ECRN Packet:

Disaster Activity Responsibilities of the ECRN

Condell Medical Center EMS System

Prepared by: Sharon Hopkins, RN, BSN, EMT-P

EMS Educator

Information contribution: Debbie Semenek, RN, RMT-P

Region X Multiple Victims & Mass Casualty Plan, July 2006

Objectives

Upon successful completion of this module, the ECRN should be able to:

• Define the differences between the Multiple Victim Policy from the Mass Casualty Plan

• State the responsibilities of the ECRN based on being an Associate Hospital (LFH) versus Resource Hospital (CMC)

• Identify resources utilized in-house • Successfully complete the quiz with a score of 80% or

greater

Disaster Plans

• Multiple Victim and Mass Casualty Plan– Local plan with local resources used– Resource Hospital for the fire department of the disaster

site serves as communication link

• Emergency Medical Disaster Plan– State response plan – POD hospitals serve as communication link

• National Disaster Medical Systems (NDMS)– Large scale national response utilized

IDPH Regions• State of Illinois divided into 11 Regions

• Geographically, Lake County is Region 10

• 4 Resource Hospitals in Region 10– Condell Medical Center (CMC)– Highland Park Hospital (HPH)– St. Francis - Evanston– Vista Health East (Victory Memorial)

• POD Hospital for Region X is Highland Park Hospital (for activation of State Disaster Plan)

CMC - As A Resource Hospital

• Affiliated departmentsCountryside LibertyvilleGrayslake MundeleinKnollwood Ambulance Round Lake Lake Bluff Wauconda Lake Forest Fire

• Associate HospitalLake Forest Hospital

What Is A Disaster?

• Difficult to use a “number” for declaring a disaster– 15 patients at 2 pm may not be as big a problem as

15 patients at 2 am based on immediate availability of resources

• A disaster is any incident that overwhelms your available resources at that particular time or for the particular circumstances of the disaster

Disaster Plans

• EMS personnel need to declare and activate one of the plans early

• Without early activation, hospitals have a hard time getting prepared; hospitals feel “behind the eight ball”

• It is easier to cancel additional help summoned than to try to work short handed

MULTIPLE

VICTIM

INCIDENT

Multiple Victim Incident• Responding EMS personnel can handle the situation

with adequate numbers of additional personnel and equipment available within a short period of time. Normal levels of care and transportation can be provided.

• Attempts are made to evenly distribute patients to receiving hospitals by field personnel

• Hospitals may need to activate their internal disaster plan

Multiple Victim Incident

• Field application triage tags are not requiredif possible, one patient per ambulance (normal

transport conditions)radio report called to the receiving hospital as

normalrun reports completed by the transporting

ambulance personnel

Multiple Victim Incident

• Note:– The first critically injured victims most likely would

be transported to the nearest, most appropriate hospital before or while the first communications are being established with the Resource Hospital

• Bottom line:– When you hear of a disaster in your region, prepare

immediately as if you are receiving patients (because you just might be!!!)

Multiple Victim Incident• Radio reports must be given on all transported

patients– This means every transporting ambulance will be

communicating about their individual patient with the receiving hospital and this will take coordination between the field and the ED

• With coordination from hospitals and field personnel, goal is to avoid overwhelming any one hospital

Multiple Victim Incident

• Think of these incidents as “mini-disasters”

– similar to the busiest day you have had in the ED

– just more patients with same or similar complaints are showing up within a tight time frame from of each other

MASS

CASUALTY

PLAN

Mass Casualty Plan

• Number of patients and nature of injuries make normal level of stabilization and care in field unachievable and/or

• Number of EMS providers and ambulances that can be quickly brought to the scene is not enough

• All attempts are to be made to evenly distribute the patients to receiving hospitals

Mass Casualty Plan

• Practical application for a MCI

– Triage tags will be used on all patients

– Ambulances may transport more than one a patient at a time

– No radio reports to receiving hospitals; care is delivered via SOP’s

– Run reports are not necessary

Field Contact With Hospitals

• Multiple Victim Incident– EMS to contact their specific Resource

Hospital (CMC) ASAP• Mass Casualty Plan

– EMS to contact their specific Resource Hospital (CMC) ASAP

• Coordination of patient transportation will be done via the Resource Hospital

First Communications From Field

• Radio report may be initially minimal• Type/nature of incident (MVC, explosion, building collapse, etc)• Incident location• Closest hospitals that could receive patients• Estimated number of victims & categories (red, yellow, green) • Types of injuries/illnesses (blunt, penetrating, burns, etc)• Special needs (ie: decontamination)• ETA for the 1st victims• Call back number & name to contact the scene (VERY

IMPORTANT TO GET THIS NUMBER!)

