Emergency/Disaster Preparedness Ch 12

In an emergency situation, how is the incident of an overturned school bus categorized? 1. Not a mass casualty 2. May be a mass casualty 3. Mass casualty 4. Act of terrorism

2. May be a mass casualty Correct: A mass casualty event overwhelms local medical capabilities. It may require the collaboration of multiple agencies and health care facilities to handle the crisis. Depending on the community, available resources, and the quantity and severity of those injured, this may be a mass casualty.

IMPACT OF RECENT EXTERNAL DISASTERS

The term "NBC" was coined to describe nuclear, biologic, and chemical threats.

IMPACT OF RECENT EXTERNAL DISASTERS

Emergency medical services (EMS) agencies and hospitals upgraded their decontamination facilities, equipment, and all levels of personal protective gear to better protect staff.

The nurse has a suggestion for improving response in the next mass casualty event. Which channel does the nurse use to introduce this idea? 1.The Administrative Review 2.The Critical Incident Stress Briefing (CISB) 3.Through the supervisor 4. Through the hospital suggestion box

1. The Administrative Review Correct: The goal of the Administrative Review is to discern what went right and what went wrong during activation and implementation of the emergency preparedness plan. In this way, changes can be made.

After successful treatment of clients involved in a mass casualty incident, the incident commander deactivates the emergency response plan. Which of these activities is most important for the emergency department (ED) charge nurse to initiate at this time? 1.Analyze the ED response to the mass casualty incident. 2.Take inventory, and re-stock the ED with supplies and equipment. 3.Initiate critical incident stress debriefing (CISD) for staff members. 4.Follow up with survivors to determine the need for additional referrals.

2. Take inventory, and re-stock the ED with supplies and equipment. Correct: The priority is re-stock the ED to return to normal operation.

The client comes to the emergency department covered with coagulated blood and a white powder. The client is hysterical and fears that it is anthrax. What does the nurse do first? 1.Administers antibiotics 2.Provides emotional support 3.Takes the client to the decontamination room 4.Triages the client

3. Takes the client to the decontamination room Correct: Decontamination should precede triage. Only the most basic life-sustaining interventions should be performed before or during decontamination. The coagulated blood indicates that the major active bleeding has likely subsided.

After losing her home to a hurricane several years ago, the client says, "I get very nervous during a thunderstorm and want to hide under the bed." What is the nurse's best response? 1. "But it is just a thunderstorm. You would have warning if a hurricane was approaching." 2."I understand. That is normal and is nothing to worry about." 3. "That is post-traumatic stress disorder. You might want to see a counselor." 4. "What do you do when you feel this way?"

4. "What do you do when you feel this way?" Correct: Check to see whether the thought is causing maladaptive behavior, and then assess whether it is normal or abnormal.

The emergency department charge nurse is making client assignments and delegating care after a mass casualty event. Care for which of these clients could be delegated to a nursing assistant? 1.A client who has multiple left rib fractures and is complaining of dyspnea 2.A client who is complaining of severe left anterior chest pain 3.A client who has a femoral fracture with palpable distal pulses 4.A client who is unconscious and has massive aortic bleeding from the chest

4. A client who is unconscious and has massive aortic bleeding from the chest Correct: This client is unlikely to survive owing to massive thoracic bleeding and would be "black-tagged" and assigned to a nursing assistant.

During a mass casualty, which injury receives care first? 1. Abdominal evisceration 2. Open fracture of the left forearm 3. Sprained ankle 4.Sucking chest wound

4. Sucking chest wound Correct: This casualty is a red tag, or emergent, because it can be quickly resolved until further help can be given. Option 1 is a Black Tag

During a mass casualty, staff roles are defined. If the triage officer is incapacitated, who is the best choice for replacement? 1.Communications officer 2. Hospital incident commander 3.Medical command physician 4.Triage nurse

4. Triage nurse Correct: When physician resources are limited, an experienced nurse may assume this role. Whoever can best meet the needs of the clients is the best choice.

DISASTERS

A disaster is commonly defined as an event in which illness or injuries exceed resource capabilities of a community or medical facility. Each facility defines its own parameters to identify when a disaster situation is present.

A nurse needs to discharge two medical-surgical clients to make room for two victims of a tornado. Which of these clients could be discharged from the unit now? Select all that apply. A. 78-year-old with telemetry monitoring for chest pain last night B. 57-year-old who had a bowel resection for cancer 2 days ago C. 44-year-old who has received 3 days of IV antibiotics for pneumonia D. 61-year-old who had a thyroidectomy this morning E. 72-year-old who had a total hip replacement 2 days ago

ANS: B, C Rationale: The 57-year-old who had a bowel resection for cancer 2 days ago could be moved to a rehabilitation center for continued care. The 44-year-old receiving antibiotic therapy can likely move to oral therapy and continue this regimen in the home environment. The 78-year-old with telemetry monitoring has been in the hospital less than 24 hours, and more assessment data and diagnostic studies need to be collected. The 61-year-old will need monitoring of thyroid hormones and calcium levels before discharge. The 72-year-old needs further inpatient physical therapy in the hospital setting since the surgery was only 2 days ago.

