Naola Austin MD, Clinical Instructor, Anesthesia
Kay Daniels MD, Clinical Professor, Obstetrics Gynecology
Laura Harwood MS, Office of Emergency Management
Kristine Taylor MSN, Nurse Quality Manager
http://archive.boston.com/news/nation/gallery/Iowa_Missouri_flooding_061308/
Naola Austin MD, Clinical Instructor, Anesthesia
Kay Daniels MD, Clinical Professor, Obstetrics andGynecology
Laura Harwood MS, Office of Emergency Management
Kristine Taylor MSN, Nurse Quality Manager
1. Understand the unique needs of obstetric units during a disaster
2. Introduction of tools for OB disaster plan3. Implement an OB disaster plan for your unit with a
Table Top Exercise4. Describe disaster training for Staff5. Perform self assessment for your facility and test your
readiness with a Tabletop Exercise
Practice with a Disaster Simulation & Debrief
• What resources do they need for continued care?
Are they readily available?
• If needing to evacuate How do you prioritize who goes first?Where are they going?How are they getting there?
35 yo G3 P2 @ 40 weeks admitted in active labor
Pmhx: chronic htn on 200 mg labetalol tid Epidural in place x 2 hours Vitals: Temp 37, BP 120/70, HR 85, RR 20 Contractions q 2 min spontaneous Exam: 8 / 100% / +2 Fetal heart tracing stable
28 yr G2 P1 s/p repeat CS x 30 min
Pmhx: NC Surgery uncomplicated with EBL 800cc Vitals: Temp 36.6, BP 110/70, HR 72, RR 15 Preop Hct = 34 Spinal anesthesia (pt unable to move legs)
33 yr G2 P2 s/p uncomplicated vaginal delivery yesterday
Pmhx: NC Vitals: Temp 37, BP 110/65, HR 72, RR 18 Baby is rooming in
30 yr G1 P0 @ 41+5 weeks admitted for induction of labor for over the due date
OB hx: uncomplicated Vitals: Temp 36.8, BP 90/60, HR 87, RR 16 Exam: not in labor Labor Induction medications placed 6 hours ago Occasional mild contractions
Surge Shelter in Place Evacuation
www.emaze.com/@ALLICORI/Northridge-Earthquake
Image credit: Robert Gauthier/LA Times
1. Designate someone to be in charge. This may be one nurse and one doctor Decide before the disaster who this should be
2. Have staff wear vests or identifiers.
3. Use job aids to assist with roles and tasks – we do not use disaster process too frequently.
• Account for safety of all staff members.• Have staff routinely check in through a
huddle schedule.1. Safety
• Assess area for resources, problems, needs. • Think about what you need to maintain your
operations for the entire shift.2. Assessment
• Report all findings back to the Hospital Command Center.
• Use the Status Report Form.3. Reporting
Hospital Command Center
L&D Unit Leader
L&D Assistant Unit Leader
MDs Bedside RNs Techs Clerk
PP Unit Leader
PP Assistant Unit Leader
Bedside RNs Clerk
RN manager RN bedside OB Anesthesia OR techs Unit clerk
Status report form Standard assessment
by each unit Helps prioritize
response to needs Want units to have
open lines of communication so that hospital is one large response
The American College of Obstetricians and Gynecologists note:
“Providers of obstetric care and facilities that provide maternity services, offer services to a population that has many unique features warranting additional consideration”
>97% of all births in the US occur in a hospital or clinical setting…which may not be accessible or may be severely damaged during a disaster event
http://www.soc.ucsb.edu/sexinfo/article/childbirth
Pregnant women are subject to the usual risks of injury at a disaster, but with more complicated care
One size ≠ all in a disaster setting for OBWithin the same footprint of any OB unit there exists a large variety of patient acuity and needs Laboring women Intra op and post operative patients Healthy postpartum patients with their newborns
In the days after Hurricane Katrina struck Louisiana, 125 critically ill newborn babies and 154 pregnant women were evacuated to Woman's Hospital in Baton Rouge
It was at least 10 days before some of the infants and mothers were reunited
Washington Post 2006
http://www.neworleans.va.gov/images/evacuate2_lg.jpg
We always have 2 patients• Ante partum = mom and fetus
• Postpartum = mom and newborn
OB TRAIN* = Triage by Resource
Allocation for IN patient
*Based on the triage system created by Dr. Ron Cohen for the NICU at LPCH and adapted for OB
(S) Specialized = must be accompanied by MD or Transport RN* MBS 6 = Patient is able to perform a partial knee bend from standing** Epidural catheter capped off
Labor status
Mobility
Anesthesia status
Maternal risk factors / fetal risk factors
Blue = Car
Green = BLS (Basic Life Support)
Yellow = ALS (Advanced Life Support)
Red = Specialized (Critical Care or with MD)
(S) Specialized = must be accompanied by MD or Transport RN* Modified Bromage Score 6 = Patient is able to perform a partial knee bend from standing** Epidural catheter capped off
26yrs @ 40 weeks
Early labor: 4cm
Can ambulate
No epidural
Cat 1 FHR No significant maternal or fetal risk factors
32 yr @ 31 weeks with severe preeclampsia undergoing induction of labor
Early labor: 2 cm Non-ambulatory Epidural in place < 1 hr Cat 1 FHR Intermittent IV
labetalol for BP control On 2 g of IV
magnesium sulfate
How will peds know where OB is evacuating to? Is there a system in place for notification?