The “Green” Disaster Victim

• Important information to obtain from the field regarding the number of “green” patients:what number of green patients can be placed in a

wheelchair or otherwise left sitting upwhat number of green patients will need a cart

• these patients are categorized green but may need transportation with a cervical collar and/or backboard due to the nature of their injuries

Activities In The Field

• Field personnel performingtriage first

• injuries sorted; patient categories assigned (red, yellow, green, black)

followed by treatment

• performed in the field in areas set up to provide treatment based on acuity levels (red is the most critical patient)

and finally transportation off the site

Triaging of Patients

• Red - victims who are most critically injured; in need of immediate care for life-threatening injuries or illness

• Yellow - those less critically injured; non-life threatening injuries

• Green - those with injuries that are not life or limb threatening

• Black - those who have died or whose injuries do not support survival

FRONT

BACK

METTAGSAMPLE

Disaster Tags - General Guidelines

• Red– Treatable life-threatening illness or injures– Patient has a altered mental status - unable to

follow simple commands– Carotid pulse present; radial pulse absent

• if both carotid & radial pulses are present, categorized considering respiratory rate and mental status

– Respirations < 10 or > 30

Disaster Tags - General Guidelines

• Yellow– Serious but not life-threatening illness or injury– Delayed care– Patient is alert– Patient has a radial pulse– Respirations less than 30 per minute

Disaster Tags - General Guidelines

• Green– Minor musculoskeletal injuries, minor soft

tissue injuries– Patient may or may not be able to walk– Patient is alert– Patient has a radial pulse– Respirations less than 30 per minute

Disaster Tags - General Guidelines

• Black– Dead or fatally injured patients– Resources limited and cannot be devoted to

these patients– If resources are unlimited, arrested patients may

become a Red (in very unique situations would this occur)

Hospital Use of Disaster Tags

• Disaster tag should become a permanent part of the patient’s chart– EMS and ED staff can use the tags to initiate

documentation– during Mass Casualty Plan, EMS run reports

are not necessary so all the information from the field is most likely on the disaster tags

Resource Hospital Responsibilities (CMC)

• Once notified, serves as medical control of the incident

• Collaborate with field personnel to identify possible receiving hospitals based on:– incident location

– transport routes open

– volume/acuity of patients

• ECRN to notify Charge Nurse immediately of the situation

ECRN at Resource Hospital• Begin filling out “Mass Casualty Incident Log”• Establish inter-facility communication

– describe nature & location of incident,– approximate number of patients– acuity & type of patients

• Continually monitor receiving hospital capabilities

• Resource Hospital also is a receiving hospital

ECRN at Resource Hospital

• Assess receiving hospitals’ resources– ability to receive patients divided into the

number of red, yellow, green that can be accepted

– blood inventory– ability to decontaminate patients– ability to send medical personnel and supplies

ED Bed Capacity

All staff need to remember:This is a DISASTER.This is a unique situationIt is a short term unusual operationTake your numbers to the max - EMS in the

field need all available beds, wheelchairs, hallways in order to transport patients off the scene

Excessive Casualty Load

• ECRN must be prepared and anticipate notification of additional receiving hospitals when casualty load exceeds capabilities in closest receiving hospitals

• May need to obtain status of specialized facilities as needed (ie: burn units, pediatrics, etc) for additional transport of patients with special needs

Communication With The Scene• ECRN at Resource Hospital (CMC) stays in

communication with scene contact (usually Transportation; but could be Incident Commander or designee)– ECRN relays to the field the receiving hospital’s

capabilities– Assists with transport management– If casualties imply need for transfusions, may need to

coordinate with lab to notify LifeSource for blood

Communication From the Resource Hospital (CMC)

• Transportation communicates with ECRN at Resource Hospital (CMC)

• ECRN at Resource Hospital (CMC) communicates with ECRN at Associate hospital (LFH)

• ECRN at Resource Hospital (CMC) is the one communication link for all hospitals

• Maintaining consistent ECRN at the radio minimizes lost information

Communication Pathway

Transportation Officer*

Resource Hospital (CMC)

Associate Hospital (LFH)

*Communication contact from the scene to the hospital is most often made with Transportation Officer at the site

Receiving Hospital• In Mass Casualty Plan, notification triggered by

Resource Hospital (CMC)

• Report to Resource Hospital (CMC) ability to receive what number of red, yellow, green patients– Need to think “big”– Doesn’t help a mass casualty situation to say you’ll

accept a small number of patients - everyone needs to think big and switch to “disaster mode” of operating/thinking/responding

Receiving Hospital

• May need to activate internal plan depending on the situation

• Maintain communication log with the Resource Hospital (CMC)

• Report increases or limitations in capabilities to Resource Hospital (CMC) ASAP

• Be prepared to send pre-assembled medical supply bags to the scene

Patient Flow

• Most critical victims from the scene may be transported to closest appropriate hospital before sophisticated communication network established