The nurse is preparing to triage clients at the scene of an airplane crash. Which of these clients will the nurse identify as emergent? A. Young woman with closed fractures of her right leg and arm B. Older woman with abdominal bleeding who is and dazed and confused C. Middle-aged man with third-degree burns over 90% of his body D. Young man with numerous bruises and superficial lacerations

ANS: C Rationale: The middle-aged man with third-degree burns over 90% of his body is the most critically ill. The man has extensive burns and will likely be hemodynamically unstable from the large amount of body surface area affected. Immediate treatment to address airway, circulation, and breathing will be critical to his survival. The young women with closed fractures is likely hemodynamically stable and not considered a trauma victim. The older woman with abdominal injuries is likely critically ill but is not as critical as the man with the burn injury. The young man with numerous bruises and superficial lacerations may be treated in the ED as an outpatient.

EVENT RESOLUTION AND DEBRIEFING

• Two types of debriefing occur following a mass casualty event or period: o Critical incident stress management programming addresses pre-crisis through post-crisis interventions for small to large groups, including communities. o A team is comprised of two to three specially trained individuals who come together quickly when called to deal with the emotional needs of health team members after a particularly devastating or disturbing incident. o The team leader typically has background in a mental health/behavioral health field.

PSYCHOSOCIAL RESPONSE OF SURVIVORS TO MASS CASUALTY EVENTS

Nurses caring for survivors with these manifestations should perform further assessment. One tool that can be used to assess survivor response to a disaster is The Impact of Event Scale - Revised (IES-R). • Provide emotional support through encouraging relaxation, listening to survivor feelings, and referring for appropriate counseling.

Goal of Emergency Preparedness for all Mass Casualty Events

To define ways to meet the extraordinary need for hospital beds, staff, drugs, personal protective equipment, supplies, and medical devices, such as mechanical ventilators.

IMPACT OF RECENT EXTERNAL DISASTERS

ED physician and nursing staff underwent hazardous materials (HAZMAT) training and learned how to recognize patterns of illness in patients who present for treatment that potentially indicate biologic terrorism agents, such as anthrax or smallpox.

EMERGENCY PREPAREDNESS AND RESPONSE

• The National Disaster Life Support Foundation offers Basic and Advanced Disaster Life Support training courses that include all essential aspects of disaster response and management. They include the core competencies of disaster management to all levels of health care professionals. • The Federal Emergency Management Agency provides Community Emergency Response Team (CERT) training to citizens. • All medical centers must have an emergency preparedness and response team in case of mass casualty (disaster).

EMERGENCY PREPAREDNESS AND RESPONSE

• The facility-level organizational model for disaster management is the Hospital Incident Command System (HICS) which is a part of the National Incident Management System (NIMS) implemented by the Department of Homeland Security and the Federal Emergency Management Agency (FEMA) to standardize disaster operations.

EVENT RESOLUTION AND DEBRIEFING

• The second type of debriefing is an administrative function directed at analyzing the hospital or agency response to an event soon afterwards. o The goal of this type of debriefing is to evaluate the implementation of the emergency preparedness plan so that changes can be made. o Representatives from all groups that were involved in the incident come together for discussion.

Disaster Preparedness Training, Drills

• To maintain disaster preparedness skills, hospital personnel and disaster teams participate in emergency training and drills or an actual event at least twice yearly. • One of the drills or events must involve community-wide resources and an influx of actual or simulated patients to assess the ability and effectiveness of collaborative efforts and command structures and must use an "all-hazards approach."

EVENT RESOLUTION AND DEBRIEFING

• When the last major casualties have been treated and no more are expected to arrive, the incident commander considers "standing down" or deactivating the emergency response plan. • A vital consideration in event resolution is staff and supply availability to meet ongoing operational needs. • Other areas in the hospital may still be under stress and need the support of the supplemental resources provided by emergency plan activation. • Severe shortages of supplies and the need to clean and restock the ED may also pose a threat to normal operations at the conclusion of an incident.

EMERGENCY PREPAREDNESS AND RESPONSE

• Notification of a disaster incident initiates the hospital preparedness plan. • Notification that a multi- or mass casualty situation exists usually occurs by radio or cellular communication between the ED and EMS providers at the scene or by notification from a state or regional emergency management agency to the ED. • Each hospital specifies who has the authority to activate and how to activate the disaster or emergency preparedness plan using technologies such as group paging systems, telephone trees, and instant computer-based alert messages.

ROLE OF NURSING IN COMMUNITY EMERGENCY PREPAREDNESS AND RESPONSE

• Nurses have important roles in preparing for, managing, and debriefing after an internal health care facility disaster. • Nurses play a major role in triage, first aid and emergency care, and shelter assistance in external community disasters.

