Hospital Emergency Operations Response: Mass Casualty Response Objectives

Hospital Emergency Operations Response: Mass Casualty Response Objectives

Hospital Emergency Operations Response: Mass Casualty Response Objectives At the conclusion of this presentation the participant will be able to: Facilitate discussion regarding disaster or medical emergency response operations Review the epidemiology of disasters Define the role of Public Health in a disaster Review the phases of disaster response Define the role of hospitals in disaster response Disaster Disaster Crisis situation causing wide spread damage which exceeds ability to recover

Disaster Management Actions taken by an organization in response to unexpected events that are adversely affecting people or resources and threatening continued operation of the organization; management of natural catastrophes Natural or Man Made Emergency Operations Response FEMA Declared Disasters By Year 100 90 80 70 60 50 40

30 20 10 0 Major Disaster Emergency Disaster http://www.fema.gov/disasters/grid/year FEMA Review BY STATE Total Disaster Declarations Average Major Disaster

Declarations Emergency Declaration 2054 344 34 6 FEMA State Major Disaster Declarations State State Alabama

56 Louisiana 58 Alaska 37 Maine 59 Arkansas 53 Minnesota

48 California 78 Mississippi 50 Florida 63 Missouri 53 Georgia

36 Nebraska 47 Illinois 51 New York 65 Indiana 39 N. Carolina

40 Iowa 48 N. Dakota 42 Kansas 47 Ohio 45 Kentucky

55 Oklahoma 70 http://www.fema.gov/disasters/grid/state FEMA State Major Disaster Declarations

Pennsylvania South Dakota Tennessee Texas Virginia Washington West Virginia Wisconsin 47 39 50 86 45 44 46 35 Disasters in 2011

Total Weather Losses: $35 Billion 700 US Disaster Deaths US - 10 Weather Catastrophes 5 Tornado Outbreaks Two Different Major River Floods Drought In Southwest Blizzards in Midwest / Northeast Hurricane Irene East Coast Earthquake Oppressive and Unrelenting Heat

Tornadoes of 2011 Wikimedia.org Tornado Hospital Impact Earthquake Events http://earthquake.usgs.gov/earthquakes Earthquake Events Drought: Potential Wild Fire 2012 Wild Fires Danger Hurricane Events Train Events

Train Events 2002 7 Events -1 Evacuation, 10 Killed, 259 Injured 2003 3 Events 1 Evacuation with Fire, 2 Killed, 48 Injuries 2004 4 Events 1 Evacuation, 6 Killed, 74 Injured 2005 8 Events 1 Evacuation, 23 Killed, 433 Injured 2006

7 Events 5 killed 2007 7 Events 2 Evacuations 2008 9 Events -27 Killed, 297 Injuries 2009 6 Events 2 Evacuations 17 Killed 2010 2 Events 2011

5 Events 5 Evacuations http://en.wikipedia.org/wiki/Lists_of_rail_accidents Commercial Aircraft Events 4 1 3 2 Commercial Aircraft Events 2000 to 2011 209 Commercial Aircraft Crashes 2000 to 2011 13 Commercial Aircraft Crashes in the United States ( 753 Fatalities, 97 Reported Injuries) 2001 Planes Used For Terrorism

School Shootings 2000 2001 2001 2002 2002 2003 2003 2004 2004 2005 2005 2006 2006 2007 2007 2008 2008 2009 2009 2010 2010-2011 2011-2012 January 1-December 21, 2012 19 Deaths 4 Deaths 14 Deaths 29 Deaths 20 Deaths

5 Deaths 38 Deaths 3 Deaths 10 Deaths 5 Deaths 6 Deaths 7 Deaths 35 Deaths Shooting Events in Hospitals Event at Psychiatric Hospital, Pennsylvania Event at Creighton University Medical Center, Illinois

Event at Physicians Regional Medical Center, Florida Event at John Hopkins Hospital, Maryland Active Shooter Procedure Code Silver Johns Hopkins Hospital: Gunman Shoots Doctor, Then Kills Self and Mother

