MassCATT: Beyond Color Coding
10:30 a.m. – Noon
Suzy Fitzgerald, MD, FAEM
Emergency Physician
Kaiser Permanente – Diablo Service Area
Emergency Preparedness
Kaiser Permanente Northern California

I have nothing to disclose
3
1
4
5


Triage from the French “trier” = to sort
Daily emergency triage

Disaster/MCI triage
 Do the most we can for each individual
 Greatest good for the greatest number
 Treat the most serious but salvageable
first
 Balance between needs & resources
6
2
7
8
Primary triage outside hospital
 Walking versus gurney
 Secondary triage by senior surgeon
 Immediate vs. delayed vs. unsalvageable
 All treatment areas under the command of
senior surgeons
 Rapid forward flow is key

9
3
Each bed staffed by an anesthesiologist,
a junior surgeon, a senior surgeon, and
two RNs
 ABCDE — trauma survey approach
w/ FAST
 Goal is airway control, vascular access,
control of external hemorrhage
 Turnaround time 5–15 minutes

10
The “Golden
Hour of Trauma”
11






Algorithmic Approach To Care
System/Flow Established In Advance
Supporting Protocols In Place
Full Medical Center “Buy-In”
High Volume = Lots Of Practice
Pre-identified Destinations For EMS
12
4
No hospital-based advanced MCI
triage systems
 Several field MCI triage systems in
existence in US

 START/JumpSTART
 Sacco Triage Method
 SMART
 Triage Sieve
13
RED/Immediate: Life-threatening but
treatable injuries requiring rapid medical
attention
 YELLOW/Delayed: Potentially serious
injuries that are stable enough to wait a short
time for treatment
 GREEN/Minor: Minor injuries that can wait
longer for treatment

14

GRAY/Expectant: With life signs but
injuries or illness incompatible with survival
in current conditions given resource
availability.
 BLACK/Deceased: Dead, i.e. without life
signs after life-saving interventions
attempted if appropriate.
15
5

CDC workgroup assembled in 2008
to standardize field MCI triage 
SALT Triage Algorithm
 Sort
 Assess
 Life-Saving Interventions
 Treatment and/or Transport
16
17
18
6

Hospital-based MCI advanced
triage algorithm that goes beyond
primary color-coding triage step

Guidelines for ED and hospital
patient management in a mass
casualty event
19
Researched
Adapted
 Reached-out
 Testing/Drilling
 Refining
 Implementing


20
Primary triage via SALT algorithm
Advanced Triage via ABCDE survey
 Prioritize/Stratify by:


 Exam findings/injury and illness
patterns
 Where they need to go next
 How quickly they need to go there
21
7
1.
Decon needed?
NO  Go to Step 2
YES  Quick visual assessment:
Walking  End of decon line
Ill-appearing  Front of line
22
2.
Primary Triage – SALT
23
24
8

Immediate care area
▪ ABCDE – ATLS/ACLS approach
▪ FAST exam/portable CXR on all pts
▪ Other bedside XRs/testing prn
▪ Assign MassCATT level
25

Delayed care area
▪ ABCDE – ATLS/ACLS approach
▪ FAST Exam/XRs prn
▪ Bedside testing/labs/other testing prn
▪ Assign MassCATT level
26







Management-changing testing only
Bedside testing whenever possible
Roving Radiology Techs
Roving US Techs
Roving Radiologists
Delayed imaging strategies
Roving C-arm/Fluoro
27
9
Example: R-OR-1
1st Designation = Primary Triage Level
2nd Designation = Next Step in Care
(1–5: 1 is highest)
3rd Designation = Priority Relative to Other Patients 28
29
Consult? • What service?
Operating Room? • What operative service?
Admit?
• What service?
• What level of care?
Additional Tests?
• CT?
• Other?
Color‐
Coded Treatment Area?
Discharge or Transfer?
‐Where?
• Pending what?
30
10

Prioritization for CT and ICU care:
 CT results must change management
 ICU care must have potential to change
immediate outcome
Certain trauma, surgical, and medical
conditions higher-risk
 Decision making must balance:

 Stability of patients relative to each other
 Resource availability
31
Priority categories 1–5
R-OR-1 priority over Y-OR-1
Ranking based on relative stability
Relative priority may change as
patients change
 Target management/outcomechanging diagnostics and
interventions




32






26 year old male presents complaining
of abdominal pain after being pinned
underneath a beam in a damaged
building.
Alert, conversant, obeying commands
Breathing with some respiratory
distress
Radial pulse present
Bleeding controlled
Primary triage level?
33
11





RED
YELLOW
GREEN
GRAY
BLACK
34
35
 Airway
◦ Talking
 Breathing
◦ Clear breath sounds bilaterally
◦ No crepitus/No step off
 Circulation
◦ No palpable radial pulses
◦ Weak femoral pulses bilaterally
◦ BP 70/40
36
12
 Disability
◦ GCS 15
◦ Moves 4 extremities
 Exposure
◦ Ecchymoses noted across abdomen in “seat
belt sign” pattern
37
FAST Exam
38
 MassCATT
level?
 R-OR-1
 R-CT-1
 R-SURG-1
 R-ICU-1
 Other
39
13






44-year old female brought in from
collapsed bridge structure with right leg
pain
Alert and interactive
Breathing with minimal to no distress
Radial pulse present
Bleeding controlled
Primary triage level?
40
RED
YELLOW
 GREEN
 GRAY
 BLACK


41

Airway

Breathing

Circulation
 Intact
 Normal
 Heart Rate 95
 BP 120/90
42
14

Disability
 GCS: 15
▪ Spontaneous eye opening
▪ Conversent
▪ Moves 4 extremities on command

Exposure
 Right leg with open fracture tib-fib, bleeding
controlled with pulses intact distally
43






MassCATT level?
Y-OR-1
Y-OR-2
Y-ORTHO-1
Y-MEDSURG-1
Other
44
Additional Second Tier development
work in progress
 Refinement of:
 Priority assignment process/priority
categories
 Movement between categories as
assessment progresses
 And so on…

45
15
Research
Adapt
 Review/Reach-out
 Teach/Train
 Refine
 Implement


46
SALT/START/etc.
ATLS/ACLS
 MCI management across the world
 Schecter, Einav, Peleg, et al.
 MCI management in the US
 Alabama/Missouri tornados
 Colorado shooting


47

The Who
 Physicians
 Nurses
 Administrators
 ED Techs
 Unit Assistants
 Registration Clerks
48
16

The What:
 FAST exams
 Digital portable x-rays
 Bedside lab testing
 Availability of specialized auxiliary
testing
49

The How:
 Operating Room capacity 24/7?
 Blood bank/rapid transfusion protocol
 Specialty support for special
populations
 Transfer processes for special
populations
50

Figure out what you have

Figure out what you don’t have
51
17

Engage the key players:
 Physician/RN/Other Medical Staff
 Administration
 Ancillary Services
 Emergency Management
 Others
52

Goal is three-fold:
 Familiarization/understanding of
MassCATT
 Opportunity for your own experts to
review
 Tailoring/implementation of MassCATT
for your facility
53

Education and Training:
 Staff/Department Meetings/Grand
Rounds/Conferences
 ED/Hospital Disaster Response Teams
 Emergency Management Training/Drill
Program
 DRILLS, DRILLS, and MORE DRILLS
54
18

Steps:
Primary Triage with SALT
Advanced Triage with ATLS/ACLS Survey
 Assign MassCATT Level



Key Concepts:
Management Changing Testing
Outcome Changing Interventions
 Fast Forward Flow


56
[email protected]
57
Questions
19