Triage Zone Module
Note: Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable
Observer: _________________________________________ Date: ____/____/_______
Observer title: ____________________________________________________________
Hospital: ________________________________________________________________
Period of time of evaluation: ______ AM/PM (Circle one.) to _____ AM/PM (Circle one.) |
1. Time Points
1a. Did the drill start on time? Y / N / U
Comments: |
1b. Time the drill began: (Circle one.) ______ AM / PM / U |
1c. Time this zone was ready to accept victims: (Circle one.) ______ AM / PM / U |
Zone Description
2a. Were the zone boundaries clearly defined? Y / N / U
Comments: |
2b. How was the boundary for this zone defined? (Check all that apply.)
a. ___ Barricade(s) b. ___ Sign(s) c. ___ Tape
d. ___ Wall(s) e. ___ No boundary f. ___ Other (specify): _________________ |
3. Personnel
3a. Did someone assume command of this zone? Y / N / U
Comments: |
3b. Was staffing for the triage zone adequate? Y / N / U
Comments: |
3c. How many minutes after the drill activities in this zone commenced did the incident commander assume command of the zone? (Check one.)
___ <10 min ___ 10 - 29 min ___ 30 - 59 min
___ 1 - 2 hrs ___ >2 hrs ___ NA
___ No one took charge. |
3d. Were the following drill participants identifiable?
a. Person in charge Y / N / U / NA b. Drill evaluators Y / N / U / NA
c. Drill organizers Y / N / U / NA d. Media Y / N / U / NA
e. Medical personnel Y / N / U / NA f. Mock victims Y / N / U / NA
g. Observers Y / N / U / NA h. Security Y / N / U / NA
|
4. Zone Operations
4a. Did the triage area function efficiently? Y / N / U
Comments: |
4b. Was the hospital disaster plan followed? Y / N / U / Partially / No plan |
4c. If not followed, what were the reason(s)? (Check all that apply.)
a. ___ Not available b. ___ Too complex
c. ___ Not relevant to drill d. ___ Participants unfamiliar with plan
e. ___ Too hard to access f. ___ Other (specify): ___________________________________ |
4d. If the hospital disaster plan was available, what was its format? (Check all that apply.)
a. ___ Complete manual b. ___ Flow diagram c. ___ Job action sheets
d. ___ No disaster plan e. ___ Other (specify): __________________________________ |
4e. Was the space allocated for the zone adequate? Y / N / U |
4f. If victims were screened for biological, chemical, or radiological exposure, how were they screened? (Check all that apply.)
a. ___ Personal interview b. ___ Physical examination c. ___ Screening device (e.g., radiation or chemical detector)
d. ___ Not screened e. ___ NA f. ___ Other (specify): ______________ |
4g. Did a bottleneck develop in this zone? Y / N / U
If a bottleneck did develop, describe in the comment box at the end of this module. |
4h. If triage occurs after decontamination, did any contaminated victims enter this zone? Y / N / U / NA |
5. Victim Documentation and Tracking:
5a. Were all incoming victims registered and given a unique identification or medical record number? Y / N / U
Comments:
|
5b. When were incoming victims registered and given a unique identification or medical record number? (Check one.)
___ Before entering this zone ___ On entering this zone
___ Not while in this zone ___ Unclear |
5c. What was the method of documenting the victim record in this zone? (Check all that apply.)
a. ___ Computer entry b. ___ Data card(s) attached to victims
c. ___ Scanner d. ___ Separate victim paper chart
e. ___ No documentation f. ___ Other (specify): ________________________________
|
5d. Were clearly visible triage levels identified for each patient prior to leaving the triage area? Y / N / U / NA |
5e. Was information about victims' prior field interventions accessible to caregivers? Y / N / U / NA |
6. Communications
6a. Were communications effective? Y / N / U
Comments: |
Were the following communications devices used in the drill for internal or external communications? (Check all that apply.) |
Communications Device |
A. Used |
B. Comments (Note strengths and weaknesses.) |
6b. 2-way radio/phone(s) |
|
|
6c. Landline phone(s) |
|
|
6d. Cell phone(s) |
|
|
6e. Personal data assistant(s) (PDA) |
|
|
6f. Numeric paging |
|
|
6g. Overhead paging |
|
|
6h. Text paging |
|
|
6i. E-mail/Internet/network |
|
|
6j. Fax machine(s) |
|
|
6k. Intercom |
|
|
6l. Megaphone(s) |
|
|
6m. Runner(s) |
|
|
6n. Satellite phone(s) |
|
|
6o. Emergency radio |
|
|
6p. Ham radio |
|
|
6q. Other (specify): _________________ |
|
|
|
7. Information Flow
7a. Was necessary information received? Y / N / U
Comments: |
|
7b. Did your zone receive updates regarding the situation outside the hospital (e.g. status of disaster events, number of victims arriving, acuity of victims)? Y / N / U |
7c. How was this zone kept aware of the ongoing general situation within the hospital? (Check all that apply.)
