Ambulances & Vehicle Ops, Major Incidents

How to Operate and Manage the MCI Transportation Group

Issue 8 and Volume 41.

The transportation group is the most work intensive position at a mass casualty incident (MCI). It requires advance preparation, practice and confidence to be performed correctly. If it’s not performed well, critical patients may be sent to non-trauma centers, hospitals may become overloaded, and patients may be delayed care or family reunification.

Because it must be established early in the incident, one of the first arriving EMS transport units should serve in this role.

Roles

The transportation group is like many parts of the incident command system: Not every role is required for every incident and there are several ways to accomplish its functions based on system design, resources and communication capabilities.

Although several roles fall under the transportation group, two essential roles are the medical communications coordinator (MCC) and the transport recorder (TR). (See Figure 1, below.) The MCC is responsible for obtaining the capacity of hospitals and deciding where each patient is transported. The TR is the gatekeeper, recording the destination of each patient. In our system, the driver of the first arriving EMS unit assumes the TR role and the officer or attendant-in-charge assumes the MCC role.

Efficient EMS transportation during MCIs
Figure 1: Transportation group roles in the MCI operations group

Although two people can operate effectively as the transportation group, three is more effective. If a third person is riding in the unit, the roles can change slightly based on experience and training. The officer can assume the role of transportation group supervisor. A transportation group supervisor can monitor the radio, help funnel ambulance crews, and troubleshoot issues while the MCC and TR check out patients. On large MCIs, it’s essential to staff the transportation group supervisor position.

Other roles in the transportation group include the air and ground ambulance coordinators, often referred to as the staging officers for air and ground assets. These two roles report to the transportation group supervisor.

As ambulances are loading and transporting patients, the ground ambulance coordinator ensures an efficient flow in and out of the scene. This role ensures that ambulances park so that no other ambulance is blocked in.

The ground ambulance coordinator can be permitted to call the staging manager directly to request additional ambulances for patient transportation rather than going up the chain of command through the group supervisor, to the branch director, and finally to the section chief.

Efficient EMS transportation during MCIs
A disaster tag stub is removed to be placed on a Transport Recorder form while another patient is entered in an electronic patient tracker.

Location Selection & Setup

Before the transportation group is established, the proper location must be selected. The transportation group should position at a funnel point where every patient leaving the scene must pass. This is known as the patient exit point (PEP). This may be between the treatment areas and the location where the ambulances are being loaded. As patients are moved from a treatment area to a waiting ambulance, they can be contacted by the transportation group. (See Figure 2, below.)

If patients are being loaded in multiple locations on a scene, the transportation group may have to position at a PEP that’s remote from the scene. The latter operational position makes check-out procedures more cumbersome as ambulances have to stop after the patient is loaded.

Notify incident command once the exact location has been identified. Incident command and the communication center should make an announcement to all ambulances about where the PEP is located.

The transportation group’s ambulance should be positioned out of the flow of traffic but close enough to obtain equipment. Ensure that exhaust doesn’t blow fumes into the area where the transportation group operates.

Efficient EMS transportation during MCIs
Figure 2: Transportation group positioning at an MCI

There are several easy steps for a crew to set up the transportation group. First, take the ambulance cot out of the ambulance and place a backboard on it. This will serve as a mobile work station. It also provides a writing surface for tracking forms.

By removing the cot from the ambulance it can no longer transport any patients. This is a good thing. Patient tracking and destination management is essential to not relocating the MCI to a hospital.

Second, obtain all transportation group equipment. Each ambulance should be equipped with the equipment and supplies to serve in the role of the transportation group. This includes MCI vests, forms, pens, a portable radio, electronic patient tracking equipment (if used) and extra disaster tags.

As the transportation group is set up, it’s a good time to verbally ensure all group members understand their roles. Everyone should know who will answer the radio if called. To ensure no information is lost and to allow the rest of the crew to focus on their individual assignments, only one person—preferably the group supervisor—should answer the radio.

