Hospital/Emergency Department Preparedness & Disaster TriageSeptember 8, 2016

Wedding Incident Command Structure (ICS)

BBQ Incident Action Plan (IAP)

Before we begin… A brief recap.

What will we be discussing?

• Hospital and Emergency Department Preparedness (Chapter 4)• Disaster Triage (Chapter 12)

The Comprehensive Emergency Management Program

Program Organization

The Emergency Management Committee

• Authorize the process and structure whereby practices and principles everyday preparedness and disaster response are developed.

• Promote collaboration • Direct the changes

necessary to provide care to patients and staff as related to disaster response.

• Evaluate disaster-related events and responses.

• Work with external entities to ensure a concerted and well planned response to disaster related actions.

Hazard Identification and Risk Assessment

• Goals• Identify threats to the

organization• Prioritize the threats

based on:

• Determine mitigation and planning strategies

• POETE

Likelihood X Impact = Risk

The Hazard Vulnerability Analysis

Hazard Likelihood Impact Risk Index

Chemical Exposure 1 3 3

Active Shooter 1 3 3

Technology Failure 2 1 2

The Station Fire

• When: February 20, 2003 11:07pm

• Where: West Warwick, Rhode Island

• Venue: The Station Nightclub

• Cause: Ignition of acoustic foam by pyrotechnics

• Impact:• 100 Fatalities (toxic

smoke, heat, stampede)• 230 Injuries• 132 escaped uninjured

The Station Fire

The Station Fire

• Front doors became blocked within one minute

• Impassable after 1:16 sec• Interior ignition temperatures reached

in one minute• Triage

• Quickly established in the neighboring restaurant after fire fighters led victims away from the fire scene (28 degrees Fahrenheit outside)

• 80-100 victims were in the street• 30+ victims in the triage area• 30-50 survivors still in the fire building• 97 perished initially in the fire

The Station Fire

The Station Fire: Triage and Transport

• Fire Department on scene four minutes after notification (911 call)• 160 Firefighters from 15 communities responded• 65 ambulances from RI and MA

• Security of the triage area was setup by State and Local Police• Logistics setup outside the building for staging and transportation• Hospital notified and provided updates (however, there were

communications problems)• Patients assigned to EMS units and to accepting hospitals

• All patients transported within 1 hour 45 minutes• Routine/constant evaluation of the victims

The Station Fire: Injury Profiles

• 40%+ with 3rd degree burns of face, hands and/or upper bodies• Most had inhalation burns and smoke• Lacerations to arms and legs• Some had crushing injuries• Several hyperventilation victims, mostly with moderate to lesser

injuries• 20-30 critical third degree victims saved from the fire by fire

extinguishers

The Station Fire: Hospital Considerations

• Early notification• Hospital Response Teams• Adequate Emergency

Operations Plan to coordinate multiple department response

• Capacity versus Capability• Internal Notification

Procedures• Morgue Capacity

Received T&R Xfer Admit

KCMH 68 41 17 7

RIH 63 17 8 38

Fatima 18 13 2 3

S. County 17 16 0 1

Miriam 12 4 2 8

RWMC 10 4 6 0

Landmark 6 5 0 1

Westerly 2 2 0 0

Memorial 1 1 0 0

197 103 36 58

Strategy Mapping: MCI-Burn

Planning

• What is our goal of an MCI-Burn plan for our hospital?

• Who are the right people to involve in the planning?

• What is the right process?

Planning: Surge Capacity

Stuff Staff

Space

Planning: Surge Capacity

Planning: Surge Capacity

• Considerations:• Triage• Decontamination• Holding Areas• Treatment Areas• Security• Direct Patient Care Areas• Capacity Plan Activation

• Ambulatory Care• Ancillary and Support Services• Mass Fatality Management• Medical Waste• Staffing• Volunteers• Staff/Family Needs

Planning: Surge Capacity

• Considerations:• Medical Supplies• Pharmaceuticals• Equipment• Restocking Procedures• PPE• Food/Water

Triage Systems

• Patient #1 *mci• Breathing? No• Reposition Airway, Breathing? Yes• Triage Determination:

• Patient #2• Breathing? No• Reposition Airway, Breathing? No• Triage Determination:

• Patient #3• Breathing? Yes• Respiration Count: Under 30/min• Capillary Refill: Under 2 seconds• Mental Status: Cannot follow commands• Triage Determination:

• Patient #4• Walks away from the incident and follows

commands• Triage Determination:

Triage Systems

• Patient #1• Global Sort: Wave• Individual Assessment:

Obeys commands, and has a few small lacerations

• Triage Determination:

• Patient #2• Global Sort: Still• Individual Assessment:

LSI – Major hemorrhage, breathing, hemorrhage uncontrolled

• Triage Determination:

Triage Tags

Emergency Severity Index - ESI

• The Emergency Severity Index (ESI) is a five-level tool for use in emergency department (ED) triage. Experienced ED nurses use the ESI to rate patient acuity, from level 1 (most urgent) to level 5 (least resource intensive). The ESI is unique among triage tools, by including both acuity and resource needs in the system of categorizing ED patients.