Who from peds has been designated to go with OB ?
To care for ‘shelter in place’ in deliveries
Delivery - NSVD versus Cesarean delivery- Time from delivery
Mobility
Anesthesia status
Maternal risk factors
Transport Car(Discharge) BLS ALS SPC
DeliveryVD > 6 hours
or CD > 48 hours
VD < 6 hours or CD < 48 hours
Complicated VD or CD Medically complicated
Mobility Ambulatory* Ambulatory or Non-ambulatory
Ambulatory or Non-ambulatory Non-ambulatory
Post Op> 2 hours
from non-CD surgery**
> 2 hours from CD< 2 hours from non-CD surgery
< 2 hours from CD Medically complicated
Maternal Risk Low Low/Moderate Moderate/High High
(S) Specialized = must be accompanied by MD or Transport RN* Modified Bromage Score 6 = Patient is able to perform a partial knee bend from standing** If adult supervision is available for 24 hours
Give them a Checklist:
1. Levels: Birthing Centers Basic Care (Level l) Specialty Care (Level ll) Subspecialty Care (Level lll) Regional Perinatal Health Care Centers (Level lV)
2. Capabilities
3. Types of providers
SENDING THE RIGHT PATIENT TO THE RIGHT HOSPTIAL
Obstet Gynecol 2015:125:502-15
Distance (mi) Hospital City Neonatal Maternal
Hospital Phone number
L&D Phone Number
0.0 LPCH Palo Alto 3 3 (650) 497-8000
18.4 Santa Clara Valley Medical Center
San Jose 3 3 (408) 885-5000
34.6 UCSF SF 3 3 (415) 476-9000
36.0 CPMC SF 3 3 (415) 600-6000
38.6 Kaiser Oakland Oakland 3 3 (510) 752-1000
17.0 Kaiser: Santa Clara Santa Clara 3 3 (408)
851-1000
19.8 Good Samaritan San Jose 3 3 (408) 559-2011
36.4 Kaiser: San Francisco
San Francisco 3 3 (415)
833-6353
53.0 John Muir Walnut Creek 3 3 (925)
939-3000
9.0 El Camino Mountain View 3 2 (650)
940-7000
32.3 SF General SF 2 2 (415) 206-8000
42.7 Alta Bates Berkeley 2 3 (510) 204-4444
45.5 Dominican Santa Cruz 2 2 (831) 462-7700
78.5 Natividad Medical Center Salinas 3 2 (831)
647-7611
81.2 Salinas Valley Memorial Salinas 2 2 (831)
757-4333
205 Sierra Vista Regional Medical Center
San Luis Obispo 2 2
(805) 546-7600
8.2 Sequoia Redwood City 2 2 (650)
369-5811
17.9 Washington Fremont 2 1 (510) 797-1111
19.9 O’Connor San Jose 2 1 (408) 947-2500
22.7 Regional Medical Center San Jose 2 1 (408)
259-5000
Give an OB train score to each of the following OB patients
Assess damage on the unit and report to Command Center
Arrange for patient care as indicated Transfer Shelter in place Discharge
Broken window with glass everywhere. Water leaking from the sink.
