It is essential to organize disaster drills in the hospital that are coordinated with community resources. These drills should include the following scenarios:
Drills should include Disaster Life Support Teams performing their respective functions.
The goal of disaster life support training is to standardize incident response across the Nation as a way of strengthening national public health. Basic disaster life support training provides a didactic review of all-hazard topics, including critical information on the role of the health care professional. Advanced disaster life support extends this training into incident-specific scenarios (e.g., decontamination of mass casualties) through didactic training and interactive sessions and drills. Drills for advanced disaster life support teams should include the following:
The pediatrician's strongest role can be in helping hospital disaster planning teams anticipate and manage pediatric victims who have been separated from their primary caregivers during a disaster. These children need immediate support until a definitive caregiver can be located.
In the event that in-hospital support services are overwhelmed, other efforts will also be needed, including the following:
In the event that community support and child-protective services are also overwhelmed, additional efforts will be needed, including the following:
Pediatricians also can help communities plan to provide other support services for families and children:
In January 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced new disaster preparedness standards, building on its prior position that health care organizations should be prepared for all types of emergencies. These standards represent an important evolution in the concept of managing emergencies. Health care organizations are expected to address the four specific phases of disaster management—preparedness, response, mitigation, and recovery—and conduct hazard vulnerability analysis.
This “all-hazards” approach should result in a thorough review and risk analysis of credible hazards and serious threats to the facility and its surrounding community, as well as the subsequent development of plans to address the ramifications of all possible hazards. After plans are developed, the organization should implement and execute them by conducting training and drills.
The new JCAHO Guidelines require hospitals to use formal emergency management processes as the foundation of their planning. These include the following:
JCAHO has published an emergency planning guide for use by officials in small, rural, and suburban communities. The guide is available at http://www.jointcommission.org/NR/rdonlyres/FE29E7D3-22AA-4DEB-94B2-5E8D507F92D1/0/planning_guide.pdf. (PDF Help).
Triage to the appropriate facility can be critical for a child. Therefore, the development and implementation of a mass casualty plan that considers the unique needs of children is imperative to avoid overloading one local facility (whenever possible). The community should have designated facilities for referral of critically injured pediatric patients. At the same time, each facility should be able to care for and at least initially stabilize both children and adults. Pediatric skills and equipment should be maintained at all facilities.
Emergency departments and hospitals should have some mechanism to provide for the physical, as well as the medical needs of pediatric populations. These needs include shelter, clothing, food, supervision, and entertainment for pediatric victims, as well as protection from the media in the critical period immediately after a disaster.
The incident command system (ICS) is widely recognized and used in the field of emergency management to effectively manage resources and casualties during a disaster. The ICS is a unified management system that allows for expandability and accountability based on the magnitude and needs created by the specific incident. It is an organizational system of “best practices” for on-scene, all-hazard incident management. There are five major management functions:
All have standardized position titles. The following nomenclature is used for organizational components and their supervisory personnel:
In a unified command structure, there is one recognizable leader—the incident commander—who has overall responsibility. Because the system is expandable, it allows for the use of many components that may be needed to manage the incident. Various component managers are granted the authority to manage their specific component, and they are held accountable for the performance of their area to the incident commander.
This type of system is widely used in everyday business. For example, in the hospital setting, the incident commander could be compared with the chairperson of the medical board, and the group managers could be compared with the various chiefs of service.
The National Incident Management System (NIMS) has been developed for use by all emergency response agencies in the country. NIMS is an updated more inclusive version of ICS. Its standardized framework, common terminology, and flexibility allow it to be used by Federal, State, and local agencies/authorities.
