Eugene Nielsen
The Hartford Consensus represents a significant shift in the approach to handling mass casualty events. By compressing the zones of care and integrating the roles of different responders, it aims to save more lives in the critical moments following such events.
The Hartford Consensus is a set of lifesaving recommendations developed in response to the increasing frequency of active shooter and intentional mass casualty events. Initiated by the American College of Surgeons and the Federal Bureau of Investigation, the Consensus aims to enhance survivability from such incidents. The approach emphasizes the importance of early hemorrhage control, even by nonmedical bystanders, to improve survival rates.
The Hartford Consensus has significantly influenced trauma systems and policies, leading to a paradigm shift in the management of mass casualty incidents. It proposes an integrated response to active shooter situations and intentional mass casualty events.
THREAT: A Critical Acronym
The Hartford Consensus recommends that an integrated active shooter response should include the critical actions contained in the acronym THREAT:
Threat suppression
Hemorrhage control
Rapid Extrication to safety
Assessment by medical providers
Transport to definitive care
Compressing the Zones of Care
A key component of the Hartford Consensus is the concept of compressing the zones of care. Traditionally, in the immediate aftermath of a mass casualty event, a wide “hot zone” is cordoned off until all threats are suppressed. This approach can lead to some lives being lost through caution.
The Hartford Consensus suggests modifying this plan to allow earlier access to victims outside the real hot zone, the location of the active shooter or a possible bomb. This requires new systems of integration and coordination between law enforcement and other teams of responders to ensure mutual understanding and sequencing of roles.
In the context of law enforcement and emergency response, the terms “hot zone,” “warm zone” and “cold zone” are used to denote different levels of threat within an area.
1. Hot Zone: This is the area where a direct and immediate threat exists. The emphasis in this zone is on threat suppression, preventing further casualties, extracting casualties from the high threat area, and implementing control of life-threatening extremity hemorrhage.
2. Warm Zone: This is the area where a potential threat exists, but there is no direct or immediate threat. Warm zone care includes the other life-saving interventions associated with applying the MARCH (Massive hemorrhage, Airway, Respiration, Circulation, and Hypothermia) algorithm in the tactical environment. Casualty collection points and rescue task forces are typically employed within the warm zone.
3. Cold Zone: This is the area where no significant threat is reasonably anticipated and additional medical/transport resources may be staged. Cold zone care generally falls under established local, regional or state protocols rather than national tactical casualty care guidelines in the civilian setting.
By compressing these zones, it means that the boundaries between these zones are minimized, allowing for a more efficient transition from one zone to another. This is particularly important in situations where time is of the essence, such as when administering bleeding control techniques. The quicker a casualty can be moved from the hot zone to the warm zone, and then to the cold zone, the sooner they can receive the necessary medical attention, potentially saving more lives.
This approach requires careful coordination and communication among all involved parties, including law enforcement, fire and Emergency Medical Services (EMS) agencies. It’s part of a broader shift towards more integrated and responsive care in emergency situations.
Challenges
Implementing the Hartford Consensus and its approach to compressing the zones of care presents several challenges:
1. Integration of Different Responders: The Hartford Consensus requires an integrated response from different responders such as law enforcement officers, Emergency Medical Technicians (EMTs), paramedics, and firefighters. This requires new systems of integration and coordination to ensure mutual understanding and sequencing of roles.
2. Training and Skill Retention: The Hartford Consensus emphasizes the importance of training immediate responders and professional first responders in effective hemorrhage control. However, maintaining skill retention over time can be a challenge.
3. Data Collection and Patient Outcomes: There is a need for improved data collection on patient outcomes to better quantify the program’s impact. This can be challenging due to the complexity and unpredictability of mass casualty events.
4. Public Resilience: Enhancing public resilience to potential hazards has been identified as a priority for domestic preparedness. This involves educating the public about the THREAT response and empowering them to act in the event of a mass casualty incident.
5. Resource Allocation: Implementing the Hartford Consensus requires resources for training, equipment and system development. Allocating these resources effectively can be a difficult task.
These challenges highlight the complexity of implementing the Hartford Consensus. However, overcoming these issues can lead to significant improvements in the response to and survivability of mass casualty events.
