Communication and information management from the field to the care facilities are consistently challenging during disaster response. A critical interdependence exists among the following: accurate information from the field about the incident, medical needs at the scene, and patient numbers and types of their injuries. Care of these patients triaged and treated will affect the demand and use of resources such as ambulances, emergency departments, surgical suites, specialist needs, and intensive care units. Similarly, information on the availability of ambulances and hospital resources will alter the management and disposition of the victims at the scene.
Patient tracking is the art (and science) of determining which patient with which condition went to which destination (and where he or she is presently). This includes identification of the patient and identification of the patient’s intermediate and ultimate destination(s). Ideal practice would also have the patient’s medical records included with this tracking information and/or travel with the patient.
Recent acts of mass terrorism and natural disasters have called attention to the urgent need to improve response during mass-casualty incidents. The risk of these mass-casualty incidents appears to be increasing as a result of population growth, industrialization (and concomitant use of high-energy chemicals and sources), and the threat of terrorism. Following the initial impact of the disaster, the casualties generated by the disaster must be determined. Relatives of patients will want to know where their loved ones are being treated; law enforcement officials may want to interview survivors and suspects; and public health officials will want summaries of patient conditions, initial dispositions, and final disposition (if there is a change). To respond effectively to inquiries about the missing, victim data may have to be collected not just from hospitals but also from alternative care sites, shelters, jails, and morgues. Victim information should be collected at a central location and made available via telephone hotlines or websites distant from the impact area. In very large disasters, the numbers of inquiries about the missing can exacerbate local telephone and cellular circuit congestion and shut the services down momentarily. Hospitals may be reluctant to provide patient information to the Red Cross or local authorities because of concern about Health Insurance Portability and Accountability Act (HIPAA) regulations and patient confidentiality. However, HIPAA regulations do allow the release of information on patient names, locations, and general status for the purposes of notifying patients’ next of kin. (See www.hhs.gov.ocr/hipaa .)
Nevertheless, most disaster evacuees do not stay in public shelters and often do not require hospitalization, but rather seek refuge with family, friends, and neighbors or at a motel or hotel. Therefore, in order to track these victims, they will need to be contacted via the mass media and encouraged to register via telephone hotlines or websites. Tracking of these noninjured evacuees is beyond the scope of this chapter.
Historical perspective
If the disaster happens in an isolated area, such as a complex multivehicle accident along I-80 in Wyoming, tracking of patients is comparatively easy; most (if not all) casualties will be taken to one or two facilities. In such a disaster, the major casualty tracking problem generated is identification of victims who have been burned beyond recognition. In large-scale disasters and/or in disasters in urban areas, casualties may have multiple potential destinations. The patient-destination matching is complicated by the large number of patients who will take available transportation to a medical facility without involving emergency medical service(s) (EMS) workers. For example, during the response to the 9/11 World Trade Center attack, only 6.8% were transported by ambulance. In addition, emergency response units from surrounding jurisdictions will often self-dispatch to the disaster. , Accordingly, they may not be aware of existing local victim-tracking system(s). Further complications include air evacuation to remote destinations, transfers to higher levels of care for patients with more complex conditions, and switch of destination during EMS transport. In response to Hurricane Katrina, for example, children were taken to different states than their parents.
In a disaster, a number of factors make it difficult or impossible to track patients from scene to final destination.
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The number of patients generated may exceed the capacity of the local EMS system.
- 2.
There may be multiple incident locations geographically separated.
- 3.
Multiple EMS systems may be assigned or may self-deploy into the affected region. These providers may use differing systems for patient tracking that may or may not be intercompatible. ,
- 4.
EMS providers may transport patients to alternate care facilities when the hospital system is overwhelmed.
- 5.
EMS providers may be diverted en route to their assigned hospital or other destination.
- 6.
Hospital facilities may be damaged and be forced to evacuate existing patients and/or divert incoming patients, while simultaneously receiving casualties from one or more disaster scenes.
- 7.
