Ch 71

disaster

"a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources." "an occurrence of a natural catastrophe, technological accident, or human event that has resulted in severe property damage, deaths, and/or multiple injuries." "any natural catastrophe (including any hurricane, tornado, storm, high water, wind driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, or drought), regardless of cause, or any fire, flood, or explosion, in any part of the United States, which in the determination of the President, causes damage of sufficient severity and magnitude to warrant major disaster assistance to supplement the efforts and available resources of states or local governments, and disaster relief organizations to alleviate the damage, loss, hardship, or suffering caused."

weapon of mass destruction (WMD)

"any weapon or device that is intended, or has the capability, to cause death or serious bodily injury to a significant number of people through the release, dissemination, or impact of (1) a toxin or poisonous chemical or their precursors; (2) a disease organism; (3) radiation or radioactivity; or (4) an explosive device."

The goal of the response to any MCI is to

"do the greatest good for the greatest number of people."

In general, most disaster events are defined by three main characteristics

(1) an event of destructive magnitude; (2) that kills, injures, or causes human suffering to a significant number of people or the environment; and (3) that requires the need for external assistance.

Hospital Preparedness

-Hospital preparedness for an MCI is a daunting task. -Effectively planning an emergency response requires hospitals to address many details such as staff safety and availability of PPE, decontamination equipment and processes, surge capacity, evacuation plans, addressing mental health or psychosocial issues, debriefing plans, and maintaining readiness.

4 phases of disaster management

-Mitigation -Preparedness -Response -Recovery

Personal Protective Equipment

-Personal protective equipment (PPE) is a means of protecting staff from hazardous materials -The selection of the appropriate PPE is a complex process and is based on a hazard assessment that (1) identifies the hazards or suspected hazards; (2) identifies the routes of entry of the potential hazard (inhalation, skin absorption, ingestion, and eye or skin contact); and (3) defines the performance of the PPE materials in providing a barrier to these hazards.

JumpSTART

-a Pediatric Mass Casualty Incident Triage tool. -designed for triaging infants and young children.

Natural Disasters

-blizzards, drought, famine, and pest infestations. -floods, earthquakes, tsunamis, tornadoes, volcanic eruptions, and hurricanes.

Sort, Assess, Life-saving Interventions, Treatment, and/or Transport (SALT)

-can be used to triage both adults and children -1st:address the "walking wounded." Those who are able to walk are prioritized last -those who cannot follow a command or have an obvious life threat are prioritized first -those who can follow a command but are unable to walk are prioritized second. The next step is to make lifesaving interventions before assigning a patient to a triage category. -control of major hemorrhage, opening the airway and providing two breaths for child casualties, decompression of a tension pneumothorax, and the use of auto injector antidotes Finally, triage categories are assigned (delayed, immediate, or expectant) based on breathing, peripheral pulses, respiratory distress, and hemorrhage control. "Expectant" category of patients should be re-evaluated frequently.

HOSPITAL RESPONSE TO A DISASTER

-hospitals need to be prepared to respond to virtually any type of event. -For disasters such as hurricanes and floods, hospitals are likely to receive advanced warning and are able to activate their disaster plan before the event.

Level A PPE

-is the highest level of respiratory, eye, mucous membrane, and skin protection. -provides protection against gas, vapor, liquid, and oxygen-deficient atmospheres. It includes a totally encapsulating chemical protective suit, often called a "moon suit," with a self-contained breathing apparatus (SCBA), gloves, and boots. This level should be selected when the hazards are unknown or unquantifiable or when the greatest level of protection is required. It provides full protection against liquids and vapors. Generally, this level is not appropriate for hospital staff.

NURSE'S ROLE DURING A DISASTER

-nurses constitute the largest sector of the healthcare workforce and are on the front lines of any disaster response. -nurses must be ready and able to respond quickly and competently to the array of sudden new demands for care. -Nursing plays a role in all aspects of disaster preparedness, response, and recovery. -role in mass casualty triage, helping to ensure patients get the most appropriate level of care. -role in putting disaster response plans into action, evacuation, and decontamination when necessary. major role in treatment: patient stabilization, medication administration including antidotes or prophylaxis where necessary, and routine or emergency care as part of the healthcare team, as dictated by the patient's condition. Nursing also provides supportive care and mental health support to victims of the disaster.

Documents r/t disaster planning

1. Birth certificates 2. Immunization records 3. Homeowners insurance policy with contact information 4. Health records 5. Driver license copy 6. Complete list of medications 7. Copies of health insurance cards 8. All emergency phone numbers for family 9. List of all credit card numbers

Other r/t disaster planning

1. Consider ways to help neighbors who may need special assistance, such as the elderly or the disabled 2. Make arrangements for pets. Most pets are not allowed in public shelters 3. Identify an out-of-state family member or friend so all your family members have a single point of contact.