• The ESI is a powerful tool for enhancing patient safety at triage as well as providing casemix data to support emergency department operational decisions, quality initiatives and clinical research.

www.esitriage.org

Disaster Triage

• EDs may plan to place a physician at the entrance to briefly assess patients as they enter.

• Based on the assessment, they will be sent to the appropriate treatment area.

Hazardous Materials

• Infectious Substances• Radioactive Materials• Flammable Liquids and Gases • Toxic Chemicals

Hazardous Materials: Routes of Entry

Field Hazmat Zones

Hazmat Decon Process

Hazmat Decon Process

Hazardous Materials: Levels of PPE

Level A Level B Level C Level D

Staffing

• The Typical Process• Notification• Assessment• Unnecessary Staff Report to Manpower Pool• Assigned to Areas Requesting Assistance

• General Manpower Pool• Medical Staff Manpower Pool• Modification of the Provider-to-Patient Ratios• External Assistance• Importance of Cross-Training

Credentialing

• Routine Credentialing Process• Disaster Credentialing Process• External Support (Medical Reserve Corps, etc.)

Disaster Resources and Logistics

• Disaster Inventory• Location, Location, Location• Readiness• Negotiating the Responsibilities• Training• Restocking

• Off-sites• Departments• Emergency Dept.

• Challenges• JITI• Vendor relationships• Stockpiling (antibiotics, antivirals,

etc. )

Security Issues in Disasters

• Access Control• Internal• External

• Traffic Control• Visitor Management• Media Management• Interaction/Integration

with Law Enforcement and First Responders

• Clery Act Responsibilities• Emergency Notification• Timely Warning

• Continuous Surveillance• Highly Sensitive Areas

Utilities

Utilities

• 96-Hour Capability• Cascading Effects of

Utility Failures• Backup Systems

UtilitiesDaily Capability Primary Backup

Electricity Power Company GeneratorWater (for

consumption and essential care

activities)Municipal Water

Bottled Water, Water dump tank,

and tankers via quick connection

Fuel (for building operations,

generators, and essential transport

services)

Fuel Tanks Multiple Vendor Contracts

Medical gas/vacuum

systems

Integrated Gas/Vacuum

Systems

Tanked Gas and Portable Suction

Devices

Elevators Elevators

Stairs, Stair Chairs,

Evacuation Sleds,

Evacuation Baskets

Steam (sterilization) Steam Plant

Conservation, Alternate Systems

Facility Evacuation

• Decision-making strategy• Destination arrangements• Shelter-in-Place• Specialty Care Units

• ICUs, CCUs, NICUs, PICU, OB

• Resources

Facility Evacuation

Trauma Centers

• Relocating the Disaster• From the scene• From other hospitals

• High-Acuity Patients Only

• De-Facto 2nd Tier Burn Center

• Higher Security Risks• Pediatric Accreditation

is Separate• Re-routing/Diversion

(last resorts)

Alternate Care Sites

• Considerations• Most appropriate location for the delivery of care is in

the hospital• ACS primary goal is to accept patients to free up

space in the hospital• There will be a shortage of resources• Location (internal, external)

• Planning Process• Hospital Coalitions• Health Departments• EMS Councils• Emergency Management• Legal/Regulatory

• Conventional, Contingency, and Crisis Standards of Care

• Needs• Stuff• Staff• Space• Integrated Processes

Alternate Care Sites

Alternate Care Sites

• Radiology• Procedure Areas• Secondary Transport• Manpower Management• Communications

Mass Casualty Incident Tabletop Exercise

Setup

• Focus Groups:• 1 – Hospital Command Center

• Identify your Administrator On-Call• 2 – Emergency Department

• Identify your Charge Nurse/Spokesperson• 3 – Trauma Intensive Care Unit

• Identify your Charge Nurse/Spokesperson• 4 – Alternate Care Site Team

• Identify your ACS Team Lead/Spokesperson

• Sit Together

Purpose

To provide participants with an opportunity to evaluate current response concepts, plans and capabilities in response to a mass casualty incident.

Exercise Instructions

• Exercise is based on a plausible, possible event (do not fight the scenario)

• Process the information as you would in a real-life incident

• There is no hidden agenda or trick questions• Participation is key to making this exercise a

success• Feel free to make valid assumptions based on the

information provided• Respond based on your knowledge of current

plans and capabilities

Rules of Engagement

• This is an open, low-stress, no-fault environment

• Offer any suggestions or recommended actions that could improve response and preparedness efforts

• Be respectful of other, as varying viewpoints and disagreements may occur

StartEx

Module 0: Setting the Stage

• Welcome to Shenandoah University Medical Center (SUMC)!