SALT Triage Guideline
Triage is essential for managing multiple casualty events and an essential component of an integrated response. It prioritizes treatment to use available resources as efficiently as possible and ensures that care is focused on those casualties most likely to benefit from the limited resources available. Without an integrated approach, some patients may arrive at the hospital without having been adequately assessed or triaged at the scene. Therefore, response to these events requires efficiency and coordination.
While several triage systems exist to assist providers in making rapid decisions during such events, there is limited scientific evidence validating any specific system. Additionally, the lack of consistency across jurisdictions within the United States further complicates the application of mass casualty triage.
To address these challenges, the Centers for Disease Control and Prevention (CDC) sponsored a working group to develop a standardized triage method. The result is the SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) triage guideline. SALT integrates elements from various existing triage systems, creating a comprehensive framework for mass casualty triage nationwide. It aligns with the Model Uniform Core Criteria for Mass Casualty Triage which is currently proposed as the national standard for all such systems. First responders use SALT to rapidly classify casualties and determine their treatment priorities.
The Components of SALT Triage
1. Sort – Initial sorting of victims based on their immediate needs. This step helps identify those who require immediate attention.
2. Assess – a thorough assessment of each victim’s condition. It involves evaluating vital signs, injuries and overall severity.
3. Lifesaving Interventions – immediate lifesaving measures are applied to victims with critical injuries. These interventions aim to stabilize the patient and prevent further deterioration.
4. Treatment/Transport – victims are categorized into different groups:
- Immediate – those needing urgent medical attention.
- Delayed – injuries are serious, but not immediately life-threatening.
- Minimal – minor injuries which can wait for treatment.
- Expectant – victims with severe injuries unlikely to survive despite intervention.
Advantages of SALT Triage
1. Standardization: SALT provides a consistent framework for first responders, ensuring uniformity in assessments and decision-making.
2. Accuracy: By eliminating the confusion of traditional “black” and “red” categories, SALT improves accuracy in prioritizing victims.
3. Nationwide Adoption: SALT has gained widespread acceptance, making it easier for emergency personnel to collaborate during large-scale incidents.
4. Efficiency: SALT triage plays a crucial role in efficiently managing mass casualty incidents, ensuring that resources are allocated effectively to save lives.
Applying SALT
Let’s break down how SALT is applied in practice.
1. Global Sorting: First, responders request any patients who are able to walk to move to a designated area. This clears space for accessing more critical patients. Next, responders ask the remaining patients to wave or make purposeful movements. Patients who did not make purposeful movements are assessed first, as they have the highest likelihood of life-threatening injuries. Patients who were able to make purposeful movements, but unable to walk, are assessed next, followed by those who were able to walk.
2. Individual Assessment: During individual assessment, responders perform lifesaving interventions, if necessary, and within their scope of practice. These interventions include controlling major hemorrhage; opening the airway (and providing rescue breaths to children, if necessary); chest decompression; and, if required, administering auto-injector antidotes (for exposure to nerve or chemical agents).
Responders evaluate the following criteria for each patient:
- Breathing: Is the patient breathing? This helps separate those who are already deceased from those who are not.
- Mental status: Can the patient follow simple commands? Altered mental status may indicate a head injury or other condition.
- Peripheral pulse: Assess for the presence of a peripheral pulse. Absence of a pulse may indicate poor perfusion due to blood loss.
- Likelihood of survival given current resources: This assessment considers available resources at the scene and may change over time.
- Respiratory distress: Respiratory distress following a traumatic injury can be a sign of a life-threatening condition.
3. Triage Tags: Based on the assessment, patients are categorized into the following groups.
- Expectant: Victims who are deceased or not expected to survive due to severe injuries.
- Immediate: Victims with severe injuries requiring immediate treatment.
- Delayed: Victims with potentially severe injuries, but treatment can be delayed for a few hours.
- Minor: Victims with minor injuries not requiring immediate treatment.
Training
Adequate training and preparation of Medical First Responders (MFRs) are essential for optimal performance in highly demanding situations like disasters. The training needs to be as realistic and productive as possible, because precise and effective behavior of MFRs under stress is central for ensuring patients’ survival and recovery.