Acts of Terrorism in USA 1900 1959 15 1960 1969 12 1970 1979 15 1980 1989 11 1990 1999

8 2000 2010 23 Acts of Terrorism 1972: Attack at Olympics in Munich Germany 1979: 80 Iranian students invaded the US Embassy in Tehran and took 52 US Hostages 1983: Hezbollah suicide bomber crashed truck of

explosives into US Embassy in Beirut; 63 killed 1983: Hezbollah suicide bomber bombed US and French military barracks in Beirut; 299 Killed 1983: Shiite suicide bomber crashed into the US Embassy in Kuwait; 5 killed 1984: Truck bomb explodes outside Aukar, Lebanon Annex of the US Embassy in Beirut; 24 killed 1984 and 1985 hijackers 1988: 757 Pan Am Flight 103 explodes; 270 killed Acts of Terrorism 1993: 2 US helicopters shot down in Somalia; 18 killed

1993: First World Trade Center bombing 1995: Truck bombing of US National Guard Training Center in Saudi Arabia; 7 killed 1996: Truck bombing of Khobar Towers in Saudi Arabia; 19 killed 1998: Car bomb US Embassy Kenya, US Embassy Tanzania; 224 killed 2000: Suicide bombing of the U.S.S Cole in Yemen; 17 killed Public Health Disaster Response Phases Disaster Policy First Response Local Response Major Disaster President Determines Warrants Supplemental Federal Aid, Provides Disaster Relief Funds Managed by FEMA Presidential Major Disaster Declaration

Long-Term Federal Recovery For Disaster Victims, Businesses and Public Entities Disaster Policy: Major Disaster Process Local Government Responds State Responds Damage Assessment Major Disaster Declaration is Requested By Governor FEMA Evaluates Request President Approves http://www.fema.gov/media/fact_sheets/declaration_process.shtm National Response Plan Align Federal Coordination

Unified, All-Discipline, All-Hazard Approach to Domestic Events Standardize Operations Establish National Framework Streamline Disaster Policy Directives / Protocols Guidelines For Long-Term Community Recovery National Response Framework Emergency Support Function #8 Public Health and Medical Services Supplemental Assistance to State, Local and Tribal Government Assess Public Health/Medical Needs

Public Health Surveillance Medical Care and Personnel Medical Equipment and Supplies Coordinator and Primary Agency is the Department of Health and Human Services NDMS http://www.fema.gov/national-response-framework Disaster Role: Health Care Systems Role First Responders: EMS, Police, Fire, Hospitals First Receivers: Hospitals Hospitals: Preparedness In Direct Odds With Productivity Regional Integration Collaborative

Partnerships Hospital Response The 7 phases of Readiness: Preparedness Planning Integration with Pre-Hospital Emergency Operations Response Plan Regional Integration After Action Review Plan Revisions

http://www.phe.gov/preparedness/planning/hpp/reports/documents/capabilities.pdf Hospital Preparedness Phase Of Information Gathering Hospital Leaders Define Federal & Regulatory Requirements Education Review of Lessons Learned Organizational Structure National Incident Management For Hospitals Adopt NIMS Organization Wide Command Management ICS, MACS, PIS

Preparedness Planning NIMS Tracking, Funding, Plan, MOU Preparedness Training 800, 700, 100, 200, 300 Preparedness Exercise All Hazard, AAR, CAP Resource Management Inventory, Acquisition Community and Information Management Standard Terminology

Preparedness CMS Provisions of Participation Joint Commission Chapter 12 Standards for Emergency Management Six Essential Elements Communications Resources and Assets Safety and Security Utilities Management Patient Clinical and Support Activities Planning

Planning Phase Is A Critical Element Follows Review Of What As Happened Hazard Vulnerability Assessment Review Response Plans Define Resources Needed Community Integration Prioritize Exercise Events Special Populations Specific Risks: Chemical, Biological, Blast Planning For Staff Needs

Planning Phase Brings Together Individuals of Interest, Resources and History Creates a Score For Each Hazard Assists in Defining Priorities For Next Twelve Months Integrated with EMO / Community / Region Planning Phase [contd] Hazard Vulnerability Assessment (HVA) Likelihood of Happening Impact on Society Define Hazard