___ Call from incident command ___ Fax from incident command
___ Other contact from incident command ___ Runner(s) from incident command
___ Contact from other internal sources (specify): ________________________________ |
8. Security
8a. Were entrances and exits strictly controlled in this area? Y / N / U
Comments: |
8b. Did any of the following security issues arise in this zone? (Check all that apply)
a. ___ Crowd control b. ___ Media control
c. ___ Unruly victims d. ___ Other (specify): _________________________________
|
8c. Were security personnel present in this zone? Y / N / U |
9. Personal Protective Equipment (PPE) and Safety:
9a. Was an appropriate supply of PPE available? Y / N / U
Comments: |
9b. Was the PPE applied correctly? Y / N / U
Comments: |
If needed, were these items for standard precautions available for the healthcare workers?
If safety materials were not available, circle "N" in column "A" and go to the next row. |
Safety material |
A. Available? |
B. Used by staff? |
C. Adequate supply? |
D. Problems with use? (e.g., donning) |
9c. Face shields/masks |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9d. Waterproof gowns |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9e. Isolation gowns |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9f. Gloves |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9g. Passive (negative pressure) filtration (e.g., N95 or N99 masks) |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9h. Respirators (e.g., powered air purifying respirator) |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9i. Other (specify): _______________ |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
|
9j. Were instructions available regarding appropriate donning and removal of PPE? Y / N / U |
9k. If available, in what format were they? (Check all that apply).
a. ___ Verbal instructions by staff b. ___ Poster(s) c. ___ Written instruction(s)
d. ___ Video e. ___ Other (specify): ___________________________ |
10. Equipment and Supplies
10a. Were there appropriate quantities of medical supplies? Y / N / U
Comments: |
Were these medical supplies available?
If the medical supplies were not available, circle "N" in column "A" and go to the next row. |
Medical Supply |
A. Available |
B. Issues |
10b. Alcohol-based hand cleaner |
Y / N / U / NA |
|
10c. Bandages |
Y / N / U / NA |
|
10d. Basic airway equipment |
Y / N / U / NA |
|
10e. Blood pressure equipment |
Y / N / U / NA |
|
10f. Oxygen masks |
Y / N / U / NA |
|
10g. Oxygen tanks |
Y / N / U / NA |
|
10h. Stethoscopes |
Y / N / U / NA |
|
10i. Stretchers |
Y / N / U / NA |
|
10j. Suction equipment |
Y / N / U / NA |
|
10k. Vascular access supplies (catheters, fluids, etc) |
Y / N / U / NA |
|
10l. Wheelchairs |
Y / N / U / NA |
|
10m. Other (specify): _______________ |
Y / N / U / NA |
|
|
Comments (If referring to a specific item, give the item number.)
|
Return to Contents
Treatment Zone Module
Instructions: This form can be used in the Emergency Department, and in medical and surgical care areas.