The training methods used to prepare MFRs for disasters vary. They include traditional methods such as lectures and real-life scenario training, as well as technology-based methods like computer-based learning and educational videos. While all methods demonstrated effectiveness, the literature indicates that technology-based methods often lead to similar or greater training outcomes than traditional trainings.
SALT triage training is available from the National Disaster Life Support Foundation (NDLSF). The NDLSF is a 501(c)(3) not for profit foundation which oversees a series of educational programs which are designed to better prepare health care professionals and emergency response personnel for mass casualty events.
Mass casualty triage skills are of utmost importance for first responders. These skills allow first responders to efficiently and effectively prioritize care during MCIs, ensuring that the most critically injured or ill individuals receive care first. As such, it is crucial that first responders receive comprehensive and effective training in mass casualty triage skills to ensure they are prepared for these challenging situations.
The SALT triage guideline provides a unified approach, combining the best available science and consensus opinion, to enhance the effectiveness and consistency of mass casualty triage across the United States.
Coordination
Coordinating with multiple agencies during a mass casualty incident can be challenging due to several factors:
1. Task Flow: This includes task allocation and scheduling. It can be difficult to determine who should do what and when, especially when multiple agencies are involved.
2. Resource Allocation: Determining how to distribute resources effectively can be a challenge, especially when resources are limited.
3. Information Flow: Ensuring clear and effective communication between responders is crucial. Miscommunication or lack of communication can lead to confusion and inefficiency.
4. Decision-Making Speed: The speed at which decisions are made can impact the effectiveness of the response. Delays in decision-making can lead to delays in response.
5. Relationships Between Responders: The relationships between different responders can impact the coordination effort. For example, if there is a lack of trust or understanding between agencies, this can hinder coordination.
6. Unified Command Approach: Because multiple agencies may have leadership responsibilities in a mass casualty incident, a unified command approach is essential. This enables disparate entities to collaborate and actively participate in the development of incident goals, objectives and an overarching response strategy.
7. Doing the Greatest Good for the Greatest Number: Efforts may need to be directed toward doing the greatest good for the greatest number of people which is counter to day-to-day trauma triage.
These challenges highlight the complexity of coordinating with multiple agencies during a mass casualty incident. However, overcoming these challenges can lead to significant improvements in the response to and survivability of such incidents.
Training for Mass Casualty Events
Ongoing training for mass casualty events and regular practice drills can help prepare first responders and hospital personnel. Public education, such as the STOP THE BLEED® Program, provides opportunities for physicians and first responders to teach the public how to assist in a bleeding emergency before first responders arrive at the scene.
Regular training and exercises can help prepare staff for the “chaotic atmosphere” of a mass casualty incident. Personnel should be pretrained to deliver “just-in-time training” to bystanders and spontaneous volunteers who may arrive at the scene of a mass casualty incident.
Communities should ensure access to necessary equipment and supplies. EMS and other first responders should be properly stocked with trauma bags, tourniquets, tarps, triage tags, boundary tape, and medical supplies.
Preparing for a mass casualty incident requires planning and training in individual knowledge, leadership preparation and team/department/interdepartmental skills.
The Hartford Consensus represents a significant shift in the approach to handling mass casualty events. By compressing the zones of care and integrating the roles of different responders, it aims to save more lives in the critical moments following such events.
Resources
1. STOP THE BLEED (STOPTHEBLEED.org)
2. National Disaster Life Support Foundation (NDLSF.org)
Eugene Nielsen is the owner and operator of a firm which provides private intelligence, security consulting and training services. He has a background in law enforcement and a BA degree from the University of California. He has written over 1,500 articles which have been published in various national and international journals and magazines. He was a member of SWAT Magazine’s contributing staff for more than 20 years.
Hartford Consensus Compendium
Stopthebleed.org is a Web site developed by the American College of Surgeons to provide training and resources on how to control severe bleeding and save lives in emergencies. The Web site offers a series of training resources available online, including a video course and a QR code link to an online version of the course.
Download A Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events compendium.
This publication serves as a guide for first responders from law enforcement, fire departments, emergency medical services, and the military in working together to frame an improved response system.
Stopthebleed.org also has a Resource Hub where training materials to learn about bleeding control techniques .