Communications

Upon establishing the transportation group, the MCC should contact the command or disaster coordinating hospital—also known as the regional hospital coordinating center (RHCC). The MCC should provide a situation, a potential number of patients, and the location of the incident. The RHCC will contact all of the surrounding hospitals that may receive patients.

After obtaining the bed capacity of the surrounding hospitals, the RHCC communicates this information back to the MCC. The RHCC should provide the MCC with the local bed capacity in less than 10 minutes.

The MCC form we use helps us manage the hospital status and the number of patients transported to each hospital. (See Figure 3, below.) The left side lists the hospitals in the local region but other hospitals can be written in at the bottom. The middle section denotes the capacity each hospital can manage and the right side lists the actual numbers sent to each hospital. Once capacity for a hospital is reached, it’s crossed off the list.

Efficient EMS transportation during MCIs
Figure 3: Medical communications form

It’s an acceptable practice to overestimate the number of casualties. This ensures that enough beds are available, especially for patients who initially claim they’re uninjured but are eventually transported or take themselves to the hospital.

While our MCC obtains hospital capacities, the TR prepares the Transport Recorder Form. One sheet is designated for each hospital where patients may be transported. This information is obtained from the MCC.

The MCC and TR should stay together throughout the event. The TR doesn’t mark which hospital the patient was transported to unless they hear this information from the MCC. The TR and MCC position themselves on the same side of the cot like a shared office desk. Although they stay together, they never manage—or even write on—each other’s forms. It’s too easy in the chaos of checking out patients for the MCC to place a sticker on a form or have the TR make a tick mark on the wrong form.

Checkout Procedures

With the transportation group positioned between the treatment areas and the loading ambulances, every patient is checked out as they’re moved to an ambulance. The MCC briefly stops the crew and asks them what the triage color is for their patient. The MCC then reviews their form and informs the crew which hospital can accept the patient. The MCC makes a tick mark on the sender side to document the patient has been transported to that hospital.

Simultaneously, the TR pulls the transportation stub off the disaster tag. The TR checks to see that this portion is complete because it’s essential for patient tracking. The TR then places the adhesive disaster tag stub on the transport recorder form for the appropriate hospital. If an electronic patient tracking technology is also utilized, this is the appropriate time to scan the bar code on the disaster tag stub.

Our experience is that once the TR and MCC check out a few patients, they become progressively faster and more efficient.

There may be an occasion when a patient is ready to leave the scene but hospital capacities haven’t been obtained from the RHCC. Experienced EMS providers will know which hospitals are trauma centers most likely to handle one or two red-tagged patients.

Situation Updates

As the incident progresses, the RHCC will want an update of the number and types of patients transported to each facility. RHCC can then communicate the progression of the incident to the region’s hospitals. This can also serve as an opportunity for the transportation group to request more bed capacity.

Other communication updates should be more regular. These consist of brief status updates from the incident commander or EMS branch leader. Command doesn’t need to get updates on the number and type of patient being transported to every individual hospital. Instead, command should communicate the total triage classifications that have left the scene (e.g., five reds, 10 yellows and 15 greens). Command shouldn’t be overly concerned with the exact number of patients who’ve been transported until they’ve all left the PEP.

Incident Demobilization

The transportation group has a few important items to address at the conclusion of the MCI.

First, the MCC and TR should compare forms. For each hospital, the number of tick marks and number of stickers should be the same.

This shows they kept an accurate count of patients as they left the PEP.

Second, they should communicate a final summation of patients—the total number transported for each triage category—to the incident commander or EMS branch leader.

Efficient EMS transportation during MCIs
The MCC should keep track of how many patients are going to each hospital.

Third, the TR and MCC forms should be archived in the electronic patient care reporting system. This step should be performed after the TR forms and MCC forms are used for family reunification, after-action reports or patient identification.

Conclusion

MCI operations training often consists of lectures and discussions of past incidents. It doesn’t often include practicing processing and tracking of patients. Using this simple process as a guide, we recommend agencies practice processing simulated patients. Recruit the local command hospital to obtain simulated hospital capacities. It’s important to prepare providers to fill transportation group roles before an incident occurs.