ICS is modular and can be expanded to meet needs that arise during an incident. In a disaster, the triage, treatment, and transportation of casualties fall to the EMS Operations Branch. The incident command officer is most often a field officer of the local EMS agency. That officer is responsible for managing all medical resources needed to effectively handle the incident and for minimizing the impact on normal operations of the EMS system. Based on the scope of the incident, the divisions of smaller functional units are formed to manage the following:
The staging officer is responsible for setting up an area where incoming resources, including personnel, can gather and await an actual assignment. The staging group can be broken down further into smaller units of operation for specific incident needs. For example, incoming ambulances would be directed to a vehicle staging area; personnel not assigned to a specific unit or task would be sent to a personnel staging location; and needed equipment would be directed to a logistical staging location. These areas may be off site from the incident but easily accessible to it. This allows greater accountability of who is on the incident ground and monitoring of their respective functions and performance.
The triage group is tasked with prioritizing casualties based on pre-established medical protocol. Simple Triage and Rapid Transport (START) allows rescuers to assess and prioritize a victim with a 30-second, hands-on assessment. Immediate life-threatening conditions are rapidly identified and corrected with minimal intervention, and casualties are identified for immediate transport (e.g., airway problems are corrected with a tilt of the head, and the patient is marked “red” for immediate transport; intubation in the field would not be done during this initial assessment). For children, a variant known as JumpSTART pediatric mass casualty triage is used (http://www.jumpstarttriage.com).
In incidents involving victims exposed to hazardous chemicals, a similar system of triage is used. Normal START procedures would be extremely difficult for rescuers in chemical protective clothing to use. In these cases, a form of triage based on observation of symptoms is used, and response to tactile stimulus determines the triage priority.
The treatment group is tasked with providing a more definitive treatment regimen for incident victims. Casualties are removed from the incident ground to a safe, protected area so that treatment can be started, particularly if transport is to be delayed. Personnel in this group constantly monitor victims for changes in their condition and change their triage priority as needed. In large-scale incidents in which the patient load would cripple normal hospital resources, victims with minor injuries may be held in an off-site treatment area for an extended time. Physicians, nurses, and other ancillary staff may be assigned to staff this area.
Victims that have been exposed to a chemical or biological agent should be decontaminated. Personnel assigned to this task should be trained hazardous materials technicians because they need to operate in chemical protective equipment. This may be as simple as a splash suit and gloves or as complex as a fully encapsulated suit and positive-pressure breathing apparatus, depending on what type of chemical or agent the victims were exposed to.
The transport group is tasked with the responsibility for transporting victims from the incident ground to field treatment centers, hospitals, or specialty referral centers (trauma, burn, replant, etc.). The group officer usually maintains listings of available hospital beds and medical evacuation and public transportation resources that may be needed to move victims. The transport group also performs the critical function of maintaining the log of destinations to which victims have been moved so that they may be tracked for public information and quality assurance reasons.
Comprehensive Emergency Medical Services Systems Act of 1973. Washington, DC: United States Congress, Senate Labor and Public Welfare Committee; 1973.
Department of Homeland Security. National Incident Management System. March 2004. Available at:http://www.dhs.gov/xlibrary/assets/NIMS-90-web.pdf (PDF Help). Accessed July 10, 2006.
JumpSTART. Combined JumpSTART algorithm. Available at: http://www.jumpstarttriage.com/. Accessed August 17, 2006.
National Health Professionals Preparedness Consortium: Healthcare leadership and administrative decision-making in response to WMD incidents. Nobel Exercise Scenario Information, v.2.0. December 31, 2002.
President's Disaster Management Egov Initiative. Available at: http://www.whitehouse.gov/omb/egov/c-2-2-disaster.html. Accessed August 17, 2006.
San Mateo County Emergency Services. Hospital Emergency Incident Command System (HEICS) Update Project. January 1998. Available at: http://www.emsa.cahwnet.gov/dms2/heics3.htm. Accessed July 10, 2006.
U. S. Department of Justice, Office for Domestic Preparedness. Hospital Emergency Management—Concepts and Implications of WMD Terrorist Incidents. Washington, DC: U.S. Department of Justice; April 2002.