ROLE OF NURSING IN COMMUNITY EMERGENCY PREPAREDNESS AND RESPONSE

• The ED charge nurse, trauma program manager, and other ED nursing leadership personnel act in collaboration with the medical command physician and triage officer to organize nursing and ancillary services to meet patient needs. • Each nurse should have a personal emergency preparedness plan which outlines their preplanned arrangements for child care, pet care, and older adult care if the need arises, especially if the event prevents returning home for an extended period of time.

Multi-Casualty vs. Mass Casualty

The main difference between multi-casualty and mass casualty (disaster) events is based upon the scope and scale of the incident and the number and severity of victims or casualties.

How does the high school nurse react directly after a random shooting at a high school? 1.Actively listens to student 2.Assesses his or her own individual feelings 3.Encourages students to vent feelings 4.Facilitates community cohesion

2. Assesses his or her own individual feelings Correct: One must be able to support oneself before supporting others.

Which essential item is added to a personal readiness supplies "go bag"? 1.Fruits and vegetables 2.Potable water 3.Television 4.Laptop computer

2. Potable water Correct: The go bag should contain 1 gallon of potable water per person per day.

A coastal town where you live is struck by an F5 hurricane. Buildings have collapsed, power has been lost, and local emergency services are overwhelmed. Two victims next door are trapped by debris in two different rooms of a house and need immediate attention: an awake but unresponsive older woman with blood partially obstructing her airway and an open fracture of her leg; and her pale, unconscious 20-year-old granddaughter who has a profuse, pulsatile hemorrhage from a radial artery laceration caused by flying broken glass. No one is available to assist you at the moment. 1. Which injured person will you attend to first and why? 2. What is your priority for emergency care in this situation? 3. Without adequate medical supplies, how will you use your creativity to care for each of these women? 4. If one of these patients dies while you are caring for the other one, how do you think you would cope with this situation?

Suggested Responses: 1. Which injured person will you attend to first and why? Care should be directed towards the granddaughter with a pulsatile hemorrhage. In this situation, the nurse may be able to control the bleeding. It may be difficult to clear an airway that is obstructed by blood without suction equipment. 2. What is your priority for emergency care in this situation? The priority is to control the bleeding in the younger victim through applying direct pressure to the wound. 3. Without adequate medical supplies, how will you use your creativity to take care for each of these women? The nurse may apply a tourniquet above the area of the bleed in the younger victim and apply direct pressure to the bleeding artery. The nurse may also try to reposition the head of the older victim to see if it clears the airway. This person should also be placed on her left side and monitored. This positioning may prevent aspiration. 4. If one of these patients dies while you are caring for the other one, how do you think you would cope with this situation? The nurse should direct his or her attention on the surviving victim. At this time, energy should be expended on trying to save one life in this situation. The nurse will need to be debriefed about the situation once help arrives, because it is often traumatic when the nurse cannot "save" each patient in his or her care.

Types of Disasters: External

• An external disaster is any event outside the health care facility or campus, somewhere in the community, which requires the activation of the facility's Emergency Management Plan. o The number of facility staff is not adequate for the incoming patients. o External disasters can be either natural, such as a hurricane, or technological, such as a biological terror attack.

Hospital Emergency Preparedness plans include different roles and responsibilities for the personnel.

o An incident commander is usually identified, along with a medical command physician, triage officer, and others responsible for public information, safety and security, in order to achieve a manageable span of control over the available personnel or resources. o The hospital establishes an emergency operations center or command center in a designated location with accessible communication technology.

Types of Disasters: Internal

• An internal disaster is any event inside a health care facility or campus that could endanger patients or staff and creates a need for evacuation or relocation. o It often requires extra personnel and the activation of the facility's Emergency Preparedness and Response Plan. o Examples of potential internal disasters include fire, explosion, and violence.

PSYCHOSOCIAL RESPONSE OF SURVIVORS TO MASS CASUALTY EVENTS

• Be honest with victims and their families, and help them adapt to their changed or new surroundings. • Take precautions to prevent staff from developing post-traumatic stress disorder (PTSD).

PSYCHOSOCIAL RESPONSE OF SURVIVORS TO MASS CASUALTY EVENTS

• A disaster may cause some survivors to develop post-traumatic stress disorder (PTSD), which can potentially last for a lifetime. o People who are unable to sleep, are easily startled, have "flashbacks" to relive the disaster, or report "feeling numb" 2 weeks or more after a disaster or traumatic event are at risk for PTSD.

EMERGENCY PREPAREDNESS AND RESPONSE

• A key process in any multi-casualty or mass casualty response is effective triage to rapidly sort ill or injured patients into priority categories based on their acuity and survival potential. • Most mass casualty response teams both in the field (at the disaster site) and in the hospital setting use a disaster triage tag system that categorizes triage priority by color and number: o Emergent (class I) patients are identified with a red tag, immediate threats to life. o Patients who can wait a short time for care (class II) are marked with a yellow tag, major injuries that need treatment within a 30-minute to 2-hour time frame. o Nonurgent or "walking wounded" (class III) patients are given a green tag, minor injuries that can be managed in a delayed fashion, generally more than 2 hours. o Patients who are expected to die or are dead are issued a black tag (class IV).