Note: Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable
Observer: _________________________________________ Date: ____/____/_______
Observer title: ______________________________________________________________________
Hospital: __________________________________________________________________________
Period of time of evaluation: ______ AM/PM (Circle one.) to _____ AM/PM (Circle one.) |
1. Time Points
1a. Did the drill start on time? Y / N / U
Comments: |
1b. Time the drill began: (Circle one.) ______ AM / PM / U |
1c. Time this zone was ready to accept victims: (Circle one.) ______ AM / PM / U |
Zone Description
2a. Were the zone boundaries clearly defined? Y / N / U
Comments: |
2b. What type of unit is this zone during regular hospital functioning? (Check all that apply.)
a. ___ Emergency Department (ED) b. ___ Intensive Care (ICU)
c. ___ Medical Inpatient d. ___ Medical Outpatient
e. ___ Surgical Inpatient f. ___ Surgical Outpatient
g. ___ Other (specify): _______________________________________________________ |
2c. Were actual patients treated in the drill treatment area (along with mock victims)? Y / N / U |
3. Personnel
3a. Did someone assume command of this zone? Y / N / U
Comments: |
3b. Was staffing of the treatment zone adequate? Y / N / U
Comments: |
3c. How many minutes after the drill activities in this zone commenced did someone assume command of the zone? (Check one.)
___ <10 min __ 10 - 29 min ___ 30 - 59 min ___ 1 - 2 hrs ___>2 hrs ___ NA
___ No one took charge. |
3d. Were the following drill participants identifiable?
a. Drill evaluators Y / N / U / NA b. Drill organizers Y / N / U / NA
c. Media Y / N / U / NA d. Medical personnel Y / N / U / NA
e. Mock victims Y / N / U / NA f. Observers Y / N / U / NA
g. Security Y / N / U / NA
|
4. Zone Operations
4a. Did the treatment area function efficiently? Y / N / U
Comments: |
4b. Was the hospital disaster plan followed? Y / N / U / Partially / No plan |
4c. If not followed, what were the reason(s)? (Check all that apply.)
a. ___ Not available b. ___ Too complex
c. ___ Not relevant to dril d. ___ Participants unfamiliar with plan
e. ___ Too hard to access f. ___ Other (specify): ___________________________________ |
4d. If the hospital disaster plan was available, what was its format? (Check all that apply.)
a. ___ Complete manual b. ___ Flow diagram c. ___ Job action sheets
d. ___ No disaster plan e. ___ Other (specify): ____________________________________ |
4e. Was the space allocated for the zone adequate? Y / N / U
If space allocated was not adequate, specify in comment box at end of this module. |
4f. Did a bottleneck develop in this zone? Y / N / U
If a bottleneck did develop, describe in the comment box at the end of this module. |
4g. How were victims managed who were not previously triaged? (Check one.)
___ Sent back to triage zone ___ Sent to another area (specify): ________________________
___ Triaged in this zone ___ Treated without being triaged |
4h. Did all victims have disposition decisions made at drill termination? Y / N / U / NA |
4i. Did any contaminated victims enter this zone? Y / N / U / NA |
5. Victim Documentation and Tracking
5a. Were all incoming victims registered and given a unique identification or medical record number? Y / N / U
Comments: |
5b. When were all incoming victims registered and given a unique identification or medical record number? (Check one.)
___ Before entering this zone ___ On entering this zone
___ Not while in this zone ___ Unclear |
5c. What was the method of documenting the victim record in this zone? (Check all that apply.)
a. ___ Computer entry b. ___ Data card(s) attached to victims
c. ___ Dictation system d. ___ Personal data assistant (PDA)
e. ___ Scanner f. ___ Separate victim paper chart
g. ___ No documentation h. ___ Expedited registration
i. ___ Other (specify): ________________________________
|
5d. Were triage designations for each patient clearly visible upon entry into the treatment area? Y / N / U / NA |
5e. Was information about victims' prior field interventions accessible to caregivers? Y / N / U / NA |
6. Communications
6a. Were communications effective? Y / N / U
Comments: |
Were the following communications devices used in the drill for internal or external communications? (Check all that apply.) |
Communications Device |
A. Used |
B. Comments (Note strengths and weaknesses.) |
6b. 2-way radio/phone(s) |
|
|
6c. Landline phone(s) |
|
|
6d. Cell phone(s) |
|
|
6e. Personal data assistant(s) (PDA) |
|
|
6f. Numeric paging |
|
|
6g. Overhead paging |
|
|
6h. Text paging |
|
|
6i. E-mail/Internet/network |
|
|
6j. Fax machine(s) |
|
|
6k. Intercom |
|
|
6l. Megaphone(s) |
|
|
6m. Runner(s) |
|
|
6n. Emergency radio |
|
|
6o. Ham radio |
|
|
6p. Satellite phones |
|
|
6q. Other (specify): _________________ |
|
|
|
7. Information Flow
7a. Was necessary information received? Y / N / U
Comments: |
7b. Did your zone receive updates regarding the situation outside the hospital (e.g. status of disaster events, number of victims arriving, acuity of victims)? Y / N / U |
7c. How was this zone kept aware of the ongoing general situation within the hospital? (Check all that apply.)