35 yo G3 P2 @ 40 weeks admitted in active labor
OB hx: rapid active phase, previous mild PPH Pmhx: mild chronic HTN (100 mg labetalol bid) Epidural in place x 2 hours Vitals: Temp 37, BP 120/70, HR 85, RR 20 Ctx q 2 min spontaneous SVE: 8 / 100% / +2 FHT cat 2 with mild variable ctx
One broken light fixture, no smoke or sparks
18 yo G1 P0 @ 37 weeks undergoing induction of labor for severe preeclampsia
Pmhx: NC Vitals: Temp 37, BP 150/100, HR 65, RR 18 SVE: 3 / 80% / -2 Ctx q 3-4 min, oxytocin 7 millunits/min Magnesium 2 grams an hour Labs:
4+ protein (urine protein cr ratio = 0.38)LFTs wnlCr 0.9Hct 42, Plts 150
Windowless room, light fixtures not working
30 yr G1 P0 @ 41+5 weeks admitted for induction of labor for over the due date
OB hx: A1GDM diet-controlled Pmhx: Appy (16 yr) Vitals: Temp 36.8, BP 90/60, HR 87, RR 16 SVE: l/c/h Cervidil placed 6 hours ago Occasional mild ctx
No major room damage. Medication machine locked, says “Fatal error #1000”
28 yr G2 P1 s/p repeat CS x 30 min Pmhx: NC Surgery uncomplicated with EBL 800cc Vitals: Temp 36.6, BP 110/70, HR 72, RR 15 Preop Hct = 34 Spinal anesthesia (pt unable to move legs)
Television fell and shattered glass on floor. Door to bathroom jammed.
33 yr G2 P2 s/p uncomplicated NSVD yesterday
Pmhx: NC Vitals: Temp 37, BP 110/65, HR 72, RR 18 Baby is rooming in
No major room damage
24 yr G1 P1 s/p CS for failure to progress, POD #3
OB hx: pt labored x 20 hours, progressed to 6 cm Pmhx: NC CS uncomplicated with 1000 cc EBL Vitals: Temp 37.7, BP 100/60, HR 89, RR 16 Post op Hct: 30 Baby is rooming in
No major room damage.
44 yr G1 P1 s/p CS @ 30 weeks for preterm labor/breech POD #1
OBHx: IVF pregnancy with donor ovum Pmhx: mild HTN CS complicated by PPH with EBL 1500 cc Postop Hct pending Vitals: Temp 36.6, BP 140/80, HR 100, RR 16 Baby in NICU
No major room damage
39 yo g3P2 @ 7 weeks gestation with poorly control insulin dependent diabetes. Here for blood sugar control.
Last postprandial blood sugar= 230
No major room damage
26 yo g1 @ 32 weeks here for premature rupture of membranes yesterday
Not in laborOn ampicillin and erythromicinBreech presentation
Knowledgeable about application of TRAIN NursePhysician
1/8/13 = 35 patients on Labor and Delivery and Post Partum
Grassroots effort by staff that was supported by the Executives
In house EPIC team did the technical changes to produce the daily reports
Uses certain fields in the EMR to classify their TRAIN category every day
Report can be used to estimate patients classified as "rapidly discharge" for a surge event
Daily reports Office of Emergency Management Nurse Supervisor
Updates with any change in documentation
Report is available to run at anytime Downtime report Decision making regarding personnel
Decrease impact to clinical workflows Non-biased categorization Administrative support Discreet data points from nursing chart
rather than from orders Validation to ensure that the coding is
correct
Computer 48 second
Manual 57 minutes
Command center request over 2 hours
MRN
Emer
genc
y C
onta
ctPh
one
Num
ber
64
TRAIN allows us to speak a common language for resource needs
Enable coordination between EMS and Regional EOC
Enhance state and national patient movement plans
Make training mandatory for all staff (if possible)
Have training based on the use of tools Periodically reinforce information and expand
as possible
Staff, patients and visitors
Fire extinguishers?
Gas valves turn-off switch?
