1. 1 Region X Disaster Preparation ECRN 2012 CE Mod II Condell Medical Center EMS System Site Code: 107200E -1212 2 hours CE credit Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. 2 Objectives Upon successful completion of this module, the ECRN will be able to: 1. Define the concept of disaster. 2. Define a small, medium and large scale incident and emergent evacuation of a healthcare facility as described by Region X 3. Describe the communication process of the different levels of incidents 4. List report writing obligations based on the level of disaster declared 5. Define reverse triage and START triage processes

3. 3 Objectives cont’d 6. Describe patient categorization of red, yellow, green, and black 7. Describe the role of the Resource Hospital 8. Describe the role of the Associate Hospital 9. Describe the role of a receiving hospital 10. Describe use of the disaster tag

4. 4 Objectives cont’d 11. Review the Region X disaster response paperwork used in the hospital 12. Identify where resource material can be found in your ED 13. Review scenarios presented in a power point. 14. Successfully complete the post quiz with a score of 80% or better

5. 5 Abbreviations ACOND – Advocate Condell CMC EMS– Condell Medical Center EMS HPH – Highland Park Hospital NLFH – Northwestern Lake Forest Hospital NGEC - Northwestern Grayslake Emergency Center

6. 6 What is a disaster? An event that occurs suddenly A crisis event that causes widespread damage of a scale that overwhelms the immediate resources that respond Event with potential loss of life, damage to property, and capability to create a hardship

7. 7 Effects of a Disaster It is the consequences of the event and the inability of the victims to cope that constitutes the disaster; not necessarily the event itself Declaring a situation a “disaster” is specific to those involved This may be reflected by what fire department is affected, by time of day based on available resources

8. 8 Lessons Learned Disastrous events are not scheduled Reason why you need to be prepared every day Training is done to help prepare for the unthinkable situation Flexibility is key Effective communication is essential Need to keep appropriate persons linked together so they can function together Functioning in a vacuum will be a disaster in itself!

9. 9 Region X Multiple Patient Management Plan A formalized plan drafted by representation of Region X members Constantly being reviewed and revised as needed Drafted to be flexible based on level of involvement of resources needed

10. 10 Components of Region X Plan Region X plan response components Business as usual Small scale incident Medium scale incident Large scale incident Emergent evacuation of a healthcare facility

11. 11 Components of the Region Plan Plan describes its components Definition of the incident Initial communication from the field Initial information provided from the field Patient disbursement process from the field Use of triage tags in the field Triage method used in the field Ambulance to hospital communication process Patient care reports to be written or not

12. 12 Business as Usual When less than 3 ambulances are required at the scene, EMS to conduct business as usual Typical receiving hospital contacted Report provided by each ambulance Normal patient care run reports to be left at receiving hospital(s)

13. 13 Small Scale Incident 3-6 ambulances respond to the scene EMS to contact closest appropriate hospital to determine maximum patient availability Typical communication from EMS: “We are on the scene of a small scale multiple patient incident”

14. 14 Small Scale Incident Initial information Event description Actual number of patients Brief description of patient conditions Patient disposition Field command coordinates transportation management and destination of patients based on input from hospital contacted

15. 15 Small Scale Incident Triage tags are not used (required) by EMS Triage of patients performed in usual rapid assessment process to categorize the patient Each transporting ambulance to contact the receiving hospital and provide report Normal patient care run reports will be completed on all patients as usual

16. 16 Medium Scale Incident 7-10 ambulances respond to the scene EMS to contact their Resource Hospital Typical communication from EMS: “We are on the scene of a medium scale multiple patient incident”

17. 17 Medium Scale Incident Initial information Event description Estimated number of patients Estimated patient acuities Red, yellow, green categories Closest hospitals to the scene listed Patient disbursement Resource Hospital coordinates transportation management and destination of patients Reports this information to scene contact

18. 18 Medium Scale Incident Triage tags MUST be used (required) by EMS Triage of patients performed following START triage process Described later in power point NO contact between transporting ambulance and the receiving hospital Limited report from Resource Hospital Normal patient care run reports will be completed on all patients as usual

19. 19 Large Scale Incident More than 10 ambulances needed to respond to the scene EMS to contact their Resource Hospital Typical communication from EMS: “We are on the scene of a large scale multiple patient incident”

20. 20 Large Scale Incident Initial information Event description Estimated number of patients Estimated patient acuities Red, yellow, green Closest hospitals to the scene listed Patient disbursement Resource Hospital coordinates transportation management and destination of patients Reports this information to scene contact