• DO NOT attempt to stop patient flow from individual ambulances not associated with the disaster activity

– These ambulances will carry on normal communication practices

Communication

• All communication must go through the Resource Hospital (CMC)– Associate Hospitals (LFH) are not to contact the

scene directly– Associate Hospitals (LFH) are not to divert

individual ambulances

• Associate Hospital (LFH) receiving 1st field call from EMS needs to direct EMS to contact the Resource Hospital (CMC)

Medical Personnel To The Scene• May be requested by Incident Command at the site

• Team assembled based on need at the scene

• Supplies specific to the incident should be brought with

• Police escort to be provided– coordinated between Resource Hospital & Incident Command

(or designee) at the site

• Team to report to Command Post for assignment

• Should be uniformed for easy identification

Dispatch To The Scene

• Self-dispatching of medical personnel to a disaster site is strictly prohibited– Causes additional chaos due to additional

undisciplined and unmonitored persons congesting at the scene

– For safety, need organized method to know who the rescuers are and where they are functioning

After Action Report

• All hospitals and fire departments involved in the Region X multiple victim/mass Casualty plan to to complete a written report following any incident or scheduled mass casualty drill

• Helps during the critique process

After-Incident ReportThe Critique

• Form utilized for post-incident critiques by the Region X DMSC committee with intent of continually reviewing and improving the multiple victim/mass casualty plan as well as the education of fire/rescue/hospital and communication personnel

HOSPITAL

DISASTER

PLAN

ACTIVATION

Internal Hospital Plan

Better to call for additional help and turn them away than not to

have them and wish you did!

Internal Disaster Plan

• ECRN needs to coordinate with:

– ED MD

– Administrator on duty

• authorizes the activation of the internal disaster plan and authorizes the cancellation of the plan

Hospital Incident Command

• Typical lines of authority in-houseAdministration on-duty; on-callNursing Supervisor on dutyED MD

• The identified person of authority makes and implements decisions to handle the situation

• Often located in a “Command Center” manned by personal with phone access

Additional Resources• You need to know when to get help and where

to find the help at your facility

– Decontamination capabilities

– Trained staff to man key areas of the ED or alternate treatment areas

• will serve as a resource for float personnel

• how will you identify an ED staff member?

–ie: vests, arm bands

Additional Resources

– RN’s - especially experienced or comfortable in the ED

– MD’s - based on nature of illness or injury– Support personnel - clerks/secretaries/registrars– Runners/transporters– Persons to man phones– Security - control flow of traffic

CMC versus LFH Disaster Plans

• The following pages are more specific for CMC staff

• The following information can be applied to most facilities any of us could be working at

• LFH staff need to determine specific language and locations for their facility based on the information given in the following slides

Hospital Disaster Plans

• Many principles and practices are generic across most hospitals

• Know where your hospital manual resources are kept (usually close to the radio)– Where are your manuals and what do they look

like?

– When is the last time you opened & looked at yours?

CMC Paging of Disaster

• Code Green External– influx of patients from external source

• Code Green Internal– Need to recruit man-power for unusual activity related

to unusual working conditions• power outage• lack of functioning emergency generators• evacuation is needed• need for all personnel on duty or off duty to be called in• damage to patient care areas (ie: flood, fire, contamination)

Manpower Resource Center• Under direction of VP of Human Resources• Located in patient Registration waiting area off

main lobby• Able to deploy staff to areas of need• If called from home, hospital personnel respond to

this area (unless preassigned to respond elsewhere)• ED staff called from home respond to the ED

Disaster charge nurse

Manpower Resource Center and Additional Resources

• When you need additional help, you inform the charge person for your area

• Charge person needs to contact Command Center for additional help

• Additional help to be assigned as needed/requested

Responding Staff Members

• If called from home:– Respond to area assigned or Manpower Resource

Center if none given– Wear hospital ID badge

• If on-duty at time of disaster page– Return to your work unit– Await reassignment if necessary– Do not respond to an area unless assigned there; adds

confusion and does not help tracking of resources

Security

• To control access points and flow of traffic by foot and vehicleonto the campusinto the facilityat key points within the building

Internal Communication

• Walkie talkies are provided by Security

• Key persons need to have easy and quick access for communication to each other

• Communication support (ie: walkie talkies) need to be requested through the Command Center

ED Charge RN

• Makes assignment of on-duty and responding staff

• Coordinates ED activity

• Communicate need for additional resources to the Command Center

• Need to continue to take care of non-disaster involved patients that will still be arriving by personal car and ambulance

ECRN Radio Nurse• Preferably have one person assigned to the radio

– continuity of conversation decreases missed and mixed messages

• Use runner to get messages to the Charge RN

• Keep Charge RN apprised of incoming messages

• Keep Triage RN apprised of incoming type and number of patients

Treatment Areas

Triage– At ambulance bay entrance– Patients assigned a location based on condition

