in a moments notice

In a Moment’s Notice: Preparing Surgical Services for Mass

Casualty EventsBarb Bisset, PhD MPH MS RN

Executive Director Emergency Services InstituteWakeMed Health & Hospitals

At least three people have been killed and another 100 maimed or injured after two "powerful" bombs were detonated at the finish line of the Boston

marathon. The coordinated blasts, the worst attack on US soil since the September 11 terror atrocities, transformed a site of celebration on a public

holiday afternoon into a scene of carnage and destruction. This is the moment one of the bombs detonated near the finish line of the Boston Marathon.

Picture: DAN LAMPARIELLO/DOBSONS http://www.telegraph.co.uk/news/picturegalleries/worldnews/9996842/In-pictures-Boston-Marathon-

bombing-several-die-and-more-than-130-injured.html

Objectives

• Identify the types of mass casualty events that can impactthe capacity (volume) and service capabilities (specializedinterventions) in the provision of patient care

• Identify Surgical Services considerations for developing aculture of continual readiness

• Identify three actions that should be taken to prepare Surgical Services to manage mass casualty events

Mass Casualty Considerations: Event’s Point of Origin

• Community-based

School event, transportation accident, mass gathering

• Hospital-based – hospital is the only facility affected, e.g. Hospital fire, plumbing break, IS downtime

• Community and hospital are both victims

Weather events

Mass Casualty Considerations: Event’s Point of Origin

4

Photo:

http://c.ymcdn.com/sites/www.leadingagemissouri.org/resource/resmgr/annual_conferenc

e/wednesday_joplin_tornado_les.pdf

Mass Casualty Considerations: Event’s Point of Origin • 2011 Joplin, Missouri

– Tornado EF 5

– 1000 casualties in community; 8000 structures damaged

– 5 hospitalized patients died and 1 visitor killed

– Unidentified number of employees injured

– Several hospital fires; broken natural gas lines; loss of power, broken piped medical gases

– 183 patients evacuated from St John’s Medical Center within 90 minutes

Mass Casualty Considerations: Source – Cause of Event

• Blast / Fire / Explosion

• Building Collapse

• Hazardous Materials – Chemical Spills

• High Security Risks– Active Shooter – Bomb Threat – Hostage

• Man-Made– Civil Disturbance

• Severe Weather – Flooding– Hurricanes– High Winds– Tornadoes– Hyper/hypothermic events

• Transportation Accidents– Airplane– Bus– Motor Vehicle Crashes– Train

7

Mass Casualty Considerations: Source – Cause of Event

• Consider origin of source for injuries – e.g. blast injuries

• Impact in OR, PACU and ICU likely to last for days or weeks

• May need to care for burn patients on an inpatient basis

• Prepare for multiple open / closed fractures

• Occult blast injuries may not be discovered until the patient reaches the ICU (or other departments)

• Majority of ICU patients will require ventilation

• Plan for event related surgeries concurrently to occur for at least 72 hours

– Identify emergency, critical interventions (death likely without intervention; extensive resources may not be available

• Positive pressure ventilation and anesthesia cause greater mortality in those with blast lung injuries– Postpone surgery 24-48

hours whenever possible

Mass Casualty Considerations:Capacity and Capability

• Capacity Surge (Volumes of Patients)

– Ability to evaluate and care for a markedly increased volume of patients exceeding normal capacity

– Surge requirements extend beyond direct patient care

• e.g. laboratory studies, imaging services, food and nutrition, case management, care of public and families

Mass Casualty Considerations:Capacity and Capability• Capability Surge (Types of Patients)

– Ability to manage patients requiring unusual or very specialized medical evaluation and caree.g. blast injuries, gunshot wounds, pediatrics, chemical contamination

– Intervention may include procedures that are not performed on a regular basis

– Expertise, information, procedures, equipment and personnel are normally not located where they are needed

