An EMS Problem (Still) With a Simple Solution
Medic 41 is dispatched as part of a mass casualty task force responding to multiple persons injured in a pedestrian-struck incident in your downtown district. It is a beautiful summer Friday night. Many patrons are dining in a vibrant outdoor area when a large pickup truck careens into several dozen patrons and their tables that are spilling over into the sidewalk. The driver eventually crashes into a pole at the end of the block. Local law enforcement stationed in the area respond immediately and apprehend the driver, who is uninjured, incoherent and mumbling incessantly while other police officers began making initial assessments and deploying their issued tactical emergency casualty care kits (TECC). Initial uninjured well-intentioned citizens, many of whom had the forethought to train beyond a Stop the Bleed® course by attending your agency’s Be the Help-Until Help Arrives program, are also acting as active bystanders tending to the wounded.
Upon your arrival in Medic 41, you find 20-30 people strewn about the block suffering from various levels of trauma. Additional resources are streaming into the area and command advises that mass-casualty incident (MCI) protocols are to be instituted and requests additional EMS resources, both ground and aeromedical. Local hospitals are notified of the developing incident by the regional communications center and are preparing for multiple victims.
- Lessons Learned from EMS Response to the Orlando Pulse Nightclub Shooting
- How EMS and Fire Processes Must Change During Dynamic and Active Threat Situations
- The Basics of Mass Casualty Triage
- How to Operate and Manage the MCI Transportation Group
Because of the chaos, an accurate patient count is unobtainable. Your agency utilizes triage tags that get affixed to the patient’s wrist via lanyard with barcodes attached, but the process is cumbersome and not well-practiced. Furthermore, the tracking system fails because of the level of detail required and it is not supported by the hospital or emergency management system. A separate information and reunification center is established by the Office of Emergency Management in an attempt to coordinate with multiple hospital personnel for victim location information. Ultimately, family members of both deceased victims and survivors arrive at area medical facilities in frustration and anguish seeking information on their loved ones believed to be involved and who are not answering their cell phones.
Many months later, during the written after-action report (AAR), the jurisdiction is faulted for not having a more robust patient tracking capability despite well-advanced patient care capabilities. In the court of public opinion, this failure highlights gaps in patient tracking capabilities despite other heroic efforts by medical and law enforcement personnel.
In total, 17 patients were transported to multiple area trauma centers and emergency departments. Nine persons with minor injuries refused transport. Three victims, including one pediatric patient, were pronounced deceased on the scene due to traumatic injuries incompatible with life. Your department also activated its peer support team and requested neighboring mutual aid for backfill of stations while personnel debriefed and returned units to service.
Historically, patient tracking and/or family reunification has been identified as an operational gap in AARs for significant responses worldwide. Whether it was the Boston Marathon Bombing, the Aurora Movie Theater shooting, Pulse nightclub, London 7-7 Bombings, or 1 Oct. massacre, these incidents struggled with accurate accountability of victims. The Aurora, Colorado AAR stated, “triage units did not use a patient identification system (triage ribbons or tags), which made tracking for transportation, and quick evaluation at the hospitals, more difficult.”1
These atypical emergencies are certainly significant in their operational response complexity. It is often concluded that inefficiencies in patient tracking or awareness of victim location would be a reasonable challenge; however, this issue is problematic even for more traditional emergency incidents — the multi-vehicle car accident, the multi-family apartment fire or the localized flood. This manuscript attempts to answer such questions as why does patient tracking and the subsequent larger challenge, family reunification, continue to be a significant gap? Why does the emergency response system continue to fail in this critical competency within the response and recovery phase? This manuscript explores contributing factors around patient tracking and family reunification and provides a recommendation on a viable and simple solution.
