu/~super1/lecture/lec3505
1/index.htm