a. ___ Call from incident command b. ___ Fax from incident command
c. ___ Other contact from incident command d. ___ Runner(s) from incident command
e. ___ Contact from other internal sources (specify): _________________________________________ |
8. Security
8a. Were entrances and exits strictly controlled in this area? Y / N / U
Comments: |
8b. Did any of the following security issues arise in this zone? (Check all that apply)
a. ___ Crowd control b. ___ Media control
c. ___ Unruly victims d. ___ Other (specify): _________________________________
|
8c. Were security personnel present in this zone? Y / N / U |
9. Personal Protective Equipment (PPE) and Safety:
9a. Was an appropriate supply of PPE available? Y / N / U
Comments: |
9b. Was the PPE applied correctly? Y / N / U
Comments: |
If needed, were these items for standard precautions available for the healthcare workers?
If safety materials were not available, circle "N" in column "A" and go to the next row. |
Safety material |
A. Available? |
B. Used by staff? |
C. Adequate supply? |
D. Problems with use? (e.g., donning) |
9c. Face shields/masks |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9d. Waterproof gowns |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9e. Isolation gowns |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9f. Gloves |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9g. Passive (negative pressure) filtration (e.g., N95 or N99 masks) |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9h. Respirators (e.g., powered air purifying respirator) |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
9i. Other (specify): _______________ |
Y / N / U |
Y / N / U |
Y / N / U |
Y / N / U |
|
9j. Were instructions available regarding appropriate donning and removal of PPE? Y / N / U |
9k. If available, in what format were they? (Check all that apply).
a. ___ Verbal instructions by staff b. ___ Poster(s) c. ___ Written instruction(s)
d. ___ Video e. ___ Other (specify): ____________________________ |
10. Equipment and Supplies
10a. Were there appropriate quantities of medical supplies? Y / N / U
Comments: |
10b. Were medications needed for treatment of victims available in the hospital? Y / N / U / NA |
Were needed medical supplies available?
If medical supplies were not available, circle "N" in column "A" and go to the next row. |
Medical Supply |
A. Available |
B. Issues |
10c. Alcohol-based hand sanitizer |
Y / N / U / NA |
|
10d. Bandages |
Y / N / U / NA |
|
10e. Basic airway equipment |
Y / N / U / NA |
|
10f. Blood drawing supplies |
Y / N / U / NA |
|
10g.Blood pressure equipment |
Y / N / U / NA |
|
10h. Burn packs |
Y / N / U / NA |
|
10i. Cleaning supplies for contaminated equipment |
Y / N / U / NA |
|
10j. Crash carts |
Y / N / U / NA |
|
10k. Intravenous fluids |
Y / N / U / NA |
|
10l. Intubation equipment |
Y / N / U / NA |
|
10m. Medications |
Y / N / U / NA |
|
10n. Monitors |
Y / N / U / NA |
|
10o. Oxygen masks |
Y / N / U / NA |
|
10p. Oxygen tanks |
Y / N / U / NA |
|
10q. Splints |
Y / N / U / NA |
|
10r. Stethoscopes |
Y / N / U / NA |
|
10s. Stretchers |
Y / N / U / NA |
|
10t. Suction equipment |
Y / N / U / NA |
|
10u. Surgical masks |
Y / N / U / NA |
|
10v. Vascular access supplies (catheters, fluids,etc.) |
Y / N / U / NA |
|
10w. Ventilators |
Y / N / U / NA |
|
10x. Wheelchairs |
Y / N / U / NA |
|
10y. Other (specify): _____________________________ |
Y / N / U / NA |
|
|
Comments (If comment refers to a specific item, give the item number.): |
Return to Contents
Proceed to Next Section