Patient tracking is the ability to understand where patients, victims or clients are at any point during an emergency; from the time emergency response agencies take “ownership” of an individual through definitive medical care. Family reunification is a broader challenge that involves patient and family accountability. Reunification is a broader challenge because it is responsible for notifying individuals post-emergency/disaster about their loved one who may or may not be alive, injured, transported or hospitalized. The importance of effectively tracking patients and victims of emergencies cannot be overstated. To understand the importance of this issue, imagine a scenario where a family member of yours is injured or missing after an incident. Having a patient tracking system that can expand to a more extensive family reunification capability is vital for accountability and timely family notification. According to the Aurora Century 16 Theater Shooting AAR, “[b]y early afternoon of the day of the incident, approximately 100 people still remained at the school.” [Family Reunification Center]. The group included 10 families and friends who were waiting for news. They were briefed periodically about the status of the investigation and the process for identifying the deceased. Each time a meeting was convened at Gateway, they prepared themselves for the official announcement. They became emotionally drained as the day wore on and each announcement fell short of the only information they truly wanted.”2 Although there are legal and criminal investigation requirements for scene processing of victims, there is little doubt that a scalable patient tracking system could have mitigated this issue.
Fire/EMS agencies are responsible for the tracking of patients on a day-to-day basis and they perform admirably with incidents involving smaller patient counts. Countless times a day, throughout the country, patients experience an emergency to which fire and EMS respond, treat and transport the individual to an appropriate destination. Because the emergency involves a small number of patients or there are enough resources on scene to manage effectively, the location and status of patients does not become an issue. The system knows where patients are going or command can, without too much trouble, determine their location when in question.
Complex emergencies and circumstances that overstress commanders or outweigh organizational capabilities lead to patient tracking challenges. These complex events require command structures and response assets that take time to organize and establish effectively. These structures require significant personnel , requiring all command components to have a thorough knowledge of mass casualty management — a rare event for most public safety agencies. Preparing for these complex events takes significant leadership and departmental effort that is rarely prioritized.
Our world is becoming more complicated and interconnected. As populations increase, urban areas are expanding, and once rural areas are being reclassified as suburban. What was previously suburban migrates toward urban. For many of these areas throughout the country, the emergency response system is also complicated. Multiple response organizations, coupled with numerous jurisdictions, entities and hospitals, confound preparedness, response and recovery efforts. Ultimately, in many urban and suburban locales, patient tracking and family reunification requires a multi-agency, multi-jurisdictional solution. But what agency or discipline is responsible for patient tracking? Who is responsible for family reunification? These are questions that must be discussed by senior leaders at the local and regional level with the goal of determining an effective patient tracking/family reunification solution.
Solutions need not be complicated. Many emergency response organizations require a patient tracking solution to be a component of a broader system that can be utilized daily that is easily incorporated into existing systems. Other desirable attributes include scalability and an intuitive interaction — requiring little to no training. Although this is, in most cases, unrealistic. It also complicates the problem. Perhaps a different approach is warranted? What if there was a solution that is simple, intuitive and designed specifically for patient tracking/family reunification?
If patient tracking is such as high priority issue, and if not managed appropriately, causes severe anguish to bystanders, family and those with a need-to-know, what then are the most basic inputs to a patient tracking system to enable success? At the core of this question, a patient’s identifiers and location are the most essential pieces of information. If emergency services could answer these questions expediently, public safety agencies could declare success as it relates to current notifications and reunification shortfalls. The fact that your blood pressure is low, or that you are unconscious is at the core of the true patient tracking issue, just extra information. Who are you, and where are you, are the imperative questions. Everything else, in the context of an extremely chaotic mass casualty incident, can, and should, wait until after lifesaving treatment. In fact, the question “where are you” may be the only question pertinent since we can solve both issues, geography and identity, with only one question by leveraging technology.
Current options are limited and do not add value to the overall goal of decreasing complexity during emergent events. Certainly, some departments may still rely on paper methods of tracking usually implemented within an EMS branch or triage, treatment or transportation group. Visibility of patient whereabouts for providers and incident commanders across the incident, and certainly the hospital staff, is non-existent with this method. Long-term documentation of patient tracking is also problematic with paper-based solutions. Other solutions currently in practice involve a triage card, with or without peelable barcodes attached, affixed to the patient usually around the wrist.