Patients may be transported to other cities, counties, states, or countries, depending on the magnitude of the disaster. Parents or guardians may or may not accompany the evacuee in this case.
- 8.
Hospital medical record systems, communications, and EMS tracking systems may be inoperable because of damage or power failure.
- 9.
With electronic systems, data from one system may be in a format that is incompatible with other systems.
Current practice
Although separate from triage, the tracking process starts with triage. As patients are categorized by the triage officer and assistant triage officers, they are often tagged with a visible indicator of their priority (triage tags) or grouped with similar types of patients in a geographic area (geographic triage). Tracking can start with the recording of these patients (and as much data as time and condition permits) as they enter the medical care system. The patient-tracking officer(s) can relay the information via phone, radio, or fax, sending the information to the destination, although in practice this is often a difficult task.
There are currently two general types of tracking systems in use in the field setting: ( ) manual, consisting of paper tags, cards, and charts and ( ) electronic, depending on bar codes or radio frequency identification (RFID) devices and/or Wi-Fi networks.
Manual Systems: Paper Tags, Cards, and Charts
When a triage or medical documentation tag is applied to the patient, the preassigned number on the tag is the patient’s first identification in the system. In some systems, this tag may be the only reported identification and documentation of medical care until the patient is taken to the hospital. (This tag may also have a bar code or an RFID to enable electronic systems.)
If the appropriate systems and supports are in place, a triage officer can rapidly prepare a patient-tracking list containing the patient’s identification number, sex, apparent age, triage condition, destination, and the time the patient left the scene. The receiving hospital prepares a similar list with identification number, sex, apparent age, triage condition, disposition, and time of disposition upon arrival of those patients ( Fig. 55-1 ). Paper tracking forms are nationally recognized and available as Hospital Incident Command System (HICS) forms 254, 255, and 260; their use is incorporated in many HICS and other incident command courses.
Several commercially available tag systems can be purchased ( Fig. 55-2 ). These include the METTAG and the Multi-Tag. These tags are preprinted with a unique number to facilitate patient tracking during an incident. Each contains a section for patient information and a section with tear-off strips to categorize the patient’s condition. Many municipal and state variants of these tags have been developed. These multiple tag and card formats may be used in the same disaster by different teams responding under cross-state mutual aid agreements. This allows the possibility of identical patient numbers for different patients, as well as creating confusion for medical providers receiving patients with different charting systems.
These tags are advocated by multiple incident training programs such as the Major Incident Medical Management and Support training program. , In these systems, either tags or a substitute (such as pieces of colored aluminum, colored chemical light sticks, or surveyor’s tape in multiple colors [red, green, yellow, black, or white]) are used to tag each patient. Other examples of medical documentation cards designed to travel with the patient include the NATO military “casualty cards” and the International Committee of the Red Cross casualty card. These alternative systems often have no unique identification number for the casualty.
There are several disadvantages to the use of paper tags and cards for patient-tracking purposes.
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Application of tags takes time. There is only a single accident where triage tags have been described as being of benefit and this was limited to 22 live casualties. Indeed, multiple casualties have been managed without triage tags, and significant time was thought to have been saved in the Sioux City, Iowa, DC-10 plane crash. (The alternative to triage tags was a geographical system of triage and sorting.)
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Triage tags are often not weather resistant and may be destroyed or mutilated easily. Water can smudge and render illegible data on triage tags.
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Triage tags provide no advance information to the destination. (The information provided is also unavailable to other sites.)
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When patient information, such as vital signs, condition, or even destination changes, it may be difficult to change the card or tag. Tear-off triage tags allow only unidirectional changes in the patient’s condition. Tear-off triage tags may be changed easily by patients or family members in an effort to upgrade the triage classification and expedite medical care or evacuation.
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There is little limited paper “real estate” space for continuation of vital signs and additional information. On the way to the hospital, the EMS provider can often obtain quite a bit of additional information, for example, comorbid factors such as diabetes and heart disease, allergies, and current medications. The usual tag does not provide space for this information to the treating physician or medical provider.
