BRINGING ORDER TO CHAOS

BRINGING ORDER

TO CHAOS

How to Prepare your Department for Mass Casualty Incidents

12 April, 2021

Dr. John B.P. Armstrong, BA MD MScDM FRCPC

Assistant Professor, Department of Emergency Medicine, Dalhousie University Medical Director, Emergency preparedness – Nova Scotia Health

Conflicts of Interest:

Financial:

- None

Academic:

Lecture Objectives:

1. Understand the critical “substrates” of disaster response

2. Recognize the importance of a Code Orange plan

3. Learn basic HAZMAT decontamination processes.

The Case…

•

12 Bed Community Emergency Department.

•

5 RN, 1 porter, 2 administrative clerks, 1 MD.

•

Hospital does have on-call General Surgery, orthopedics.

• No Thoracic, vascular, or cardiac surgical specialists on call.

•

In-house radiology technician 24/7.

• _{Radiologist is on-call > 17:00 for CT scanner (1 operational).}

The Case…

•

Your ED:

• All beds occupied.

• _{3 people in waiting room}

• 1 Ambulance waiting to offload in your hallway; CTAS2 chest pain • _{You are trying to get a sip of}

The Case…

The Critical

Substrates

Critical Substrates of Disaster Medicine

•

S

• Things to work with

•

S

_?

• SUPPORT

Staffing:

•

How many people?

Staffing:

•

Support Now

• What redundant staffing does your department have?

• _{How many nurses, physicians, and auxiliary staff are available?}

• 4 on 5 off?

•

Relief Later

• You should avoid calling in people who are working soon.

Staffing:

•

Call-in-list

• Do you have one?

• _{Fan out or single-source?}

• Who does the calling? It can’t be you.

•

Demobilization is critical

• Don’t keep idle hands if not needed.

•

Will you need to alter shifts?

Staffing:

DOC 1 DOC 2 DOC 3

Space/Structure:

•

Expand Available clinical space

• Defer – Do not accept new transfers

• _{Discharge – Stable patients with non-emergent presentations}

• Consider a follow-up role

• Decant – Remove consulted patients and “admitted” patients from the ED

• This can be a lengthy process

• Often patient attendant dependent. • Coordinate with inpatient units.

• Inpatient units must be involved

Space/Structure:

•

Expand to non-clinical space

• Emergency access gurneys - folding/stackable • _{Cafeteria tables}

• Simulation rooms

Stuff:

•

Most hospitals have “just in time” delivery of supplies.

• Saves cost on storage and minimizes waste.

•

Having readily accessible supplies for a mass casualty is important.

• Wound care supples

• Chest tubes and water-seals

• _{Sterile Trays ß can be a rate limiting step} • Pain medication

Stuff:

•

Consider having a “Disaster Cart”

• Cycle through supplies

• For deployment to non-clinical / overflow area • Focus on “walking wounded” care

•

Items:

• Sterile gauze and wound care. • Antiseptics, water, soap

• Splints

• Casting supplies

Stuff:

•

Consider a new tray type

• Mass Casualty Treatment Tray

• 1 needle driver • 1 scissor

• 1 toothed forceps • 2 mosquito clamps

Support:

•

Disasters DO NOT STOP in the ED.

• Administrative and leadership support upstairs • _{All departments need buy in}

• Designate a EP liaison and buddy them with an administrator

•

Education, Preparation

Code Orange Plan:

ACE your plan:

• Must be ACCESSIBLE • _{Must be CONCISE} • Must be EASY

Clear ROLES for positions, not people

Step by step instructions

Code Orange Plan:

•

Key Components

1. Code Orange Level Descriptions

2. Activation Protocol – Key Notifications 3. Deployment of Staff, Stuff Protocol 4. Registration and Triage

5. Decontamination Process 6. IMS/ICS Organization

7. Security Operations

Code Orange Plan - Levels:

•

Level Descriptions:

• Not all or nothing

• Code Orange Alert (CoA) • Code Orange Level 1 (Co1) • Code Orange Level 2 (Co2)

- Continue CTAS triage system

- Hold waitlist OR cases for 30 minutes

- Attempt to move admitted patients to floors if possible - MD/RN to re-assess potential dischargeable patients

- Must ACTIVATE or STAND-DOWN after 30 minute alert - Initiate START triage system

- Waitlist OR halt until stand down - Elective OR halt for 1 hour

- Admitted patients push to floors immediately - Discharge stable patients pending investigations - Begin staff call-in

- Can increase to level 2 if needed

- Will stand down once situation stable - All OR must halt until stand down

Code Orange Plan - Activation:

•

Activation and Notification

• Trauma Nova Scotia

• _{Local ED – may be in different zones}

• On-call administrator for your department, hospital, and Emergency Management

• Activate your zone IMS team

Code Orange Plan - Deployment:

•

Deployment of Staff and Stuff

• Have a huddle

• Charge Nurse, Manager if available, Charge Physician, Pod/Zone representative RN, Security liaison

• Determine:

• Decanting and discharge of patients

• Medication schedules and early administration • Bare-bone treatment team set up

• Management of Red, Yellow, and Green patients

• Deploy:

Code Orange Plan – Registration/Triage

•

START Triage for all patients

•

Ideal to have “ready charts”

for patients

Code Orange Plan - Decontamination

•

Most patients in a mass contamination situation should be

decontaminated on scene.

• EHS does not transfer grossly contaminated patients

•

Most contamination is removed by removing clothing

•

Washing with tepid water and detergent is ample

Code Orange Plan - Decontamination

•

HAZMAT Guidebook

• Recommend printing and keeping in your ambulance

Code Orange Plan - Decontamination

•

Decon teams

• 1-2 people in appropriate PPE

• Level D or C

• Helping patients decon

• Clean reception team

• Receives clean patients and helps the dirty team doff their PPE safely.

Code Orange Plan - Decontamination

•

Decon Ready Bags

• Johnny Shirt/socks inside a pt belonging bag

• Towels inside a biohazard waste bag

Code Orange Plan - Decontamination

•

For non-ambulatory patients

• Gurney with no mattress for showering

• Cut away clothing

• Large volumes of water, detergent

• Dry and transfer to clean hospital gurney • KEEP WARM

•

For critical patients

• Cut away clothing

Incident

Code Orange Plan - IMS

•

Incident Management/Command Systems

•

Important for maintaining command and control over multiple

operational periods

• 8-12 hours

•

Exists at Zonal and NSH levels

Code Orange Plan - IMS

Review:

1. Understand the critical “substrates” of disaster response

• Staff, Stuff, Structure, Support

2. Recognize the importance of a Code Orange plan

• _{Levels, Activation, Triage/Registration, Treatment}

3. Learn basic HAZMAT decontamination processes

• PPE, HAZMAT handbook, ready bags

4. Be familiar with the ICS framework for command and control