Introduction
From the horrors of the terrorist attacks on September 11, 2001, to the chaos in the aftermath of the Joplin, Missouri, category EF5 tornado in 2011, disasters are a scary but very real aspect of working in the emergency department (ED). Before understanding how to prepare for and respond to a disaster, it is first important to understand the term disaster . The World Health Organization defines a disaster as a “serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses that exceed the ability of the affected community or society to cope using its own resources.” Key to this definition is the concept that the event overwhelms the available resources. In fact, a disaster does not have to be a large-scale event, and it is context and location dependent. A three-car accident may be a disaster to one hospital while barely impacting another. It is the disruption of normal functioning that requires additional consideration and training.
Disasters can be broken up into a variety of categories including natural versus man-made, internal or external, and even acute versus prolonged ( Table 26.1 ). Understanding the nature of a disaster is essential in creating an effective plan to mitigate and respond. Disaster science has advanced significantly in recent decades, and the Federal Emergency Management Agency (FEMA) has become the lead agency in the US government’s federal response. According to FEMA, an all-hazards approach (one that accounts for the full spectrum of emergencies and disasters) is key to adequately preparing for a disaster.
| Type of Disaster | Example |
|---|---|
| Natural disaster | Tornado, hurricane, flood, tsunami, earthquake, volcanic eruption, pandemic |
| Technical/man-made disaster | Mass shooting, bombing, vehicle ramming, cyber attack, plane crash, chemical or biological attack |
| Internal disaster | Power outage, IT failure, flooded hospital unit |
| External disaster | Terrorist attack, plane crash, chemical plant explosion |
| Acute disaster | Tornado, mass shooting, bombing |
| Prolonged disaster | Pandemic, drought, prolonged civil unrest |
| No-notice event | Terrorist attack, volcanic eruption, cyber attack |
| Common Terms | Definition |
| CBRNE | Chemical, biological, radiologic, nuclear, explosive |
| Weapon of mass destruction (WMD) | A device typically using a chemical, biological, radiologic, nuclear, or explosive source to cause harm to a large number of people |
Disaster Cycle
Although a disaster may be a singular event or series of events, the disaster cycle is a continuous spectrum of activities ( Fig. 26.1 ). This cycle can be broken down into four phases: response, recovery, mitigation, preparation ( Table 26.2 ).
| Phase of Disaster Cycle | Definition |
|---|---|
| Mitigation | Actions to minimize probability of a disaster occurring or its negative impacts, such as morbidity and mortality, through structural and nonstructural means |
| Preparation | Ongoing planning, training, evaluating, and corrective action, ensuring the highest level of readiness |
| Response | Actions taken after a disaster occurs to prevent further morbidity or mortality |
| Recovery | Actions taken to restore, resume, and ideally improve normal operations |
Although a deep dive into hospital emergency management is beyond the scope of this text, many resources are available on this topic, including https://www.FEMA.gov .
Disaster Declarations
A common saying in disaster management is that “all disasters are local.” Although this saying is true, the response to a disaster can vary widely depending on the severity of the event and resources available. At each level of response, there are different organizations and groups that are responsible. To initiate the appropriate response, a disaster must first be declared. This can be done at the institutional, local, state, regional, national, or international level.
Institutional: At the hospital level, this declaration will typically be made by a predesignated set of senior staff, such as the nursing house supervisor, ED attending physician, or chief medical officer. A hospital disaster declaration will initiate a number of processes and resources available to the institution in order to minimize damage to life and property and restore normal functioning as quickly as possible.
Municipal/State: If an event impacts more than one institution, a disaster may be declared at the municipal or state level. These designations are made by a mayor or governor, respectively. This designation makes additional resources available and allows public officials to exercise emergency powers to preserve life, property, and public health.