Effective Plan Impact on Individual Response Plan Staff Know What To Do Impact on Community Resources/ Equipment to Response

HVA Natural Man Made Tornado Flooding Hurricane Earthquake Landslide Mudslide Wildfire Extreme Temp Volcano Transportation Industrial Hazmat Structure Collapse Weapon Violence Fire

Explosion Terrorist Chemical Terrorist Biological Terrorist Radiation Planning ICS / Command Center Medical Decontamination Training EMS Traffic Routes / Triage Medical Care

Unidirectional Flow Minimal Standards Staffing Patterns Evacuation of ED / Trauma Areas Surge Staff Notification / Staff Traffic Routes Communication Redundancy Security Planning Just-In-Time Inventory

Medication Distribution Infrastructure Contingency Business Continuity Casualty Tracking Planning Written Emergency Operations Response Plan Input of Medical Leaders, Administration, Nursing, Trauma Program, and Representatives From all Key Departments All Hazard Response Plan Job Action Sheets Leadership Training Departmental Training Hospital Response

Event Recognition Situational Awareness Activation of Response Level of Response Notification Establish the Command Center Incident Command System Incident Command Logistics Section Operations Section

Planning Section Finance Section Communication Incident Action Plan Incident Command System Organization Chart http://www.fema.gov Community Central Command Incident Commander Public Information Officer Safety Officer Liaison Officer Logistics Section

Operations Section Planning Section Finance Section Hospital Response Initial Response Procedures Security / Lockdown Reorganization to ICS Job Action Sheets Unit Priorities Emergency Department

Trauma OR ICU General Units Alternate Care Sites Elective Procedures Hospital Response Medical Decontamination Security / Access Triage Echelon of Triage Disaster Standards of Care

Patient Tracking Special Populations Unresponsive Casualties Morgue Casualties Families Media Exercise & Training HVA Utilized to Define Exercises Table Top, Specific Exercises Communication, Medical Decontamination Full Function Exercises Exercise Controllers Regional Exercises After Action Reviews

Emergency Operations Response Plan Revisions Special Considerations Blast Injuries Chemical Exposure Radiation Exposure Biological Exposure Blast Injuries Blast High Speed Chemical Decomposition of Explosive Materials

Shrapnel Fragments Incendiary Material Surrounding Materials Conventional Materials Ammonium Nitrate Fuel Oils Gun Powder Plastics / Others Characteristics Dependent on Composition and Components Blast Effect

Caused by High Pressure Shock Waves Radiates Outward From Explosion Size and Type of Explosive Distance From Explosive Transmittal Medium Reverberations of Blast Negative Waves Followed by Shrapnel, Fragments, Heat, Smoke and Fire Concern for Toxic Fumes / Dust Potential Structural Collapse Chemical Exposure Agent

Effect Onset Treatment Nerve Agents: Vapor Liquid Both Miosis (pinpoint pupils) Rhinorrhea SOB, LOC, Seizures Excessive Sweating GI Distress Vapor seconds to minutes Liquid- minutes to

hours Atropine Pralidoxime (2-PAMCI) Benzodiazepines ABC Support Cyanide (Smells like bitter almonds) Cherry Red Skin Nausea, LOC Dizziness Metabolic Acidosis Transient Rapid Breathing, LOC, Apnea, Cardiac Arrest Seconds to minutes

Cyanide Kit Amyl Nitrate Sodium Nitrate Sodium Thiosulfate ABC Support Blister Agents: Mustard Lewisite (Smell of mustard, onion or garlic) Redness of skin. Blisters, Irritation of Eyes, Cough, SOB, Airway Injury Pulmonary Edema Mustard: Bone Marrow Suppression

Mustard: Hours Lewisite: Minutes Lewisite: British Anti-Lewisite Chemical Exposure Agent Effect Onset Specific Treatment Pulmonary Agents Phosgene Chlorine (Smells like fresh cut grass or hay)