Home disaster plan

1. Draw a floor plan of your home. Mark two escape routes from each room. 2. Make sure everyone in the household knows how to shut off water, gas, and electricity at the main switches. 3. Post emergency phone numbers by the telephones. Teach children how and when to call 911. 4. Identify two meeting places: The first should be near your home in case of fire; the second should be away from your neighborhood in case you cannot return home 5. Keep car gas tank filled.

Liaison officer

A command staff position who acts as the on-scene contact point for assisting agencies.

Federal Emergency Management Agency (FEMA)

A federal agency responsible for disaster preparedness, response and recovery. Now under Department of Homeland Security.

Public information officer

A member of the command staff who is responsible for advising the incident commander on all public information matters relating to the management of the incident. This person also manages the media, public inquiries, warnings, rumor monitoring, and other functions required to gather, verify, coordinate, and disseminate accurate, accessible, and timely information related to the incident.

Safety/Security officer

A member of the command staff who is responsible for monitoring and assessing personnel hazards and unsafe situations.

Personal/Family Disaster Planning

Disaster Supply Kit 1. Water for 3 to 5 days (remember water for pets also); a normal person needs 2 quarts of water per day 2. Cans of food 3. Food items such as nuts, dried fruit, and other packaged snacks 4. Blanket, small pillow 5. Inflatable bed (may be used as a float if needed) 6. Closable waterproof plastic bags 7. Backpack for carrying items 8. Battery-operated radio (change the batteries every 6 months) 9. Medications to sustain 14 days 10. Personal hygiene items 11. Extra eyeglasses 12. Manual can opener 13. Flashlight with extra batteries 14. Face masks to protect from dust 15. Traffic flares 16. Duct tape and scissors 17. Whistle 18. Plastic sheeting 19. Work gloves 20. One complete change of cloths 21. Heavy duty plastic garbage bags and ties—for personal sanitation uses—and toilet paper 22. Compass 23. Waterproof matches 24. Waterproof markers (used to write a young child's name, address, phone number, and next of kin number on children's feet) 25. Over-the-counter medications for diarrhea, headache, nausea, and vomiting 26. Basic first aid kit 27. Cell phone charger 28. Water purifier kit 29. Sunscreen and insect repellent 30. Cash

Maintaining Readiness

Disaster drills or disaster exercises are an integral element of preparedness and should be conducted twice yearly. The goal during an exercise is to assess disaster processes and staff performance when systems are stressed during a simulated emergency. During the exercise, performance should be critiqued to identify deficiencies and opportunities for improvement facilitating modifications/improvements of the EOP. Disaster drills and exercises should test every aspect of the EOP including: • Setting up the incident command center • Receiving casualties • Triage • Testing communications systems, both internal and external, with response to agencies, including other healthcare organizations • Evacuating and transporting patients • Requesting and receiving emergency supplies • Staff roles and responsibilities • Utility management • Safety and security • Resources and assets, including the following equipment: decontamination, PPE, transportation, communication, and emergency supplies

Hospital Preparedness

Disaster plans should address the following: • Staff safety/personal protective equipment • Decontamination equipment and processes • Surge capacity • Mental health • Lockdown procedures • Mass fatality management • Evacuation • Altered standards of care • Allocation of scarce resources • Mass employee medication prophylaxis • Internal utility failure • Workplace violence including active shooters • Bomb threats • Civil unrest

Hospital Evacuations

Evacuations may be necessary due to fire or damage from a natural disaster such as a hurricane, earthquake or flood. The decision to evacuate a hospital should be based on the ability of the hospital to meet the medical needs of the patients. Hospitals should have in place plans for either a full or partial evacuation and those plans should be consistent with regulatory requirements. A full evacuation of a hospital should generally be considered a last resort. There are two types of hospital evacuations: "advanced warning events" and "no advanced warning events."

There are three goals for patient decontamination.

First, hospitals must not allow contaminated patients to enter the facility. Hospital security staff needs to lock down the entrances and exits in order to protect patients and staff. Ideally, when medically appropriate, patients should be decontaminated at the incident scene. However, complete on-incident scene decontamination may not be possible because of the medical condition of the patient as well as weather conditions and equipment availability. This may require that decontamination sites and triage station be set up immediately outside the hospital ED. If needed, decontamination is carried out prior to triage. Second, hospitals should decontaminate patients as rapidly as possible. This means the decontamination equipment must be easily deployable and the staff trained to set it up Third, hospitals must plan to protect the decontamination team from secondary exposure and injury. This includes having enough decontamination suits, respirators, boots, and gloves on hand to sustain the facility for at least 24 hours with a cadre of staff rotating through the process.