National: A national disaster declaration can only be made by the US president; this is referred to as invoking the Stafford Act. This allows federal organizations such as FEMA to provide assistance to disaster victims. Additional federal resources available include teams of medical professionals including physicians, nurses, paramedics, pharmacists, and respiratory therapists, as well as logisticians known as disaster medical assistance teams. There are also material supplies, known as the Strategic National Stockpile (SNS), which include large quantities of mechanical equipment such as ventilators and cardiac monitors, personal protective equipment (PPE), and medications, such as antibiotics and antidotes for chemical attacks. These stockpiles are distributed throughout the US in secured locations.
Disaster Planning and Operations
Planning and preparing for a disaster is fundamental to success. To standardize and assist in these planning efforts, FEMA has developed the National Response Framework, which describes best practices including the Incident Command System (ICS). The ICS describes planning and management functions for responding partners to work in a coordinated and systematic approach by defining common terminology, coordinating resource management, and defining job titles and roles. This resource has been adapted to better fit the hospital environment and is known as the Hospital Incident Command System (HICS).
Beyond identification of roles and responsibilities, a key to successful disaster preparedness is the development of an emergency operations plan. This is an institution-specific document that details the plan and procedures using an all-hazards approach, as well as disaster-specific guidelines. These plans are developed and maintained by a hospital emergency manager or emergency management committee. Once developed, the plan must be tested with drills, which can range from virtual, tabletop exercises to full-scale scenarios using real equipment to treat simulated victims. These drills and the subsequent knowledge gained from them are essential to an institution’s success in preparing for and responding to a disaster.
ED Operations
The environment during a disaster can be vastly different from normal operations. Patients and healthcare workers will likely be under significant stress, and standard operations can be critically disrupted. One way operations may differ is the need to rezone or restructure patient flow in order to streamline appropriate care. An example is creating red, yellow, and green zones in which patients with similar levels of injury or medical need can be grouped together. Additionally, it is common that patient documentation and tracking will be completed on paper charts and using whiteboards, as using computer systems may be too slow or burdensome.
It may also be necessary to work beyond the normal ED technician (EDT) scope of practice for your hospital (e.g., giving basic medications or starting intravenous lines). It is essential that under these circumstances, explicit permission has been designated by the hospital administration or appropriate authority and that the requisite skills and proficiencies are already established. Conversely, ED staff may find themselves asked to perform seemingly unskilled tasks, such as patient movement or equipment stocking. It is necessary to remain flexible under these stressful circumstances.
Disaster Triage
During a disaster incident, hospital resources are overwhelmed, and the approach to patient triage is different. The goal of triage during a disaster is to “do the most good for the greatest number of people.” This means that resources should be directed to saving the most patients, not necessarily the sickest patients. It is for this reason that during a disaster, patients that exhibit no signs of life or injuries with very little chance of survival are not triaged at the highest priority. Instead, resources are directed toward the many sick patients that have a better chance of survival. If and when the hospital system is no longer overwhelmed, then triage should resume back to prioritizing the sickest patients.
During a disaster, patients are triaged into one of four categories that corresponds to a colored tag:
Immediate (red tag): these patients are critically ill and have a chance of survival with immediate treatment.
Delayed (yellow tag): these patients have serious and often life-threatening injuries that need urgent care; however, they are likely to survive with delayed treatment.
Minor (green tag): these patients have minor injuries and are likely to survive if care is delayed several days.
Deceased/expectant (black tag): these patients are either already dead or very unlikely to survive given the severity of injury and/or the availability of resources.
This simplified system helps quickly sort patients based on acuity of illness and chance of survival with immediate, delayed, or prolonged treatment. Red tag patients are treated first, followed by yellow tag patients, and finally green tag patients. Black tag patients that exhibit signs of life should be given palliative care such as pain medication, supplemental oxygen, and other comfort measures.
There are two widely accepted disaster triage algorithms: the START (Simple Triage and Rapid Transport) system ( Fig. 26.2 ) and the SALT (Sort, Assess, Lifesaving interventions, Treatment/Transport) system ( Fig. 26.3 ).