These triage cards are sometimes difficult to keep with the patient and, depending on the environment, can be difficult to document information. Blood, sweat or other fluids can significantly decrease the capability of these cards. In some other cases, duplicate tags may be printed, or the tag may detach from the patient. If laminated to resist moisture, special writing instruments may be needed to document information fully. Finally, some newer solutions scan barcodes or QR codes to upload a tag into a patient care record using a digital device. Many of these systems are bogged down by extra information which impedes usage and user adherence to the system. Indeed, given the myriad of technological advances we currently leverage in EMS, emergency management and the fire service, there must be a better and more efficient way to solve the patient tracking problem.
New Solutions to Patient Tracking
Albert Einstein ascribed that we cannot solve our problems with the same thinking we used when we created them. Newer systems that leverage technology to the advantage of EMS currently exists, which decreases overall incident complexity. This adds to the ability to potentially solve patient tracking in terms of efficiency within an operation and overall government effectiveness. In the above examples mentioned, EMS is adding a unique identifier to the patient, such as a barcode or triage card. What if the patient already had a unique identifier that they were born with that required no additional information to be added? What if your face acted as your bar code?
A patient’s face is sometimes used, depending on the agency, to accurately identify a victim in law enforcement cases and at the medical examiner’s office. Therefore, why does EMS not utilize a patient’s most unique identifying feature as well; their face? This enables positive control and tracking across the life-cycle of an incident. New technologies currently in use in EMS have the ability to facial match victims, which is a gamechanger. Jeff Dulin, strategic advisor at the International Association of Fire Chiefs (IAFC), has developed multiple innovative and geospatial platforms enabling first responders to be more effective and efficient. He states, “the problem of patient tracking is well documented and becomes an impediment when done poorly to what first responders do best, which is to protect the public and save lives. This new commercial off-the-shelf (COTS) technology incorporating geospatial awareness is already proven effective by DHS for fire and EMS and it should be broadly implemented to finally solve this issue.” Incorporating devices that providers are already bringing to the incident is critical for the adoption of any new technology.
Many EMS providers are already familiar with navigating their camera, which adds to the adoption rate of the technology. A provider can snap a picture at the point of injury and enter very minimal patient information if available and upload the data for processing. This can be completed multiple times in an incident, in a triage area, in the back of an ambulance, in the registration section at definitive care, or at a recovery/assistance center. All images get compiled into one patient record by the technology for an incident commander, EMS transportation supervisor, EOC, or hospital administrator to view in real-time. All of it is secure, fully HIPAA compliant and customizable, which are critical features required to aid the adoption of new technologies within EMS to solve patient tracking.
What are the Drivers for New Action?
Implementing a Systems Approach
Patient tracking systems in the United States have never been coordinated nor optimized from a systems approach. Agencies wishing to solve the issue have sought solutions that may have met some of their needs but were not implemented throughout the entire ecosystem of response and recovery. This issue begets problems in training and maintaining the capability as well as negating momentum towards standardization of patient tracking efforts.
The Israeli’s have a long history of dealing with terrorism and disaster response and instituted a national system of identification and patient tracking using photographs that are administered by the hospital system. While the political and structural differences in the Israeli national model diverge from the United States, a systems-based approach must be envisioned to solve this issue.3 If patient tracking is everyone’s problem in emergent response and recovery, it is actually no one’s problem to own. Leadership must emerge somewhere within the response chain and build consensus with stakeholders to drive capability development in solving this issue. The EMS system in partnership with emergency management and the hospitals are a logical team to coalesce.