Advanced Warning Events

Hurricanes are the most common example of an advanced warning event. With advanced warning events, the hospital incident commander has time prior to the event to make a decision but must remember there is a limited opportunity to evacuate. As the event draws nearer, the opportunity for a safe evacuation diminishes. Evacuation requires consideration of two factors: (1) the nature of the event, including its expected arrival time, magnitude, area of impact, and duration; and (2) the anticipated effects on both the hospital and the community. Once notified of an impending disaster, the hospital incident commander may decide to (1) preemptively evacuate the hospital while the hospital structure and surrounding environment are not yet compromised or (2) shelter in place (SIP). Sheltering in place is defined as "the need to take immediate shelter in a current location. Shelter in place (SIP) is a rapid and effective way to protect the hospital occupants from an external or internal threat. Plans should also define what happens to those persons "locked out" when the hospital is "locked down."

casualty

Includes all persons who are ill, injured, missing, or dead as the result of the incident.

Level C PPE

Level C provides the same skin protection as Level B but a lesser level of respiratory protection than Levels A and B. Level C consists of a nonencapsulated chemical-resistant suit (splash protection), air-purifying respirator (APR)

Level D PPE

Level D PPE consists of a surgical gown, mask, and gloves. It provides no additional protection for respiratory or splash hazards, only minimal protection for nuisance contamination.

Disaster cycle

Mitigation: activities that eliminate or reduce the chance of occurrence or the effects of an event if it occurs. Preparedness: planning how to respond when an emergency or disaster occurs. Response: emergency assistance to victims of the event. Recovery: activities directed at restoring essential services and resuming normal operations.

No Advanced Warning Events

No advanced warning events include earthquakes, building fires, tornadoes, and explosions. Decisions must often be made very quickly in the midst of the disaster or immediately afterward.

Preparedness

Preparedness, the next phase, is planning how to respond when an emergency or disaster occurs. This step builds an organization's capacity to manage the effects of an event should it occur. These activities help to save lives and minimize damage by preparing people to respond appropriately. Examples include disaster drills, evacuation plans, and fire drills.

Recovery

Recovery begins almost concurrently with response activities and is directed at restoring essential services and resuming normal operations. This phase may require a large amount of time, money, and resources

Evacuation

Regardless of the warning, successful hospital evacuation requires the symphonic coordination of personnel, transportation, communication and the tracking of patients and materials. Additional considerations during an evacuation include: • Sequences of the evacuation: The most medically fragile and resource-intensive patients are usually evacuated first, as soon as appropriate transportation and staff are available. However, in cases in which all patients are in immediate danger and evacuation must be conducted as quickly as possible, some suggest that the most mobile patients should be evacuated first. Urgency of the evacuation: It is important to distinguish between an orderly and planned evacuation, in which there is time to move patients in a manner that maximizes safety for all, and a "drop-everything-and-go" evacuation, in which patients and staff are in immediate danger and must exit the unit and/or hospital as quickly as possible. Optimal procedures for safely moving patients may be abandoned in favor of the fastest possible egress. • Extent of the evacuation: A hospital evacuation will be planned differently depending on whether the entire area/community is being evacuated or just one hospital. If just one hospital is being evacuated (e.g., because of a fire), patients can be more easily dispersed among nearby hospitals. In most metro areas, the transport would be for a distance of less than 10 miles, and ambulances could cycle back and forth moving patients. • Condition of hospital infrastructure: Although unlikely to be a problem during an "orderly and planned" evacuation, egress from a hospital may be severely constrained during a "drop-everything-and-go" evacuation. Stairwells or exits may be obscured by smoke or unavailable because of fire. Stairwells may be dark if backup power has failed. Elevators can also be out of service, lengthening the time required to move all patients out of the hospital. • Types of patients: Highly complex patients—especially intensive care unit and other specialty-care patients—may be difficult to place in the surrounding community. • Road conditions: In a disaster where a community and more than one hospital are affected, evacuating transport destinations may be far away. Traffic-choked highways and the lack of refueling stations preventing ambulances from quickly cycling back for repeated evacuation trips could slow the evacuation process. • Transportation resources: Transportation resources include not only the vehicles but also the staff, equipment, and supplies that must accompany the patient in the vehicle.

Response

Response covers the period during and immediately following a disaster. During this phase, emergency responders and public officials provide emergency assistance to victims of the event and try to reduce the likelihood of further damage.

Incident commander

Responsible for all aspects of the response. This person has the overall authority and responsibility for the entire operation; develops the incident objectives and manages all incident operations. Four section chiefs report to the incident commander. Each section chief is part of the general staff and supervises a team of responders.

Operations chief

Responsible for all tactical operations, including decontamination, rescue/extrication, triage, treatment, transportation, communication, and medical control.

