Do we need to reassess patients in an MCI?
Question# 811
In the case of an MCI where one (or more) patients are VSA, when patients are initially triaged as "black" and do not be the criteria for obviously dead, should resuscitation be attempted if/when enough resources have arrived on scene?
Answer:
The mainstay of MCI management is the concept of triage, which dates back to the Napoleonic War in the 1800s. Triage comes from the French word “trier”, which means to “separate out”.
As you’re aware, we can’t see every patient at once, so the concept is prioritizing patients on the basis of their clinical acuity. During routine practice when there are enough resources to manage the critically ill patients and eventually get to everybody, the main tenet is to get early care to those who need it most, rather than devoting the limited available resources to patients who may not need or benefit the most from emergent care. Under these circumstances, hospitals and paramedics devote resources to those who are the sickest, with the understanding that eventually we will get to everyone and the less acute patients can wait without any anticipated harm coming to them as a result. Under MCI conditions there are not enough resources to address all the immediate needs, and triage shifts to doing the most good for the most people, which can mean a shift of priorities away from those who likely are not salvageable. Having responders prioritize patients based on the severity of their injuries and need for resources, takes center stage in MCIs and is essential for maximizing the chances of survival for the greatest number of individuals.
The importance of triage when caring for multiple patients, when the current system is overwhelmed, cannot be understated. This can mean withholding resuscitation from patients who do not start breathing after a basic airway opening (START triage), to focus on those who have a higher likelihood of survivability.
When it comes to a defining a multiple causality incident (MCI), there is no clear consensus. These are complex and wide-ranging events/situations, that are fluid, dynamic, and evolve over time. Historically, these events are large scale in nature, have a high degree of patient acuity (or illness severity), and often have diverse patient needs.
The MOH has previously defined a MCI as “an incident where casualty numbers exceed the capacity of the ambulance resources arriving at the scene within 15 minutes and therefore requires a coordinated ambulance response.” The determination of MCI depends on the resources available, which is often dictated by the practice setting. For a paramedic service in a large city with multiple ambulances responding from short distances, a motor vehicle collision with five critically ill patients may not overwhelm the system and require MCI designation with the shift to START triage. The same collision in a small community with two ambulances and delays for other help to arrive may prompt the decision to implement MCI triage.
Boiling it down however, a MCI is a disaster or major incident that’s presented to you, that is greater than the resources you have at accessible at hand. This determination is made at a moment in time and no triage decision is final. This determination is fluid as things can change quickly, and in well-resourced areas the responders can find they have adequate resources relatively quickly.
It’s important to note that the first assessment/triage of a patient should not be their only assessment/triage, especially if MCI conditions prevailed initially. Once all patients have been triaged, and as additional resources arrive and become available, there will likely be opportunities for reassessments. When that occurs, patients should receive primary and secondary assessments, and treatment as required. Patient conditions can and do change over time as well, and reassessment is warranted. A patient initially triaged as “green” may deteriorate to “red”, and the converse is also true.
Thus, as resources arrive on scene, and the MCI is more “manageable”, patients initially triaged as “black” should be reassessed. In these cases, if the patient is not Code 5, then a transition to a more traditional approach is recommended.
The RPPEO BHPs are always available for consultation if there are questions, and if/when you connect with the physician, it would be prudent to advise them of the delay to resuscitation attempt(s), including a statement that MCI triage circumstances prevailed initially, but that traditional assessment and treatment was provided once resources became adequate. This delay should also be mentioned in your documentation.
MCI management is traditionally under the purview of the MOH and paramedic services, and we would encourage you to engage your service as well as part of these discussions.
At the provincial level, discussions are underway to update the patient care standards to reflect the needs. In addition to liaising with your paramedic service, Emergency Management Ontario offers Incident Management System (IMS) courses that serve as a foundational framework for coordinated emergency response for municipalities throughout the province.
As you’re aware, we can’t see every patient at once, so the concept is prioritizing patients on the basis of their clinical acuity. During routine practice when there are enough resources to manage the critically ill patients and eventually get to everybody, the main tenet is to get early care to those who need it most, rather than devoting the limited available resources to patients who may not need or benefit the most from emergent care. Under these circumstances, hospitals and paramedics devote resources to those who are the sickest, with the understanding that eventually we will get to everyone and the less acute patients can wait without any anticipated harm coming to them as a result. Under MCI conditions there are not enough resources to address all the immediate needs, and triage shifts to doing the most good for the most people, which can mean a shift of priorities away from those who likely are not salvageable. Having responders prioritize patients based on the severity of their injuries and need for resources, takes center stage in MCIs and is essential for maximizing the chances of survival for the greatest number of individuals.
The importance of triage when caring for multiple patients, when the current system is overwhelmed, cannot be understated. This can mean withholding resuscitation from patients who do not start breathing after a basic airway opening (START triage), to focus on those who have a higher likelihood of survivability.
When it comes to a defining a multiple causality incident (MCI), there is no clear consensus. These are complex and wide-ranging events/situations, that are fluid, dynamic, and evolve over time. Historically, these events are large scale in nature, have a high degree of patient acuity (or illness severity), and often have diverse patient needs.
The MOH has previously defined a MCI as “an incident where casualty numbers exceed the capacity of the ambulance resources arriving at the scene within 15 minutes and therefore requires a coordinated ambulance response.” The determination of MCI depends on the resources available, which is often dictated by the practice setting. For a paramedic service in a large city with multiple ambulances responding from short distances, a motor vehicle collision with five critically ill patients may not overwhelm the system and require MCI designation with the shift to START triage. The same collision in a small community with two ambulances and delays for other help to arrive may prompt the decision to implement MCI triage.
Boiling it down however, a MCI is a disaster or major incident that’s presented to you, that is greater than the resources you have at accessible at hand. This determination is made at a moment in time and no triage decision is final. This determination is fluid as things can change quickly, and in well-resourced areas the responders can find they have adequate resources relatively quickly.
It’s important to note that the first assessment/triage of a patient should not be their only assessment/triage, especially if MCI conditions prevailed initially. Once all patients have been triaged, and as additional resources arrive and become available, there will likely be opportunities for reassessments. When that occurs, patients should receive primary and secondary assessments, and treatment as required. Patient conditions can and do change over time as well, and reassessment is warranted. A patient initially triaged as “green” may deteriorate to “red”, and the converse is also true.
Thus, as resources arrive on scene, and the MCI is more “manageable”, patients initially triaged as “black” should be reassessed. In these cases, if the patient is not Code 5, then a transition to a more traditional approach is recommended.
The RPPEO BHPs are always available for consultation if there are questions, and if/when you connect with the physician, it would be prudent to advise them of the delay to resuscitation attempt(s), including a statement that MCI triage circumstances prevailed initially, but that traditional assessment and treatment was provided once resources became adequate. This delay should also be mentioned in your documentation.
MCI management is traditionally under the purview of the MOH and paramedic services, and we would encourage you to engage your service as well as part of these discussions.
At the provincial level, discussions are underway to update the patient care standards to reflect the needs. In addition to liaising with your paramedic service, Emergency Management Ontario offers Incident Management System (IMS) courses that serve as a foundational framework for coordinated emergency response for municipalities throughout the province.