In the Boston AAR, “several hospitals reported having difficulty sorting and tracking patients.”4 Someone must take ownership, and more importantly leadership, of optimizing patient tracking as an expected service of the government. The issues discussed with patients arriving at medical facilities either by private citizen transport, self-referral or by law enforcement emphasize the need for hospitals to coordinate their efforts with the authority having jurisdiction. The Pulse AAR demonstrated a “lack of communication and coordination [that] impacted the ability of OFD incident command to properly track the number of patients, their injuries, and the medical facilities to which they were transported.”5
Given the cited examples of historical confusion and breakdown in reunification efforts after mass casualty events, there are also legal implications for fixing the issues in patient tracking. After the Pulse Nightclub massacre, collective efforts were made to standardize preparedness efforts for high-threat events which previously did not exist. As a result, the National Fire Protection Agency has now published its standard for Active Shooter and Hostile Event Response (ASHER). While this standard is not a legislative mandate, it does give consensus-based guidelines for action that an agency will be held to in court. It also recommends “use of electronic, web-based systems for victim tracing, notification of families and loved ones, and hospital capabilities (i.e., numbers of victims per triage category that can be managed as the incident progresses).”6 Unified command also has the responsibility to provide for immediate recovery and victim reunification. Using a simple patient tracking tool that can be used for both injured and uninjured meets the much-needed guidelines of NFPA 3000.
Interestingly, NFPA 3000 was not siloed in development and represented consensus across all disciplines and stakeholders within the active shooter workspace, not just fire and emergency medical services. Current image-based patient tracking systems extend beyond just prehospital EMS into Emergency Operations Center (EOC) and recovery functions representing additional efficiencies and cost savings. This issue is not only limited to the United States. During the 7/7 bombings, “the London Ambulance Service has itself acknowledged that there was inadequate tracking of injured patients…This problem causes unnecessary distress to the injured and their loved ones, and can result delays of several hours, and in some cases days, before families are notified of the whereabouts of their missing relative or loved one.”7
Increasing Atypical Transport Platforms of Victims from Hostile Events
In several high-threat incidents, to include the Aurora Colorado shooting, victims were transported by law enforcement, or as in the 1 October event, many civilians volunteered their vehicles as evacuation platforms. These atypical transports apply additional complexity to the problem of patient tracking. Many of these issues could be mitigated with a systems approach incorporating both hospitals and law enforcement into the patient tracking ecosystem, not just traditional partners, such as fire and EMS. Some law enforcement agencies routinely transport trauma patients from the incident scene before the arrival of EMS, making this issue prevalent for immediate action.8
Bring Your Own Device/Commercial Off the Shelf (COTS)
Many modern workforces are experiencing and leveraging employees who bring their devices to work (BYOD). This opportunity represents cost savings and increases in efficiencies if technology can be integrated appropriately. Many in emergency services already use smart devices, including cellphones and tablets, to accomplish their daily mission. They also use software-as-a-service applications to realize greater situational awareness of incidents. These larger industry trends should be captured in future patient tracking systems for several reasons. Device familiarity and workflow are already established. Any additional training required is minimal. Finally, the agency does not have to maintain separate equipment for patient tracking, and it can be integrated into daily operations promoting adoption. The COTS architecture facilitates just-in-time training when required leading to increased proficiency of use by EMS personnel.
One unique issue for any patient tracking technology is scale. An effective platform must meet the needs of low acuity events such as multiple vehicle accidents that have multiple patients with minor injuries to large scale natural or manmade events that threaten large numbers of lives with severe injuries. The system should also flex to accommodate atypical or catastrophic events that get to be so big you can, unfortunately, see them from space. If the patient tracking tool uses facial recognition technology, scaling becomes a low hurdle. This new and novel system is also designed to adapt for infrastructure degradation issues when connectivity is absent. Scaling also becomes easier from a training and equipment standpoint when the technology is intuitive enough to become proficient just-in-time or with minimal effort. Software-as-a-service provides value across all sizes of organizations such that cost, especially start-up and sustainment costs, are manageable for any size organization.