21. 21 Large Scale Incident Triage tags MUST be used (required) by EMS Triage of patients performed following START triage process Described later in power point NO contact between transporting ambulance and the receiving hospital Limited report from the Resource Hospital SMART triage tags  will serve as the written report Patient care run reports will NOT be completed on any patient

22. 22 Emergent Evacuation of a Healthcare Facility These involve patients that require medical care EMS to contact their Resource Hospital Typical communication from EMS: “We are on the scene of an emergent evacuation of a healthcare facility”

23. 23 Emergent Evacuation of a Healthcare Facility Initial information Event description Estimated number of patients Closest hospitals to the scene listed Potential alternative receiving facilities Patient disbursement Resource Hospital works in conjunction with field command and administration of affected facility to determine where patients will be transported

24. 24 Emergent Evacuation of a Healthcare Facility SMART triage tags  MUST be used (required) by EMS Within facility reverse triage performed Prior to transport START Triage of patients performed Described later in power point NO contact between transporting ambulance or vehicle and the receiving hospital Triage tags will serve as the written report Patient care run reports will NOT be completed on any patient

25. 25 Reverse Triage A form of triage in which the more critical patients are attended to first In a Healthcare facility, these patients cannot remove themselves from the danger Rescuers must care for the sickest first and then go back to remove the less ill

26. 26 START Triage S imple T riage a nd R apid T ransport A widely recognized and used triage process Does not require a specific diagnosis Is a process that follows a diagram and progresses based on patient’s physiological responses

27. 27 Triage The practice of sorting General accepted definition: To do the most good for the most persons Determine: Which patients need immediate care to live Which patients will survive despite a delay in care Which patients will die regardless of what we do for them

28. 28 START Triage Step wise fashion of assessment in the adult population First assessment is ability of patient to walk Respiratory effort assessed next Then pulse/perfusion evaluated Lastly, neurologic status is evaluated

29. 29 START Triage Helpful process to sort (triage) those less severely injured from those that are more critically injured Assessment/sorting/triage continues and patient status can be modified as needed START process categorizes patients into red, yellow, green, black categories

30. 30 Red Categorization Most critically injured patient Requires immediate lifesaving attention Ideally should be some of the first patients to be transported from the scene Hospitals should be prepared to immediately receive 1-2 reds while transportation issues being finalized for the majority of the incident

31. 31 Yellow Categorization Patients with injuries that do not require immediate lifesaving interventions Patients with conditions that have the possibility of deterioration without medical care

32. 32 Green Categorization Patients with minor injuries Patients who can tolerate a delay in care without increasing their risk of mortality In the past, referred to as “walking wounded” Remember: they may not be walking if there are lower leg injuries; yet, injuries are still minor

33. 33 Black Categorization Patients who are found apneic and pulseless or Patients with injuries incompatible with life and inadequate resources to provide in depth care to patient An emotional situation for rescuers to deem a patient “black” who has not yet expired

34. 34 START Triage Process A process typically used in the field for adults but can be used for a surge at the hospital Evaluates patients in 4 categories Ability to walk Respiratory effort Pulse or perfusion status Neurologic status Takes seconds to minutes per person to complete

35. 35 START Triage Process Any patient that can walk is directed to move from the incident site and regroup to a designated spot “If you can hear my voice and can walk, go to the tall tree by the shed” The assumption is that if the patient can walk and remove themselves from the scene, there are less patients to walk through to find the true “reds” “Walkers” are retriaged for appropriate categorizing

36. 36 START Triage Process – Next Step : Respirations If respirations are absent, open airway If still no respirations, patient tagged BLACK If respirations return, tagged RED

37. 37 START Triage Process – Respirations Present If over 30 per minute for the adult, tag them RED If under 30 per minute, move to assessing perfusion

38. 38 START Triage Process – Next: Perfusion Status If no radial pulse or capillary refill is >2 seconds, tag patient as RED Control life threatening bleeding

39. 39 START Triage Process – Perfusion Status Adequate If radial pulse is present or capillary refill <2 seconds, move on to assessing neurologic status

40. 40 START Triage Process – Lastly Neurologic Status If the patient cannot follow simple commands, tag them RED If the patient can follow simple commands, tag them YELLOW

41. 41 START Triage At any point in the triage process that the patient is deemed to be RED, the triage process stops There is no need to waste time, they won’t get any redder! Time to move onto the next patient

