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Triage and Discharge Acuity scale (TAS/DAS) for mass gathering events Derivation, validation, and application of the TAS/DAS to assist in the planning, execution, and study of medical services at mass gathering events Department of Family Medicine Research day June 17, 2011 Dr. Lyndsey J. Wong, R2

Acknowledgments • UBC Department of Emergency Medicine • Lion’s Gate Hospital Foundation • Royal Columbian Hospital Authors: – Dr. Adam Lund – MD, MDE, FRCPC – Dr. Sheila Turris – PhD, NP, RN – Dr. Samuel Gutman – MD, CFPC-EM (RockDoc) – Kerrie Lewis – EMR, LPN, RA • Michael Wasdell – Statistician • Camila Guan – MS-III No direct conflicts of interest.

Objectives • Define and describe: – Mass gathering events (MGE) – Mass Gathering Medicine (MGM) – MGM Interest Group (MGMIG) – Triage • What is TAS/DAS? • Reasons for the TAS/DAS project • Summary of ongoing work • potential Impact

Mass Gathering Events • >1000 people – Concerts – Sporting events – Political – Cultural – Festivals • Spectators, participants, performers • Sudden increase of Local population • Metropolitan, community or remote setting – Large event sites

Why do we care? • Increased injuries in healthy individuals • Delayed emergency response – limited access /other challenges • Overwhelm local medical services – Primary Care Providers – Community Resources – Volunteers • Planning based on experience – No evidence of best Practice

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Mass Gathering Medicine : Interest Group (MGMIG) • Disaster / Emergency Medicine • Primary Care Principles • Community Health • Founded in 2008 – Drs. Samuel J. Gutman and Adam Lund • multi-disciplinary team

Triage • Means of prioritizing patients’ care – Disaster / pre-hospital / hospital • Determine acuity • Resource allocation • Track workload • Predict outcomes • Future projections • combination of measures: – Physiological – Anatomical (Mechanism)

Triage and Discharge Acuity Scale (TAS/DAS) Project • Phase I: Literature Review on Triage Systems • Phase II: Retrospective Application – Part 1 : 30-case Online Survey – Part 2 : Retrospective Cohort Study • Phase III: Prospective Application

PHASE I • Literature review – Is there a triage system that we can use in the setting of mass gatherings? • Review of triage and systems utilized in Mass Gatherings and disasters • “needs assessment” for phases II and III – No perfect triage system

Why create TAS/DAS? • Lack of consensus in the literature • no existing system for MGEs • So how do we… – "classify" patients? – Measure acuity of presentations? – quantify work? – Track acute vs non-acute presentations? – Communicate between care providers? – Compare between events?

What is TAS/DAS? • Patient-sorting system – Built on START and CTAS • 5 categories: – BLACK: deceased / expectant – RED: emergent – YELLOW: urgent – GREEN: minor – WHITE: dispensary • color is assigned: – On arrival – On discharge

PHASE II • Retrospectively: – What is the inter-rater and intra-rater reliability of the TAS/DAS scale within a group of multi-disciplinary health care providers? – Is the TAS/DAS accurate in predicting acuity for a set of patient encounters?

Phase II: Part 1 • Retrospective Application of TAS/DAS – Quantitative Survey • Teaching presentation to MGM care providers (n=~60) – 30-case online test – Triage Acuity Scale (TAS) level and Discharge Acuity Scale (DAS) level for each case

Phase II: Part 2 • Retrospective cohort study design – 4 MGM health care providers – 100 cases from past MGM events – Both TAS and DAS levels – recorded in an electronic format – Responses will be exported for statistical analysis

PHASE III : Field Test • Prospectively: – What is the inter-rater reliability? – Is the TAS/DAS accurate in predicting acuity? • Live application at ~ 10 events – ~2500 patient encounters  500 cases – standardized, blinded, prospective dual scaling of patients

Potential Impact • Patient care • Primary Care / Health Care Providers • Inter-disciplinary Team – Communication • Community resources / health system • Literature – Common Dialect • Evidence-based Medicine – MGM “Handbook” • Future planning and finances

References • www.ubcmgm.ca • Lund A, Turris SA, Gutman SJ, Bayliss A. Mass Gathering Medicine Online Registry Project. Department of Emergency Medicine, UBC. Last accessed on December 31, 2010 at URL: = http://www.ubcmgm.ca/registry/ • Turris SA, Lund A. Triage During Mass Gatherings. 2010. (Publication accepted to Prehospital & Disaster Medicine in December 2010.) • Navin DM, Sacco WJ, McCord TB. Does START triage work? The answer is clear! Ann Emerg Med. 2010 Jun; 55(6):579,80; author reply 580-1. • Murray M, Bullard M, Grafstein E, CTAS National Working Group, CEDIS National Working Group. Revisions to the Canadian Emergency Department Triage and Acuity Scale Implementation Guidelines. CJEM 2004 Nov; 6(6):421-7.

Step 1: The Quick Look LOOK : “sick” or “not sick” FEEL: Radial pulse ASK: name If: not alert , not conversing appropriately, obviously breathless , and/or weak HR < 50 or >140 = unstable  RED (Otherwise  Step 2)

Step 2: Chief Concern If: potentially serious (e.g., severe pain, collapse, etc) AND the quick look was stable  Assign YELLOW , GREEN , or WHITE  Proceed to Step 3

Step 3: Considerations – drug and/or alcohol involvement – mechanism of injury (e.g., fall <10 feet)  Bump up a color  REPEAT upon discharge or transfer

Triage : BLACK – RARELY used (Red during resus) – Warm and dead at the scene – Burns over 100% of body – Gunshot wound to head with absent vitals Deceased/Expectant

Triage : RED – Fall from greater than 10 feet – Collapse – Chest pain – Anaphylactic reaction Emergent

Triage : Yellow – Fall from less than 10 feet – Overdose without compromise to airway, breathing, or circulation – Shortness of breath – Severe pain Urgent

Triage : Green – Ankle injury – Mild to moderate back pain – Minor wound – Rash – Prescription requests Minor

Triage : White – Bandage or product dispensing – Sunscreen requests – Privacy • independent insulin injection • breastfeeding or diaper change Dispensary

Test your knowledge… 1. Hives with normal vital signs and alert 2. Cardiac arrest with no vital signs, not rousable 3. Bandaid request 4. Severe back pain, alert, normal vital signs 5. Breathless with normal vital signs and alert 6. Fall from 8 foot ladder with loss of consciousness at scene 7. Diaper change request 8. Scratchy eyes with normal vital signs and alert 9. Blunt trauma with no vital signs, unresponsive 10. Cough with normal vital signs, alert

Answers 1. Green 2. Red 3. White 4. Yellow 5. Green 6. Red 7. White 8. Green 9. Black/Red 10. Green