Mass Casualty Considerations: Capacity and Capability

• Children

• Adults

• Geriatrics

Mass Casualty Considerations: Capacity and Capability

• Some or all casualties may be pediatric

• Accompanied or unaccompanied by family / care providers– Children may have been in different location at the time of the event,

e.g. school

– Children and parents may have initially be together, but got separated at time of event

– Children may be uninjured, but with injured parent

– Children may be injured, parent is not injured

– Both children and parents may be injured

– Children may be unidentified; parent may be unidentified

– Children may be orphaned due to loss of parents

Mass Casualty ConsiderationsCapacity and Capabilities• Trauma Centers

• Burn Centers

• Non-trauma hospitals

• Hospitals with general services, but without intensive care units

• Hospitals with/without age specific services, such as pediatrics, geriatrics

Mass Casualty Considerations:Timing and Arrival of Victims • Initial Rapid Influx

– Victims will start to arrive in minutes

– Most severely injured arrive after minor injuries

– In acute event, plan for 50% to arrive within the first hour

– 85% will bypass emergency services and will self direct

• Secondary Influx

– There may be victims from event days or weeks later

Mass Casualty Considerations: Timing and Arrival of Victims

Madrid Bombing Data– Between 7:37 am and 7:42 am, 10 bombs were detonated on four

trains

– 177 people killed instantly

– Greater than 2000 injured

– 966 patients taken to 15 hospitals

– Closest hospital• Received 312 patients

• 272 arrived between 7:42 am and 10:00 am

• Hundreds of radiographs, CTs, ultrasounds

• Multiple surgical procedures

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Mass Casualty Considerations: Crime Event

• Community may have curfew, e.g. Boston Bombing

• Control internal and external environment– Controlled Access

• Identify traffic patterns

• If criminal investigation, event requires collection of evidence and maintenance of chain of custody– All items removed from patients could be considered evidence

– All items, including shrapnel, nails, etc that are surgically removed must be preserved

Emergency Management Principles

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Continual Readiness

Acts of Random Preparedness*

versus

Methodical Planning & Practice & Prepare

=

Continual Readiness

*(Dodgen, Don, PhD, (2009, May 12th), Planning and Preparedness for Children’s Needs in Public Health Emergencies, http://archive.ahrq.gov/prep/childneeds/chneedslidestst.htm)

Mass Casualty Continual Readiness

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Approaches to training suggest “random

acts of preparedness”.

Multi-casualty Incident drills, irrespective of

populations, appear to be retraining every

time.

Improved training methods to embed

responses, behaviors and actions should

be developed and applied.

Johnson, Kelly & Dodgen, Daniel, (2009, May 12th) Planning and

Preparedness for Children’s Needs in Public Health

Emergencies, Agency for Healthcare Research and Quality

Those who fail to plan, plan to fail.

Benjamin Franklin


• Mass casualty patients of all ages may present to ANY hospital

• Critically ill patients may present to ANY hospital

• Transfer of patients to specialized hospitals may not be possible

• All mass casualty patients at all hospitals require:

– Emergency Evaluation (EMTALA)

– Surgical Services

– Critical and/or Acute Inpatient Care

– Psychological Support


– Incident Management Team

• Command

• Operations

• Logistics

• Planning (Intelligence)

• Financial

Command Section

Operations Section

Logistics Section

Planning /Intelligence

Section

Finance / Administration

Section


• Communication Systems

• Equipment

• Supplies – PAR Levels

– Critical Resources

• Pharmaceuticals

• Transportation

• Staffing – Specialties

– Support Departments

• Imaging

• Lab

• Transporters

– Force Multiplier


• Ability to rapidly activate emergency operations plans– Identify authority 24/7 in building

– May have less than 10 minutes to get things into place

• Plan resources to cover multiple shifts– Staffing, supplies, equipment

• Plan method to track all patients associated with event– Patient Registration icon

• Incident Management Team to set objectives for multiple phases when indicated– Monitor activities to determine when facility can start to demobilize


• Notifications

– Staff contact information needs to be kept current

– Rapid and robust notification system

– Plan for actions staff should take should communication system fail

– Staff communications systems• Social media, recorded voice mail, emails, scheduling software

capability


• Involve Administration, Strategic Sourcing and Pharmacy in planning – agree to inventory