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Triage tags are often discarded at the hospital, even though they should be part of the medical record. They are often an awkward shape to put into the medical record and may not be recognized by the medical records clerks as part of the medical record. Documentation cards that are attached to the patient in some form are more likely to remain with that patient and document recent medical interventions to the receiving hospital.
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When a destination is overwhelmed and the ambulance is diverted to a different destination, the paper triage tag does not reflect a new destination back to the triage officer.
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One of the factors that complicates the use of tracking systems (e.g., triage tags) is the logical and appropriate tendency in disasters to abandon paperwork in favor of treating patients.
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In some disasters, triage tags have not been available where needed.
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Triage tags do have significant advantages:
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They are cheap and simple to use.
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They are widely used, so many prehospital providers are familiar with their use and layout.
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Even cross training with different tag formats is relatively rapid and simple.
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They require little financial outlay for the disaster response team prior to the accident.
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They consistently work despite degradation of power supplies and adverse weather conditions.
Electronic Systems: Bar Codes or RFID and Wi-Fi Networks
Commercial package tracking as used by FedEx and UPS allows customers to find the shipping status and location of bar-coded packages and envelopes online. These tracking programs use RFID or bar codes to allow electronic reading of the package identification and subsequent transmission of package location. Extension of this technology to triage and patient-tracking programs remedies most of the faults of the paper system and allows the hospital, EMS dispatcher, triage officer, and other appropriate parties to track the human package from triage site to final destination. , Alternative schemes with handheld collection devices to supplement basic triage tag data collection have added additional medical information and linked this to the triage tag number and the medical record.
There are no current nationally recommended electronic systems, although data exchange standards are in development. Several victim-tracking systems have been designed to aid the reunification of family members following a large-scale disaster. The Department of Defense (DoD) and National Disaster Medical System (NDMS) in the United States uses a system developed by the U.S. Air Force, called TRAC2ES, which tracks patients transferred to partner hospitals in the DOD and/or NDMS system. The American Red Cross uses a system called “Safe and Well,” in a website that allows individuals on the Internet to notify others that they are safe and well.
A bar code is an optical machine-readable representation of a unique alphanumeric number. Originally developed in the 1960s to identify railcars from a distance, they have become ubiquitous identification of stock numbers in many industries. Bar codes for patient tracking may be found on triage tags or bracelets that are attached to the patient. Bar code readers can be dedicated devices or even programs (apps) on smartphones or computers and are inexpensive and readily available.
RFID is a non–line-of-sight and contact-less automatic identification technology. It is capable of communicating remotely, even when obscured, and without direct contact between the chip and the receiver. The identification data are stored on chips that can be attached or imbedded in products, tags, or even humans. The chip is an integrated circuit (about 0.4 × 0.4 mm in size) and an integrated antenna. The antenna size dictates the distance from which the chip can be interrogated by a reader. Chips may have an integral power supply or be powered by induction or radiation from the reader. An inherent strength of RFID chips is that they can provide both spatial and temporal context to the tagged subject, in addition to the unique identity code.
By scanning a unique patient wristband, tag, or RFID at any location (disaster site, site treatment center, emergency department, hospital ward, operating suite, or ICU), the electronic system can track and provide the last known location of patients. , These systems have been tested in simulated disaster drills in the United States and Europe with good efficacy. , Similar systems using an RFID chip can allow remote query of the triage tag or band. , Marathon runners at large races are tracked during the race with similar technology, which can provide an accurate location of each runner during the race. The addition of a Wi-Fi network collection point would allow real-time tracking, dispatch, and diversion updates to all participating hospitals and agencies. This gives any participating agency the ability to direct family members to the last known location of the patient.
Bar-coded tags or RFID with Wi-Fi networks do have some significant disadvantages, however.