42. 42 START Triage Process Flow chart used in the adult

43. 43 JumpStart Pediatric Triage Modifications made to START triage to accommodate physiological differences in children Similar flow chart in the assessment algorithm Guidelines: If patient appears to be a child, using JumpStart triage If patient appears to be a young adult, use START

44. 44 JumpStart Triage

45. 45 Differences START from JumpStart If breathing is absent in peds patient, can attempt 5 rescue breaths and evaluate effectiveness In adult, you only open airway and if not breathing, tagged black Pediatric respiratory rate is range of 15-45 as normal Adult respiratory rate “normal” is <30/min Only peripheral pulses palpated in peds Adults assessed with capillary refill OR peripheral pulses Uses AVPU process for neurological eval

46. 46 AVPU Neurological Assessment A – awake and alert; not necessarily oriented V- responds to voice May only be small muscle movement P- no response until tactile stimulation added “Pain” response DOES NOT have to be to some “painful” stimulation U – unresponsive with NO response to any stimuli – not even an eye lash flicker

47. 47 Resource Hospital Functions Contacted by scene personnel when number of ill or injured exceeds routine transport to nearest facility Resource Hospital to coordinate patient distribution with scene personnel Acts as “Hospital Command” for medium or large scale incidents

48. 48 Resource Hospitals This determination is specific to the fire department relationship EMS making initial contact will contact THEIR Resource Hospital EMS Systems as Resource Hospitals in Region X Condell EMS System Highland Park Hospital EMS System North Lake EMS System (Vista) St. Francis EMS System

49. 49 Resource Hospital cont’d To collaborate with scene personnel to identify potential receiving hospitals Contact potential hospitals Assess their capability To receive patients by categories red, yellow, green Blood inventory Ability to decontaminate patients Ability to send medical teams & supplies to scene

50. 50 Resource Hospital Functions Maintain communications with scene personnel Get a call back number and name Need to prepare to also function as a receiving hospital

51. 51 Resource Hospital Forms to Complete Hospital Communications Flow Sheet Emergency Department Log Form After Action Report These forms can be found in the Region X Multiple Patient Management Plan notebook near the EMS radio

52. 52 Associate Hospital Functions Function as a receiving hospital In small scale incident, may function as the communication link to the field and the only receiving hospital Will communicate with any additional hospitals to confirm capability to receive additional patients if EMS indicates they want to transport more than 2 patients to an alternate desired hospital Most likely members of the same family Receiving hospitals will receive usual reports from transporting EMS provider

53. 53 Receiving Hospital Functions For medium or large scale events, the Resource Hospital serves as the communication link from field to hospital Transporting ambulances WILL NOT contact receiving hospital(s) prior to arrival Resource Hospital will receive field information and forward to receiving hospital Number of patients enroute Triage category of patient(s)

54. 54 Receiving Hospital Functions Consider activation of internal hospital mass casualty/disaster plan Be prepared to report availability of medical personnel to send to scene Maintain log sheet of communication with Resource Hospital Report increases or limitations to Resource Hospital Be prepared to send pre-assembled bags of medical supplies to scene

55. 55 Medical Personnel Requested to Scene Request communicated from scene through Resource Hospital Personnel would be assembled based on specific needs Supplies gathered based on specific needs To respond to scene via police or other official escort Report to Command Post at scene Wear green helmet or reflective vest (“Medical Team”) for easy identification

56. 56 DO NOT SELF-DISPATCH TO THE DISASTER SCENE WAIT TO BE SUMMONED VIA OFFICIAL CHANNELS

57. 57 Medical Supply Bags State and regional guidelines Pre-determined list of supplies packaged and ready to be disbursed Need to be reviewed periodically for outdates Generally maintained by EMS office &/or disaster/emergency management committee in each facility

58. 58 Medical Supply Bags Advocate Condell 2 bags in the decon room Medication packs obtained from pharmacy Northwestern LFH 2 bags in ambulance bay on the shelves Mediations obtained from pharmacy

59. 59 Hospitals on Bypass Small scale event EMS to contact closest appropriate hospital regardless of bypass status Individual hospital ED staff including ED MD to determine capability to accept patients or divert Medium and large scale events Hospitals MUST receive patients from these events regardless of bypass status

60. 60 Routine Ambulance Traffic For those transports NOT associated with the multiple patient event, do not attempt to stop the flow of patients

61. 61 Receiving Hospital Communication Flow Once the Resource Hospital has been activated from the field, all communication must go through the Resource Hospital Do not attempt to contact the scene Do not attempt to contact dispatch Do not divert individual ambulances