Main ED– Red, critically ill/injured patients

Lower level dining room– Additional treatment area for yellow and green

categorized patients

Decontamination

• If 10 or less patients (<10) can be provided in the ED decon room

• If more than 10 patients (>10) to be provided in the locker room at the Centre Club - Libertyville

• Manpower Resource Center to disseminate supplies as needed

Infection Control

• Remember to consider proper use of PPE’s (personal protective equipment) based on the situation– If patients are coughing, think of an airborne problem– Provide and help place surgical masks on the patient

(surgical mask helps contain spread)– The medical personnel should also put on a mask

• The N95 mask will protect the medical provider from inhaling microscopic matter

Clerical Support• Assigned to areas of need

– triage– patient registration– manning phones

• Registrars have patient chart packets at main desk that need to be given out at Triage

• Disaster log maintained

Media• Public Relations personnel to serve as liaison

between hospital and media

• No staff member should provide ANY kind of information to any persons not privileged to have the information

• Public Relations to coordinate with the Command Center information being provided

• Goal - keep media as far away as possible from victims & family

System Wide Crisis Preparedness• A Region X policy to enhance communication

between EMS System Resource Hospital, Associate Hospital, EMS providers and community agencies

• To be used for potential or actual area-wide crisis such as:overcrowding events for patients with same or similar

signs and symptomsweather related problemsspecial events

System Wide Crisis Preparedness

• Purpose of activating this plan is to help all agencies involved be prepared for a crisis that may impact any or all parties– ie: summer heat wave in Chicago resulting in large number

of deaths

• Any individual involved can identify a potential or actual crisis

• The agencies’ supervisor is contacted• Resource Hospital EMS Coordinator or designee is

contacted

System Wide Crisis Preparedness

• The decision is made to activate this policy

– POD hospital is notified (HPH for this area)

– POD hospital member will contact IDPH if necessary

• Communications continued between all applicable parties

Surge Capacity

• Remember to anticipate a larger number of victims than you think you are getting

• Not all patients come by ambulance where you receive an advanced call

• Many victims will self-transport (ie: private car)• Often, the “worried well” think they have

symptoms that they want evaluated• How are you going to handle this surge?

SO,,,,

WHAT DO THESE DISASTER PLANS

MEAN TO ME?

Example #1

• Non-CMC sponsored fire department calls with information regarding a disaster in their town (ie: Gurnee, Lake Villa, Highland Park, Lincolnshire)

• The ECRN should direct the fire department to their Resource Hospital

Example #1

• The respective Resource Hospital (ie: Vista East or Highland Park Hospital) would call potential receiving hospitals (ie: CMC, LFH) to report pertinent information

Example #2

• LFH receives a call from Lake Forest Fire that they are responding to an incident involving 50 plus students from a local school overcome with fumes

• LFH should direct Lake Forest Fire Department to contact CMC (Resource Hospital) with the information and assistance with patient distribution

Example #3

• Lake Forest Fire calls Lake Forest Hospital with report of 10 persons injured in a 2 vehicle crash.

• Lake Forest Hospital directs Lake Forest Fire to contact the Resource Hospital (CMC) to assist in patient distribution

Example #4• Grayslake Fire contacts CMC with

information regarding an incident involving 30 persons injured in a bleacher collapse

• CMC, as the Resource Hospital, will coordinate location of receiving hospitals

• CMC will also function as a receiving hospital• Each hospital decides if they need to activate

their own internal disaster plan for resources

Example #5• A mass casualty incident occurs in the southern end of

Lake County• Highland Park Hospital (Resource Hospital for that

fire department) will be the communication link between incident and receiving hospitals

• HPH contacts CMC, LFH, and other indicated hospitals to determine patient capabilities

• HPH does the communication to the incident site & back and forth to hospitals

Example #6

• Libertyville Fire Department responds to an incident on the tollway involving 7 patients

• Libertyville Fire Department calls CMC

• CMC can take all 7 victims

• No additional involvement with other receiving facilities is necessary - CMC can handle all the injuries with minimal use of some additional resources in-house

Example #7

• CMC receives a call from NWCH stating we are going to be receiving patients from an incident in Buffalo Grove

• What is CMC’s response?– CMC is functioning as a receiving hospital– Communication will occur through NWCH to

the site and NWCH to the receiving hospitals– CMC does not function as a Resource Hospital– Communication to LFH would be from

NWCH, if LFH would be receiving patients

Bottom line...

• Know where your Disaster Manuals are and how to use them

• Review the disaster manuals often enough to be comfortable to respond without much prompting

• Be familiar with your own facilities resources, know who functions in the charge role, and know how to get the disaster response activated