• Develop Critical Resource Document – documents number of hours of available resources

• Identify specialty equipment/supplies for capability events− Pediatrics, burns, ortho injuries, vascular injuries

− Mass casualty caches need to be mobile; easily moved between departments

• Confirm who is checking emergency supplies and equipment

• Determine how mass casualty inventory use will be tracked


• Rapid discharge procedure system

• Emergency Department patients take priority for admissions

• Operating Room needs to plan to potentially function 24/7 for several days

• Clinical and Support departments need to have plan to increase capacity/productivity: e.g. Lab, Imaging Services, Case Management, Respiratory Care, Environmental Services , Food and Nutrition


• Emergency Departments need to identify method for rapid patient triage and registration – Triage locations) – Triage method – Initial and secondary patient assessment– Rapid Registration– Log in everyone

• Identify who will triage resources, e.g. Operating Rooms, CT scans– Suggest trauma team leader

• Suggest OR leadership presence in the ED


• Policy to delay or cancel elective interventional procedures or elective surgeries

• Consider the following spaces for alternate functions:

– Day Surgery

– Endoscopy

– Cath Labs

– Interventional Procedure Holding Areas

Mass Casualty Continual Readiness • Identify casual pool capabilities

• Departments should review their role in mass casualty events on an annual basis

• Integrate many mass casualty principles into normal operations capacity management

• Take care to keep staff in “reserve” should event last multiple shifts.

• Incident Management Team – pre-assign 3 levels of experts; individuals should be familiar with their part of the plan

• Consider Staff Force Multiplier Models: experts can supervise others

• Staff must always practice within scope of license


• Know where competency based data is kept

• Policy that all staff are considered essential to emergency/disaster events

• Personal preparedness blitzes; confirm with staff their plans are in place

• Develop checklists to provide direction

• Incorporate emergency training into competency blitzes


• Staff and/or families may be victims of event

• May be exposed to difficult situations that are not within their “usual” practice

• Staff may fear responding

• Duties may need to be altered

• Staff fatigue


Staff Care

• Psychological First Aid

• Spiritual Care

• Critical Incident Stress Management– Review “normal” reactions

– Review healthy coping skills

– Identify “red flags” that more in-depth support or counseling is needed

Mass Casualty Continual Readiness • Staff Training

– High Level Awareness– Specialist– Experts

• Drills / Exercises- Tabletop- Functional - Full Scale

• Evaluation – After Action Reports – Identify Opportunities for Improvements

• Corrective Actions– Follow progress monthly basis

Mass Casualty Continual Readiness• Drills & Exercises

– Set objectives

– Test weakest points

– Everyone participates

– Everyone provides feedback

– Develop After Action Report

– Follow Action Plans through closure

Mass Casualty Continual Readiness • After Action Reports are important

• Take time to close identified gaps

– e.g. Freeman Healthcare System After Action Report Type of injuries – 200 mph winds cause deep wound injuries

• OR emergency lighting very limiting

• Not enough emergency power outlets

• Only used Imaging Services for life threatening cases

• Just-in-Time deliveries could not keep up with demand for resources

• Orthopedic supplies were critically short

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• What you practice is what you will do

• Select one objectives

• No one should get out of planning and drilling – everyone counts

• Practice, practice, practice plans!

