MPI Management: Providing Structure for Care

The Incident Command System (ICS) has been widely accepted and utilized by the United States Fire Service for several years. Many fire agencies establish ICS on all calls for service, allowing proficiency to be acquired on the routine responses and leading to better coordination of major scenes. When it comes to EMS, use of ICS seems to be less common. When challenged with a multiple patient incident (MPI), the use of ICS is essential to the successful operations and to the outcome of the patients involved.¹ Providing structure to a chaotic scene is a necessary component to allow appropriate care to be delivered.

Preparing an organization to manage the worst emergencies is a tall task. This information provides a plan for preparing for and responding to MPIs. By providing the needed tools for the job and training the staff to be the best at the most challenging of emergency scenes, we can ensure that our community is better served in situations involving multiple patients.

Definitions and Task Assignments

The definition of a MPI may vary depending on system resources, but is best defined as a situation in which resources needed outnumber resources available.² It is important that EMS systems pre-plan based on anticipated resources and define what constitutes an MPI in our individual system. In this article and in our practice, we choose to use the term multiple patient incident over multiple casualty incident (MCI), but recognize that these terms are used interchangeably.

In our local system, the quest to have an EMS department proficient in ICS was pursued due to the potential for, and frequent occurrences of, MPIs. Agency administrators noticed that on several typical calls, EMS would arrive on the scene first and quickly select a patient and initiate care. Adding to the concern, routine motor vehicle crashes often create complicated scenes. It was clear that better preparation was needed for these events. In addition to being ready for scenes with a large number of patients such as the occasional bus crash or aircraft down, it is important to be prepared for things we all deal with on a regular basis. Because an MPI is defined as an event in which our needs outweigh our resources, a seemingly simple collision can quickly meet these criteria. Like the fire service, being successful on small scale routine calls helps ensure our success on the large-scale, low-frequency events.

Administrators must accept that without an organized plan for units arriving on-scene, the necessary structure will never be established, and chaos will reign. Through sharing ideas and beginning discussion, any EMS system can design a plan to install ICS concepts on calls that involves more than three patients. Once the criteria for an MPI are defined for the EMS system, it is then important EMS providers know their roles on scene and have access to task cards reminding them of essentials tasks. Using concepts consistent with the National Incident Management System (NIMS), we can deliver this paradigm shift throughout our EMS systems.

Establishing Groups

In addition to training on staging, triage, treatment and transport, our focus is to organize and structure the scene. This begins with the initial arrival. The first EMS unit, if arriving as the first emergency services unit should establish command and triage. Having one provider establish and perform the initial functions of the incident commander allows the process of structure creation to occur. Having the other provider establish triage serves as a reminder to the crew that their initial role is to sort and assign, as opposed to select and treat as we are so accustomed.

By having the crew designate the role of triage, it allows the provider to focus on their objective and help nudge the appropriate behavior. When arriving on scene, after establishing the necessary components of ICS, priority should be given to performing an examination of the scene to provide the complete picture of the incident and to complete the scene size up. Performing the examination may lead to discovering hazards, additional patients or other challenges not originally anticipated.

Once the supervisor’s unit arrives, they establish command if not already performed by a fire unit and medical branch if command is already in place. By designating a medical branch, they are assuming the role of medical branch director. In this position, they will begin coordinating EMS resources and operations within the ICS and oversee triage, treatment and transportation groups. In the grand scope of ICS, the medical branch director will report to the operations section chief, if established. If not, the medical branch director will report directly to the incident commander.  

The first priority for the medical branch director is to ensure enough triage teams are in place. Performing rapid triage is the primary objective of the triage teams. Obtaining demographic information or performing more detailed assessments is conducted with secondary triage or in the treatment area and should not be performed during primary triage. Several triage algorithms are available, but we recommend a simple and subjective approach using the clinical judgment of providers. Primary triage should be quick and focused. Once the triage group is filled adequately we typically then assign the treatment group.

The treatment group provides on scene care to patients after being triaged but prior to leaving the scene. If a transporting ambulance is available, no critical patient should be delayed, but typically the resources are being overwhelmed. In this area of the operation, secondary triage can be performed and additional patient information obtained. This group will require several crews, depending on the size and scope of the scene. We will need to assign appropriate resources to each of the treatment areas and ensure the appropriate gear and medical supplies are available. We should remember when locating this group that we want to select a location that will allow us to be discreet as possible since care is being delivered. Also important when considering a location is to be in close proximity to the transportation group to facilitate the patients leaving the scene efficiently. Within the treatment group it is essential to have equipment to assist, such as colored tarps. Our system originally had our colored tarps on our MPI trailer, which is a resource that will arrive late in the operational period. We quickly learned that the treatment tarps were needed early in the event, and we added a set to each supervisor and administrative vehicle.

Once treatment is managed, we must assign our transportation group to remove the patients from the scene. Communication with area hospitals is key in regards to transportation. We found providing early information and regular updates helps with a better understanding of the scene and decreases anxiety as the hospital staff awaits the transporting units. The location of the transport group is an important factor to consider. Ingress and egress of the EMS unit should be easily conducted, preferably without having to back the EMS unit. Backing can be dangerous, and we should do our best to avoid it.³

The transportation group should be in close proximity to the treatment area and allow for a safe and efficient loading zone with a coordinated flow of EMS units. If possible, a one-way in and one-way out location works to prevent congestion. Our system learned of the need to inform providers that the transport group supervisor would decide on the transport location of each patient, as opposed to the assigned EMS crew deciding on a hospital. This provides equal patient distribution among the emergency departments. Transport also is responsible for patient tracking, which will be important as the event unfolds. Our system has yet to have a scene in which we weren’t asked by a parent, school administrator or other stakeholder, where a specific patient was transported. Having a system in place to track the transport of each patient will make the system appear well coordinated and adequately prepared to handle such a scene. There are some helpful resources within the SMART system and tags that assist with patient tracking, such as the detachable tabs. There are also more technical and advanced systems available. Regardless of the equipment used, you want to obtain he patient’s name, age, a description of injuries, transporting unit and destination.