Planning chief

Responsible for continuously evaluating the response and "keeping ahead of the disaster"; maintains resource status, evaluates future resource needs and personnel, maintains all incident records, develops the strategy and action plans with the incident commander for the other section chiefs to implement.

Logistics section chief

Responsible for obtaining and providing services and resources, obtaining equipment needed, and staff support.

triage models that can be used to sort patients.Simple Triage and Rapid Treatment (START) and SALT

Simple Triage and Rapid Treatment (START) and SALT SALT -Sort -Assess -Lifesaving Interventions, -Treatment/ transport Simple Triage and Rapid Treatment (START) -is designed to be completed in 60 seconds or less. -It is based on three observations: (1) respirations (2) perfusion (or pulse) (3) mental status. mnemonic "RPM" -allows for only two interventions during the triage process: (1) direct pressure to control bleeding (2) basic airway-opening maneuvers. "green," or "minor." -begins by directing all patients who are ambulatory to move to a safe area. -capable of ambulating and understanding directions and have adequate perfusion to follow commands and stay upright. Deceased/ Black label Patients with no spontaneous respirations receive airway repositioning. If they remain apneic, they receive no further care or interventions. red or "immediate." -If repositioning the airway initiates respirations -Patients with respirations greater than 30 breaths per minute or capillary refill longer than 2 seconds (or who lack a radial pulse) or who are unable to follow simple directions Delayed/ Yellow - the remaining Pts

Mental Health Considerations

The psychological casualties following a disaster may include those who cared for the victims of the disaster, including prehospital workers, ED staff, social workers, and pastoral care staff. In the aftermath of the September 11, 2001, attacks, the Psychiatric Department at St. Vincent's Medical Center, just one of many healthcare facilities in the area, provided counseling to more than 7,000 patients and received more than 10,000 calls to its help line during the first 2 weeks. Hospitals need to make provisions to accommodate and manage these acute mental health needs.

Finance/Administration chief

chief Responsible for documenting all financial costs of the incident including the cost of recovery for services and supplies.

incident

defined as an event that requires scene or casualty management.

Regardless of whether a situation is classified as a disaster, a mass casualty incident, or a complex emergency, an effective triage method is needed to optimize overall patient outcomes. This is done through the process called

disaster triage.

Incident Command System (ICS)

goal: establishing command and control. is an organizational tool that is used to provide the management infrastructure to support any disaster response. The structure is the same regardless of the nature of the disaster The structure is built around five major management activities/functions required in a disaster setting regardless of size or type. The functions are -command -operations -planning -logistics, -finance/administration. For some terrorist incidents, a sixth role, intelligence gathering the overall response is led by an incident commander Additional functions that aid in the response include liaison, public information, and safety/security.

Mitigation- Prevention

includes activities that eliminate or reduce the chance of occurrence or the effects of an event if it occurs. Disaster mitigation programs have shown that communities can do a lot to prevent major emergencies or disasters from affecting them negatively. If communities cannot prevent disasters, they can at least reduce the damaging impact, for example, requiring roof reinforcements to reduce damage from hurricane winds or passing legislation that prevents new construction in floodplains.

Regardless of the system used, the primary goal of disaster triage is to

maximize the number of survivors.

Level B PPE

provides the greatest level of respiratory protection but a lower level of skin protection than Level A. It differs from Level A in that the suit is not fully encapsulated and airtight, but it provides splash protection against liquids

mass casualty incident (MCI)

refers to any large-scale event in which emergency medical resources such as supplies, medical/rescue personnel, or equipment are overwhelmed by the number and severity of casualties, thus requiring prioritization of medical care by triage. All MCIs are disasters, but not all disasters are MCIs. "when the healthcare needs exceed the healthcare resources."

post event disaster debriefing

should be held within 24 hours of the disaster response. This debriefing should include all participants in the disaster response. The purpose of the debriefing is to critically analyze all aspects of the response and to identify strengths and areas that need to be improved. Additionally, this debriefing allows hospital leadership to begin to identify staff who may need assistance recovering from the disaster response

Surge capacity

the ability of a healthcare system to "expand rapidly and to obtain adequate staff, beds, supplies, and equipment to provide sufficient care to meet the immediate needs of an influx of patients following a large-scale incident or disaster.

Triage

the process of placing the right patient in the right place at the right time to receive the right level of care.

complex emergency (CE) as "situations of disrupted livelihoods and threats to life produced by warfare, civil disturbance and large-scale movements of people, in which any emergency response has to be conducted in a difficult political and security environment." Such "complex emergencies" are characterized by the WHO as involving:

• extensive violence and loss of life • displacements of populations • widespread damage to societies and economies • the need for large-scale, multifaceted humanitarian assistance • the hindrance or prevention of humanitarian assistance by political and military constraints • significant security risks for humanitarian relief workers in some areas