• Drill until you fail

• Drill with hospital departments

• Drill with community partners

• As leadership goes, so goes staff

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• Freeman Healthcare System Response- Joplin Tornado

– 130 patients immediately presented to 40 bed ED

– Staff lounges converted to treatment space

– Total of 1,000 patients treated at the ED and the Alternate Care Site

– 22 life saving surgeries performed within first 12 hours when facility was on emergency power

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Mass Casualty Continual Readiness• Capability Surge (Types of Patients: Blast Injuries – Boston Marathon Bombing –• Brigham and Women’s Hospital Timeline, April 15, 2013• 08:00 Per standard Marathon Day procedures, the Brigham and Women’s Hospital Emergency Operations• Center is partially activated.• 14:49 Scan of the emergency department (ED) shows 66 patients in the 55-bed ED and 30 of 42 operating• rooms (ORs) active or in use.• 14:50 Reports of the explosion heard over Boston EMS/Fire radio frequencies.• 14:54 Hotline from Centralized Medical Emergency Dispatch (CMED) rings in ED, reporting 2 explosions• and incoming patients.• Emergency medicine physician, nurse in charge, and emergency-management director huddle to• implement “Code Amber,” the hospital’s mass casualty incident plan.• Call from the Medical Intelligence Center (MIC) at the Boston Public Health Commission informs• hospital that it will soon receive 8 patients from the scene.• 14:59 Nurse in charge mobilizes providers to ready multiple operating rooms.• 15:00 Trauma Service notified of explosion. Phone tree notifies orthopaedic surgeon, neurosurgeon, chief• resident in surgery, OR front desk, and all 7 trauma surgeons in the hospital that day.• 15:08• to 15:38• Nineteen bombing patients arrive, each of whom is assigned a multidisciplinary team to conduct• trauma surveys and perform resuscitations, intubations, and blood transfusions if necessary.• 15:15 OR medical director huddles with orthopaedic, emergency medicine, and trauma team leaders to• coordinate direct flow into ORs for most seriously injured patients, bypassing preoperative areas.• 15:30 Core leaders of orthopaedics, trauma, and anesthesiology assembled.• 15:39• to 16:38• Brigham and Women’s Hospital receives 7 more bombing patients.• 16:00 Senior general surgeon positioned in ORs to facilitate surgical administrative issues.

Overall, Brigham and Women’s Hospital treated 40 Marathon patients. Nine required immediate operative intervention.


“We Fight Like We Train”

Success came from “colleagues working alongside familiar teammates performing

familiar tasks.”

Drs Eric Goralnick and Jonathan Gates

“We Fight Like We Train,” NEJM, May 1, 2013.


• Incorporate into daily operations

– Daily capacity reports

– Daily huddles; increase as needed

– Written guides/ checklists specific to each department

– Establish paging and e-mail groups

– Test specific indicators on a regular basis

In a Moment’s Notice : Preparing Surgical Services

• Identify the types of mass casualty events that can impact the capacity (volume) and service capabilities (specialized interventions) in the provision of patient care

• Identify Surgical Services considerations for developing a culture of continual readiness

• Identify three actions that should be taken to prepare Surgical Services to manage mass casualty events

Resources • Agency for Healthcare Research and Quality (AHRQ), (Archive as of June 30th

2011), Pediatric Terrorism and Disaster Planning http://archive.ahrq.gov/research/pedprep/pedtersum.htm

• Agency for Healthcare Research and Quality (AHRQ), (no date) Preparation by General Healthcare Facilities for a Surge of Critically Ill Children, U.S. Department of Health & Human Services, http://archive.ahrq.gov/prep/pedhospital/pedhospital6.htm

• Gawande, Atul (2013, April 17th), Why Boston Hospitals were Ready, http://www.newyorker.com/news/news-desk/why-bostons-hospitals-were-ready

• Medical Response to Joplin Tornado May 22, 2011 Report (2011, August 2nd)

• Resnick, Lloyd, A Special Report From the Publishers of The Journal of Bone & Joint Surgery and the Journal of Orthopaedic & Sports Physical Therapy (2014, March) It Takes a Team: The 2013 Boston Marathon, Preparing for and Recovering from a Mass Casualty Event, http://sites.jbjs.org/ittakesateam/2014/report.pdf

http://archive.ahrq.gov/research/pedprep/pedtersum.htm

http://archive.ahrq.gov/prep/pedhospital/pedhospital6.htm

in a moments notice

Education

types of mass casualty

hospitalbased hospital

source cause of event

origin of source

blast injuries impact

hospitalized patients

icu likely

downtime community