Staging and Transporting Ambulances

Staging must be assigned and established early in the evolution of the scene to prevent vehicle congestion. Staging also prevents confusion about assignments and roles. During training, explain that the first units in will fill the essential groups and needed coordination roles listed above. Once those groups are assigned, have a designated assignment for all other units, such as “transport ambulance.” This designation becomes their pre-defined assignment and truly allows an assignment for all units, even those not filling the initial ICS positions. Having this assignment also means the crew will report to staging and stay in their unit, unless called to do otherwise. If they are called to depart their apparatus, the staging officer should require that the doors are unlocked and the keys remain in the vehicle. The last thing we want is to need to move a truck, but be locked out. Once the transport group calls staging to send resources, the transport ambulance will be sent to transportation to load a patient and transport to the assigned emergency department.

Equipment and Planning

In order to be successful at the assigned tasks, we must provide the necessary equipment. In our experience, each EMS unit was supplied with an accountability passport, a custom made MPI kit containing task cards for each role within the ICS structure, note pads, ink pens and clipboards. Supervisor units were outfitted with MPI task card kits, position vests, treatment tarps and SMART Command Packs, allowing them to oversee and coordinate the medical operations of a scene.

Additional training was needed for supervisory staff to perform incident command and medical branch roles. Training should be in place on NIMS and ICS standards for all personnel. Additional information and training on the National Incident Management System (NIMS) can be found at https://training.fema.gov/nims/. Another excellent resource for training your responders on the essentials of ICS can be found at https://training.fema.gov/emiweb/is/icsresource/index.htm.

In addition to training and use of ICS, an alarm system was created for dispatching a defined number of resources including EMS units, supervisor and administrative units based on the size of the scene and anticipated patient counts. Never before achieved in our system, this process ended years of requesting needed resources one-by-one. With the assistance of our training and administrative support staff, each unit was outfitted with a visor card containing each alarm level, when to request and what resources would be dispatched. Our system believes that the best performance is achieved by those best prepared. Adding this instant resource request was one of the best advancements of this planning process and we feel it is critical to MPI preparation. I recommend having some procedure in place to request multiple units at one time. This should be dependent on your system and number of available resources, but having a plan in place to request these units will aid your responders when there is a need to assist several patients at once. This system also assists those on the scene with knowledge of the number of responding resources, based on the alarm level that has been requested.

It is important for administration to foster an environment in which we call for resources early. Otherwise, we risk being behind from the beginning and we will cause delays in patient care by waiting until we know exactly how many patients we have. We also must foster a culture in which there is no criticism for calling more units than needed and no shame in placing only one patient per ambulance. The days of transporting three or more patients unsafely in one unit, just to save resources should be behind us. It is up to the crews and incident managers to decide how many units are truly needed on a scene and up to administration, through previous planning and system design, to ensure there are enough resources to meet the demand.

Conclusion

With preparation comes success. Our EMS system has already witnessed the success that comes with such thoughtful preparation. Just since the implementation of ICS for EMS, the system has responded to a school bus crash with 51 victims, a single vehicle crash of a 15 passenger van and a tour bus crash with several trauma patients, including a fatality. In addition, we continue to encounter routine vehicle crashes that meet the criteria of an MPI. The system also successfully tested our plans with other stakeholders in April 2015 at our Regional Airport in a mock crash scenario involving over 30 patients and several complicating factors.

Although the initial reaction to using ICS in EMS will receive mixed emotions, we must remember that we are changing long lasting paradigms, not just protocols. There is no reason that EMS personnel cannot be trained to establish the critical structure needed in the first minutes of any emergency scene. It is clear that if we don’t get control of the scene early, we seldom capture it. The Incident Command System is not about being in charge or issuing orders, rather it is all about structure, assignments and resources. In order to achieve our mission of excellent care, we must first provide the structure.

References

1. United States Fire Administration. (January 1999.) Incident Command for Emergency Medical Services. Retrieved January 5, 2016, from https://fire.nv.gov/uploadedFiles/firenvgov/content/bureaus/FST/ICSforEMS_SM.pdf

2. Bledsoe, Porter, & Cherry. Multiple-Casualty Incidents and Incident Management, Paramedic Care Principles and Practice. Volume 7 Operations. Pages 36-54, Upper Saddle River, New Jersey. 2013

3. Coffey, K. What Backing Up has to do with Our Corporate Safety Culture. Retrieved January 5, 2016, from Upside: The UPS Blog:

https://blog.ups.com/2013/03/01/what-backing-up-has-to-do-with-our-corporate-safety-culture/

Joshua B. Holloman, MHS, NRP, CEMSO, is the chief of the EMS Division for Johnston County Emergency Services in North Carolina. He is a certified firefighter, rescue technician, and fire, EMS and EMD instructor. He is an advocate for increasing education, professionalism, and leadership within emergency services