• It is September 9, 2016, 2300 hours (11:00pm).

• Your Emergency Department is at 90% capacity (45/50 beds filled). Housewide is 100%.

• You are a Level I Trauma Center with three trauma bays and six “contingency bays”.

• Your staffing (nursing, physician, techs, diagnostic techs) is at “par” for a Friday night.

• You are not a burn center

Module 0: Setting the Stage

• Alternate Care Site: Not open

• Hospital Command Center: Closed

• TICU: 17/18 patients and 0/6 patients in the overflow unit

Module 1: Early Notification

• At 2305, the Emergency Department Communications Nurse overhears on the county radio that all available units fire/rescue units are being dispatched to a fire at a nightclub.

• There are reports of people trapped inside.

Module 1: Early Notification

• At 2310, the on-scene Incident Commander calls the hospital and indicates that there are 100’s of patients with smoke inhalation, burns, varying degrees of trauma, and some that triage is being setup now.

• Actual patient counts are not available.• Air Medical is being requested to respond to the scene for

transport of the highest-acuity patients.

Module 1: Early Notification - Questions

Emergency Department Hospital Command Center• What are the questions we should ask

the Incident Commander?

• What are our immediate actions?

• Who are we contacting?

• What are we communicating?

• What are we sharing with patients and visitors?

(you are not open and don’t know anything at this point)

Trauma Intensive Care Unit Alternate Care Site(business as usual) (you are still a part of your unit, work with

TICU)

Module 2: The Patient Count Comes In

Module 2: The Patient Count Comes In

• At 2313, the on-scene Transportation Officer has reached out the Regional Healthcare Coordinating Center to request an alert to all area hospitals and request an available bed count.

• The RHCC has assumed control of patient allocation and has made the following INITIAL allocations:

Hospital Red Yellow Green TOTAL

SUMC 16 3 0 19

MRMC 3 12 0 15

ILH 1 6 20 26

IAH 0 6 10 16

Module 2: The Patient Count Comes In - Questions

Emergency Department Hospital Command Center• Now that we know the initial patient

count, what are our actions?

• What are we communicating to who?

• How are we getting more stuff?• What are we asking for?• Where do you want it?• How fast do you need it?

• How are we making space?

• Hospital Command Center, are you open?

• How will we make space in the hospital to accommodate these patients?

Trauma Intensive Care Unit Alternate Care Site• How are we making space?• How are we getting more stuff?

• What are we asking for?• Where do you want it?• How fast do you need it?

(you are still a part of your unit, work with TICU)

Module 3: The Second Wave is Allocated

• You have received the first wave of patients as initially allocated.• At 0000 hours, the RHCC has allocated the following additional

patients to the area hospitals.• All ED beds are filled. All available staff have been called in.• These are in ADDITION to what you have already received.• 5 patients have just self-presented to the ED with smoke

inhalation.• The Hospital Command Center decides to open the Alternate

Care Site in the Lobby for lower acuity patients.

Hospital Red Yellow Green TOTAL

SUMC 25 15 0 40+19

MRMC 8 8 0 16+15

ILH 0 2 15 17+26

IAH 0 0 17 17+16

Module 3: The Second Wave is Allocated

• 14 RNs, 2 MDs, and 20 Clinical Technicians have reported to the Manpower Pool and have been assigned to the Alternate Care Site in the Lobby.

• The media is calling the hospital asking for a comment on the situation.

• Some media have attempted to enter the hospital as a family member of a patient.

Module 3: The Second Wave is Allocated - Questions

Emergency Department Hospital Command Center• Where are you putting patients?• Are you conducting secondary triage at

the ED?• What are we communicating at this

point and to who?

• Hospital Command Center, are you open?

• Have your objectives changed?• How are you coordinating the

response?• Who have we reached out to

outside of the hospital?• How are you handling the media

presence on campus?• Who else have we called in to

support the response?

Trauma Intensive Care Unit Alternate Care Site• Have you called in additional staff?• You may have received burn patients –

how are you handling these unusual cases?

• What resources do you need to manage your new unit?

• How are you communicating needs?• How are you controlling access?

EndEx

• Hot Wash Questions• What did the group do well?• What are the important planning considerations?• Who should we involve?• What are the challenges with opening an Alternate

Care Site?• What are some decompression strategies (how do

we make room in an already full hospital)?• What did we not talk about?

Questions?

L. Keith Dowler, MA, CEMEmergency Management Coordinator

Department of Public Safety and Emergency ManagementInova Fairfax Medical Campus

3300 Gallows RoadFalls Church, Virginia 22042

T 804-776-6418 |M 804-937-1921 |S 66418 |P ID 169032

Thanks!