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The technology requires a Wi-Fi network infrastructure to be set up at the disaster site. This requires a substantial hardware and software outlay for all participating agencies and hospitals. The system may be unavailable if any electromagnetic jamming occurs, and will be destroyed by any electromagnetic pulse (EMP) effect, which is significant in the case of a nuclear weapon explosion.
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The overall security of Wi-Fi networks is open to question. Both modification of data and compromise of patient medical data can occur with Wi-Fi networks.
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Each bar code system represents a proprietary software system that may be incompatible with another similar system. This may have significance in adjoining city, county, or state governments and some mutual response agreements. As noted below, standards are being developed to mitigate this problem.
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Bar code systems require the presence of providers with scanning devices to obtain the tracking data. Keyboard entry of data can occur, but it is much slower and requires a computer with attendant power supply.
Use of bar code readers or RFID and networked computers has significant advantages to all parties, including the patient:
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Information about prospective patients is readily available to the receiving hospital. (Information about final destination is available to the dispatch officer for further transportation planning.)
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Information about patients at one facility is readily available to other participating hospitals and agencies.
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Information entered travels with a casualty and can be cross-referenced to medical history, when available. Allergies, medications, and comorbid factors can be entered at participating sites, at any point in the evacuation process. This information can follow the casualty through all levels of medical treatment and be concisely printed for the patient’s final chart.
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Information is not limited to a small amount of paper “real estate.” This information can even include pictures of the patient and identifying personal effects.
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Entry of initial data and identification of patients in a selected area are both rapid as the bar code is scanned with a reader.
The disaster medicine practitioner should remember that bar codes and RFID are simply a rapid means of data entry and not the tracking system itself. They do not give the patient condition or location without the accompanying and functioning software program and associated network and hardware.
General Considerations
In the design of tracking systems, whether manual or electronic, the following factors must be considered:
- 1.
Data entry
- a.
Who will enter the data?
- i.
Does data entry require specialized tools or training?
- ii.
How much data can be automatically uploaded or entered to minimize data entry burdens?
- i.
- b.
How will it be entered?
- i.
Can the data be entered under adverse conditions such as in the back of a moving ambulance?
- i.
- c.
How much data will be entered about each patient?
- i.
What are critical data?
- ii.
What additional elements would be desirable but not mandatory?
- i.
- d.
How long will it take to enter the data?
- i.
Typically providers prefer to do patient care rather than data entry, so data entry often suffers when providers feel that patient care is jeopardized.
- i.
- a.
- 2.
Data dissemination
- a.
How will the data be aggregated?
- b.
How will it be disseminated?
- c.
Who will get the data and how much data will be transmitted?
- i.
As communications degrade, data transmission rates will markedly decrease.
- ii.
Does the system automatically decrease data transmitted by shedding noncritical elements, retaining these in a common server as communications degrade? (Pictures are large data items and often not immediately critical elements.)
- i.
- d.
How will the data be protected from inappropriate access?
- e.
Where will the data be stored?
- a.
- 3.
Who is the system meant for?
- a.
Should the system be designed only for “local use,” or is it meant to collect and share with multiple communities, counties, the entire state, neighboring states, national, or even international.
- a.
- 4.
What is the current system in place?
- a.
Is the current or proposed system compatible with other systems employed by EMS providers that may respond to a disaster?
- a.
- 5.
How much will the system cost?
- a.
How much will equipment cost?
- b.
How much will training cost?
- c.
How much will maintenance cost?
- a.
- 6.
How well will the system work when power supplies, communications systems, or logistical resupply is degraded?
- a.
What is essential to ensure the smooth functioning of the system under adverse weather considerations?
- a.
- 7.
Will the system actually be used in a real disaster if it is substantially different from the day-to-day systems used by responders and clinicians?
Related posts:
Role of Emergency Medical Services in Disaster Management and Preparedness
Psychological Impact of Disaster on Displaced Populations and Refugees of Multiple Traumas
Nongovernmental Organizations in Disaster Medicine
Worker Health and Safety in Disaster Response
Community Hazard Vulnerability Assessment
The Role of Social Media in Disasters
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