Avoid a minor problem becoming major….
Disaster equipment boxes too high
Need flashlights / headlamps
Need non-rechargeable batteries
Denial exists
Home preparedness is criticalhttp://www.ready.govhttp://www.redcross.org/prepare/location/home-family/get-kit
Situational awareness
Staff responsibilitiesPhysical fitness and stamina?Family and pet housing? Commitment to patients vs. family
Institutional policies Mandatory disaster-duty requirement? Overtime / disaster pay? Disciplinary action?
Policies about trainees“In a disaster situation, licensed residents are allowed to perform tasks that are needed for patient safety”
Identify your champion Someone familiar with the unit and its unique needs
Organize disaster box with vital equipment Flashlights / batteries / head lamps can be Used in a simple electrical outage
Create a disaster binder Required, but make it useful
Assign disaster roles Use the generally accepted terms: unit leaders, assistant unit leaders Each facility will have unique disaster roles assignments
Unit leader = the role given to the staff position that is always in house
Create ‘job action sheets’ for each designated role
Create ‘grab and go bags’ Imagine you are delivering in the parking lot
Create a ‘phone tree’
Based on distance from the hospital
A list of hospital first respondersResponders who will / can come in immediately
Begin simulation disaster training for all personnel on the unit
Follow-up training and drill
L&D Disast er Plan Checklist for Unit Leaders
(Resource RN & SWC At t ending/ Chief Resident )
1. Locate Disaster Binder (tube room)
2. Send Tech to get Disaster Boxes (O R hallway supply room)
3. M eet at white board or other safe area to assign Disaster roles (fill out Disaster Roles Poster and hang it next to white board)
4. Distribute Job Action Sheets, decide on best form of communcation (runners, phones, etc), and designate regular meeting times (ie: every 20-30 minutes)
5. Locate Fire Extinguishers (Near OR A, OR C, LDR 8, and elevator)
6. Locate O 2 Supply Valves (N ear each O R, lunch/ breakroom, and L&D entrance)
7. Ensure that only life-sustaining equipment is plugged into red plugs (to avoid overloading generator)
8. Assistant Unit Leader(s) and Tech(s) team up to: 8a: Assess unit for damage and fill out Department Damage M ap (map can be used to fill out Department Status Report for hospital command center)
!
8b: Write on each door (paper sign for SIM ) with a sharpie “SAFE” or “DAN GER”
!
8c. TRAIN Triage each patient
!
9. Bedside RN s fill out Paper Patient Forms in case of computer failure or evacuation
!
10. Bedside RN s or Techs fill up Grab & Go bags to be prepared for possible evacuation
!
11. In event of evacuation/ transfer order from Hospital Command Center, assist with putting patients in M ed Sled that will be brought to L&D. (Emergency management/ transfer folks will belay patients down the stairs)
Disaster Transfer Summary L&D or AP (DRAFT 6-3-13) ROOM # _______Train Score:
Hospital level needed: Neonatal LEVEL 1 2 3 (CIRCLE ONE)
Maternal LEVEL 1 2 3 (CIRCLE ONE) Patient name: (Last, First) MRN: (MRN) DOB: Primary OB provider: (PMD) Other important outside care provider(s): Date of Admission to LPCH: A G P EGA i l l i l P i
Blue Green Yellow Red
Know what you have Think of what you need What is you plan?
Equipment Staff Practice, Practice, Practice EMS
Assess your organization Group together with others from your organization
to assess your facility using the self assessment tool
Assess your capabilities as regional partners Review the maternity hospital levels of care and
determine where you can send each of the patients you TRAINED in table top exercise #1
Let’s discuss gaps and solutions
Gaps Challenges Possible solutions
Stanford Disaster website for OB tools
obgyn.stanford.edu/community/disaster-planning.html
Want more information including peds and NICU TRAIN and to join quarterly webinars:
https://stanforduniversity.qualtrics.com/SE/?SID=SV_aeBdluNgaCcizFb
Divide into 3 groups Group 1 Group 2 Group 3
Photo by John Moore/Getty Images
It is 4 am and an 8.0 earthquake has hit your
hospital
You have had extensive damage to your unit
Please work with your group to care for the
patients on your unit
The command center is at your disposal