62. 62 After Action Report Should be completed following every multiple patient incident Provides a means of critiquing the event by those present Forwarded to the hospital EMS coordinator Forward original of log sheets and disaster related records to hospital EMS coordinator within 48 hours of event

63. 63 Triage Tags Region X using SMART tag  One color shows at a time Tag can be refolded as patient condition changes Triage process meant to be repeated 1 st triage is at site and used to sort victims based on vital signs and level of consciousness 2 nd triage prioritizes treatment and transport Based on anatomic and physiologic criteria

64. 64 SMART Tag  for Triage

65. 65 SMART Triage Tags Attached to patient usually via elastic band to an extremity Will serve as the only documentation for large scale incidents Normal written patient care reports to be completed by EMS for all small and medium scale incidents

66. 66 Region X Disaster Paperwork Hospitals will complete Emergency Department Log form Communications Flow Sheet (Resource Hospital) After-Action Report See attached samples Know where these masters are kept in your ED

67. 67 Federal Plan In event of major disaster, Governor requests federal assistance President may make declaration FEMA coordinates federal responses National Disaster Medical System (NDMS) may be activated Large coordinated event with a written progression of the communication system

68. 68 Federal Plan - NDMS Illinois Masonic notifies Highland Park Hospital in this area Bed status will be generated every 12 hours Illinois Masonic will assign receiving hospitals for patients arriving via O’Hare Prior to landing, patient manifests will be distributed

69. 69 State Plan Does NOT take place of NDMS plan Addresses preparedness, response, and recovery to emergency medical situation in State of Illinois Goal Provide assistance for EMS and healthcare facilities to work together when local resources are overwhelmed

70. 70 State Plan Governor notified by local government Governor declares a disaster – initiates the State disaster response plan Highland Park Hospital directs communication for Region X Resource Hospitals contact their Associate and Participating Hospitals Information gathered on the Hospital Health Alert Network (HHAN) Frequent updates are made by designated personnel in each facility

71. 71 State Plan Information Required ED availability Adult monitored beds Pediatric monitored beds Total other beds Total units blood # ventilators – adult, peds, both # field bags # walking decontamination patients per hour # littered decontamination patients per hour Special needs

72. 72 Finding Resources in Your ED Advocate Condell Binders by radio Northwestern Lake Forest Binders by radio Northwestern GEC Binders by radio

73. 73 Paperwork Examples On the following slides are examples Emergency Department Log Form Important!!! Get the call back phone number from your scene contact!!! After Action Report Complete for all incidents Forward to EMS office at your facility Communications Flow Sheet Condensed form for Resource Hospital to record incident related information

74. 74 Critiques Most events are followed by a critique Valuable to determine what worked well and what needs revision If you find absolutely nothing that could be changed, it all went SO well, you may not be looking critically enough There will always be lessons to learn and opportunities for changes  Remember: complete After Action Report and forward to EMS coordinator

75. 75 Post-Incident Recovery Northern Illinois Critical Incident Stress Management Team 800-225-2473 Agency to be contacted to provide critical incident stress management to any level provider group FYI: There has been controversy in the literature regarding the value of post event stress management; it is still offered

76. 76 Scenario Practice Review the following cases Determine what you would do As the Resource Hospital (Condell staff only) As the receiving hospital This is everybody!

77. 77 Scenario #1 You receive report from your local provider “We are on the scene of a small scale multiple patient incident” 3 car MVC 5 patients 1 patient unresponsive, Category I trauma with chest and head injuries 1 patient stable but with tender, bruised abdomen 3 patients with multiple contusions and minor orthopedic injuries

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79. 79 Scenario #1 What is your response upon receiving this report? Determine your capacity for how many patients you can receive Category I trauma patient to be transported to a Level I trauma center if within 25 minutes (i.e.: Advocate Condell) All facilities taking report to use the “Emergency Department Log Form”

80. 80 Scenario #1 What else can you expect? Transporting ambulances will provide individual patient reports to the receiving hospital Patient care reports will be completed on each patient Receiving hospital(s) to complete an After Action report and forward to your EMS office

81. 81 Scenario #2 ACOND receives report from the scene “We are on the scene of a medium scale multiple patient incident” 4 car MVC 2 red 3 yellow 4 green Closest hospitals are NLFH, ACOND, NGEC, Vista