SOB, Coughing, Chest Tightness, Laryngeal Spasm, Delayed NonCardiac Pulmonary Edema Urticaria or wheel skin Irritation Symptoms Immediate No Antidote ABC Support Riot Control Agents Pepper Spray Tear Gas Pain, Tearing, Redness of Eyes, Burning of Nose /

Throat, Sneezing, Rhinorrhea SOB, Bronchospasm, Respiratory Distress Skin Erythema, Possible Conjunctivitis Seconds Delayed Pulmonary Edema Irrigate Eyes Copiously With Water / NS Wash Skin With Sodium Bicarbonate, Alkaline Soap, or Large Amounts of Cool Water Bronchodilators

Radiation Exposure Potential Terrorist Events Nuclear Explosion Meltdown of Nuclear Reactor Dispersal of Material Through Conventional Explosives: Radiation Dispersal Device (RDD or Dirty Bomb) Placing Radioactive Material In Public Areas Radiation Exposure

Alpha Particles Beta Particles Gamma Rays Neutrons Radiation Exposure External Contamination Radiation Debris Is On The Body and Clothing Contamination Is Removed By Medical Decontamination Prevent Internal Contamination By Inhaling, Swallowing or Through Open Wounds Internal Contamination Caused By Inhalation, Ingestion or Absorbed By Open Wounds

Potential Thyroid Gland Injury Unit Measures 100 Rad = 1 Gray (Gy) 100 Rem = 1 Sievert (Sv) Amount of Radiation Human Absorbs Measured in RAD Biological Effects of the RAD Exposure is Measured in REM Radiation Exposure: Prodromal Symptoms Symptoms Time of Onset Approximate WholeBody Radiation Dose

Physiological Illness Nausea, Vomiting First 48 Hours 1 Gray 100 Rad Decrease In White Blood Cells and Platelets Nausea, Vomiting First 24 Hours 2 Gray

200 Rad Hematopoietic Syndrome Marked Decrease in White Blood Cells and Platelets Nausea, Vomiting, Diarrhea First 12 Hours, 8 Hours for Diarrhea 4 Gray 400 Rad Gastrointestinal Damage 50% Mortality in Absence of Treatment

Nausea, Vomiting, Diarrhea Within 5 Minutes 10-30 Gray 1,000 3,000 Rad Severe Gastrointestinal Damage Very Poor Prognosis CNS Impact, Mental Status Changes Within Minutes 30 Gray 3,000 Rad

Neurovascular Syndrome Severe CNS Damage, Cardiovascular Collapse Lethal Biological Exposure Biological Terrorism Epidemic / Pandemic Potential Biological Exposure

Disease Unusual Or Does Occur Naturally Multiple Diseases Large Numbers of Military and Civilian Massive Point-Source Aerosol Route High Morbidity / Mortality Disease Limited To Localized Geographic Area Low Exposure in Air Filtered Locations Dead Animals Absence of Natural Vector Biological Agents

Anthrax Tularemia Plague Smallpox Botulinum Toxin Viral Hemorrhagic Fevers Ethical Consideration Autonomy Nonmaleficence Beneficence Justice Regional Integration Regional Hazard

Vulnerability Assessment Regional Coordination Regional Communication Patient Tracking Mutual Sharing Exercise Development After Action Review Regional Medical Operation Centers RMOC

Foster Agency Collaboration / Involvement Provide Educational Resources Integration of Multi-Agency Health / Medical Professionals / Public Health EMS Providers / Medical Control / Medical Directors Medical Examiners Office Community Leaders School Systems City / County / Emergency Managers Law Enforcement Agencies Business Community Questions What is the definition of disaster

management? What are the four public health disaster response phases? How does the hospitals response to a disaster reflect preparedness of the seven phases readiness? Summary Define the Hazards That Impact Your Community and Complete an HVA Define Members of Your Emergency Operations Response Committee Define Response Priorities Develop Emergency Operations Response Plan Educate Define Special Response Needs Define Realistic Exercises To Test Response Plan Complete After Action Reports Define Performance Improvement Needs Revise Plan

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