Any new technology always has predicted patterns of adoption, which can be enhanced by accounting for other risks.9 Those risks include funding, privacy issues and security. New systems in place today account for all three. Given the technology employed and the software-as-a-service business model, costs are lower than comparable electronic technology that has been previously brought to market. There is also a higher rate of return on the investment since this new technology is designed to be used within multiple disciplines within the jurisdiction, completing a true systems approach. One review of federal grant funds spent on an electronic patient tracking system for the National Capital Region (NCR) showed millions of dollars of funds encumbered without any appreciable increase in current capability representing significant leadership failures, fiduciary irresponsibility, and lost opportunity.10
New patient tracking must also value the security of medical data to ensure successful implementation. New systems use bank-level encryption and are validated to be HIPAA compliant by third parties. While no electronic data is ever completely immune from hackers, this represents a risk mitigated strategy to have both an efficient tool and adequate security measures. Privacy is also substantively addressed. Some law enforcement agencies cannot use facial imaging as an identifier by local ordinance. This is an evaluation that every jurisdiction will have to undertake. However, the newest systems restrict access to patient information by the provider to soften this concern and architect other safeguards to ensure privacy. Also, given these new tools are used for specific purposes during medical treatment for exigent circumstances and not for law enforcement identification, the use case has been accepted as a technological enhancement of the current standard of care.11
In summary, new technologies for patient tracking currently in use today represent the way forward for emergency medical services. Accurately identifying where a victim is located is a key metric associated with successful resolution of mass casualty and high-threat incidents. Using paper or barcode-based technology is duplicative and inhibitive to patient tracking since each patient already possesses a unique identifier. Leveraging technology while understanding human systems in emergencies can decrease the complexity and failure points associated with patient tracking. Ultimately, agencies must partner more broadly to initiate a systems approach for full patient tracking capability development within a jurisdiction. This should be occurring anyway to prepare for high-threat incidents which necessitate a multi-discipline response. New facial recognition patient tracking technology expands return on investment, helps meet national standards and undoubtedly can provide quicker physical and emotional resolution to chaotic events by optimizing the patient tracking system.
- TriData Division, System Planning Corporation, “Aurora Century 16 Theater Shooting After Action Report for the City of Aurora, Colorado,” April 2014, 79, https://www.policefoundation.org/wp-content/uploads/2016/08/Aurora-Century-16-Theater-Shooting_AAR.pdf.
- TriData Division, System Planning Corporation, 125.
- Hospital Underground,” EMS World, accessed April 19, 2021, https://www.emsworld.com/article/10318687/hospital-underground.
- “After Action Report for the Response to the 2013 Boston Marathon Bombings,” December 2014, 92, https://www.policefoundation.org/wp-content/uploads/2015/05/after-action-report-for-the-response-to-the-2013-boston-marathon-bombings_0.pdf.
- National Police Foundation, “After-Action Review of the Orlando Fire Department Response to the Attack at Pulse Nightclub,” October 2018, 19–20, https://flingtrack.com/images/files/Orlando_FD_Response_to_Pulse_AAR.PDF.
- National Fire Protection Agency, “NFPA 3000: Standard for an Active Shooter/Hostile Event Response (ASHER) Program,” 2021, 3000–3037, https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=3000.
- London Assembly and Greater London Authority, eds., Report of the 7 July Review Committee (London: Greater London Authority, 2006), 75.
- Eric Winter et al., “Association of Police Transport with Survival among Patients with Penetrating Trauma in Philadelphia, Pennsylvania,” JAMA Network Open 4, no. 1 (2021): e2034868–e2034868.
- Everett M. Rogers, Diffusion of Innovations, 5th ed. (New York: Free Press, 2003).
- DC HSEMA, “National Capital Region: Urban Areas Security Initiative,” November 1, 2011, https://hsema.dc.gov/sites/default/files/dc/sites/hsema/publication/attachments/Urban%20Area%20Security%20Initiatives.pdf.
- Omnicon Health Group, “The Face as the Key to Unlocking Health Information,” October 2017, https://omnicomhealthgroup.com/pdfs/OHG-Facial-Recognition.pdf.