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83. 83 Scenario #2 What is your response? Consider what resources you need to mobilize based on your hospital’s internal disaster plan Resource Hospital (ACOND) to contact anticipated receiving hospitals to determine capabilities ACOND to relay information back to the scene

84. 84 Scenario #2 Communication pathway for a Medium and Large Scale Incident Scene Resource Hospital Receiving Hospitals Resource Hospital scene

85. 85 Scenario #2 Triage tags will be used Resource Hospital will contact receiving hospitals with number of patients, acuity (red, yellow, green status) and ETA NO contact between transporting ambulance and receiving hospital EMS to complete patient care report

86. 86 Scenario #2 Paperwork to use/complete during event Resource Hospital Initiate the “Hospital Communications Flow Sheet” Use the “Emergency Department Log Form” Receiving Hospital A log sheet of communication with Resource Hospital All - After Action Report and forwarded to your EMS office

87. 87 Scenario #3 ACOND receives report from the scene “We are on the scene of a large scale multiple patient incident” 1 bus with 35+/- patients 3 cars involved with 4 patients 2 red 4 yellow 34 green Closest hospitals are ACOND, NGEC, NLFH, Vista

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89. 89 Scenario #3 What is your response? Activate your hospital internal disaster plan Paperwork to initiate Resource Hospital “Hospital Communications Flow Sheet” “Emergency Department Log Form” Receiving Hospital A log sheet of communication with Resource Hospital

90. 90 Scenario #3 Communication pathway for a Medium and Large Scale Incident Scene Resource Hospital Receiving Hospitals Resource Hospital scene

91. 91 Scenario #3 Triage tags will be used Resource hospital will contact the receiving hospital with patient number, acuity (red, yellow, green status), and ETA NO contact between transporting ambulance and receiving hospital SMART Triage tag  will be used as patient care report

92. 92 Scenario #3 Paper work to complete after event After Action Report and forwarded to your EMS office Forward comments through your chain of command for the after event critique

93. 93 Scenario #4 Your facility receives report from a local provider “We have 3 patients from a MVC” “There will be 2 transporting ambulances” How would you handle this call?

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95. 95 Scenario #4 This call will be “business as usual” Scene personnel will have direct contact with receiving facility(s) If one facility cannot take all patients, try to keep family members together at least Report will be provided on each patient to the receiving hospital Patient care run reports will be completed for each patient

96. 96 Scenario #4 Paper work to complete after event After Action Report and forwarded to your EMS office Forward comments through your chain of command if you have a critique in your facility

97. 97 Scenario #5 ACOND receives report from the scene “We are on the scene of a large scale multiple patient incident” “There was a bleacher collapse at a school” “There are approximately 150 patients 10 red 15 yellow 125 green

98. 98 Scenario #5 Information from the scene “Closest hospitals are HPH, NLFH, ACND, NGEC, and Vista” What is your response? Each ED should prepare to receive 1-2 red patients immediately while bed availability is being sorted Each hospital should activate their internal disaster plan

99. 99 Setting up treatment areas

100. 100 Scenario #5 What is your response? Activate your hospital internal disaster plan Paperwork to initiate Resource Hospital “Hospital Communications Flow Sheet” “Emergency Department Log Form” Receiving Hospital A log sheet of communication with Resource Hospital

101. 101 Scenario #5 Resource Hospital To contact potential receiving hospitals to obtain bed availability Bed availability information will be forwarded to the scene from the Resource Hospital when the information has been relayed from potential receiving hospitals to the Resource Hospital requesting the information

102. 102 Scenario #5 Communication pathway for a Medium and Large Scale Incident Scene Resource Hospital Receiving Hospitals Resource Hospital scene

103. 103 Scenario #5 Triage tags will be used Resource Hospital will contact the receiving hospital with patient number, acuity (red, yellow, green status), and ETA NO contact between transporting ambulance and receiving hospital SMART triage tag  will be used as patient care report

104. 104 Scenario #5 Paper work to complete after event After Action Report and forwarded to your EMS office Forward comments through your chain of command for the after event critique in each facility

105. 105 Important Real Life Lesson Learn to be flexible The plans can provide groundwork of how things should go Not all events follow the script anticipated based on the plans as written Be flexible Remember your goal: do the most good for the most people

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109. 109 Bibliography Region X Advanced Life Support Standard Operating Procedures February 1, 2012; Approved by IDPH 1/6/12 Region X Multiple Patient Management Plan Amended March 1, 2013 Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices Fourth Edition. Brady. 2013.