10/12/2015. PA s Role in Disaster Operations

Transcription

1 Physician Assistant s Role in Disaster Operations Salishan 10/23/ Todd Adelman, RN, CEN Mustard gas victims PA s Role in Disaster Operations First U.S. aid flight lands in cyclone-hit Myanmar China quake kills nearly 9,000, toll likely to soar EPA testing air after twister in toxic Okla. Town Man Cuts 12,000 Volt Power Line Smallpox is again raising fear and new concerns Army Corps says condition of many levees a mystery Turkish Earthquake Orient Physician Assistants to healthcare facility disaster activation and the Emergency Operations Plan (EOP) 1

2 Orient Physician Assistants to healthcare facility disaster activation and the Emergency Operations Plan (EOP) PA s role as a Licensed Medical Practitioner and technical advisor in the Hospital Incident Command System (HICS) Orient Physician Assistants to healthcare facility disaster activation and the Emergency Operations Plan (EOP) PA s role as a Licensed Medical Practitioner and technical advisor in the Hospital Incident Command System (HICS) The differentiation of standard triage contrasted to disaster triage and Medical Screening Exams (MSE) LIFE SAFETY CONTROL 2

3 Volunteers: Unlicensed and licensed management system TJC EM Participate in disaster relief through established channels Support comprehensive, team-based health care Prepare for and expect the possibility of scarce medical resources and non-medical assignments in disaster situations Provide documentation of their qualifications at any disaster site Be familiar with standards of disaster response Maintain a high degree of cultural sensitivity when working with ALL populations 14 Pages Essential elements of disasters preparedness and response Public health needs versus clinical needs Preparation through education Credentials and Roles State Laws/Federal Exemptions Responding to international crises Beware the ill-prepared relief worker Disaster response standards Standards for crisis care Guidelines for PAs responding to disasters Federal Model The Joint Commission Standards Centers for Medicare & Medicaid Services (CMS) DHHS National Response Framework National Incident Management System Presidential Policy Directive 8 / PPD-8 Core Emergency Support Function Annexes Support Annexes Incident Annexes Partner Guides Preparedness Communications and Information Management Resource Management Command and Management Ongoing Management and Maintenance Strategic National Risk Assessment National Preparedness Goals National Preparedness System National Preparedness Report National Planning Frameworks Federal Interagency Operational Plans Build and Sustain Preparedness 3

4 National Incident Management System (NIMS) Preparedness Communications and Information Management Resource Management Command and Management Ongoing Management and Maintenance Hospital Incident Command System (HICS) Unity of Command Only one supervisor Common terminology Plain language Management by objective Develop an action plan Flexible and modular organization Expands and contracts as needed Span of control Supervising 3-7 personnel, with 5 optimal PA roles and responsibilities related to disaster management. General principles of disaster triage. Importance of pre-planning, training, and implementation of a centralized management system for dealing with mass casualties. Disaster management, and the medical response to disasters, is a multifaceted and continuously evolving discipline. Disaster triage is unique in that it requires a change in the paradigm to the allocation of limited resources for the greatest good for the greatest number of casualties. 12 4

5 2003: 255 million persons affected by disasters 180% increase over 10 years 2004: More than 240,000 deaths from natural disaster 2005: 360 natural disasters worldwide Earthquake (Pakistan); 73,338 (#1) Hurricane Katrina (USA); 1,332 (#3) 13 Differentiation Resource Management Crisis Management Occurs during our daily facility-level function Patient and family crisis management Concentrate resources on most critical 5

6 Facility and community resources conserved Personal crisis management Concentrate resources on most viable Focus on recovery and resiliency Resource capability and capacity failure Need for outside resources (Stafford Act) Highest risk for Life/Safety issues Extremely difficult recovery and resiliency Always a critical incident Facility is overwhelmed Crisis management for crisis managers Everyone is affected 6

7 Primary prevention Awareness of the need for realistic information Planned response for emotional and psychological support Secondary prevention Immediate emotional and psychological support Assessment of patients with psychological stress (tachy, SOB) Moving those with psychological symptoms to a safe place where they can be observed Judicious use of medications to control psychoses and delirium Critical Incident Stress Management (CISM) Useful for first responders and other health care providers to prevent PTSD 19 Up to 80% of presenting victims AKA: Worried Well, Mass Sociogenic Illness Can and should be triaged and segregated from physical trauma victims Can be triaged and treated at remote security area and ACS Excellent Resource: Veterans Affairs: Psychological First Aid: Field Operations Guide A sudden natural or man-made event that causes widespread destruction and distress The number, severity, and variety of casualties that present to emergency departments after disasters occur can often overwhelm local and regional health care systems 21 7

8 Institutional-based Internal disaster disrupts normal hospital routine functions External disaster occurs in the community resulting in an arrival of patients that overwhelms the hospital s capabilities Community-based natural or man-made, that overwhelms a community s ability to respond with existing resources 22 Damage from an earthquake in Tangshan Important distinction because it determines whether or not there is a need to prepare for casualty arrivalsor manage resources within the hospital Multiple patient incident < 10 casualties Multiple casualty incident < 100 casualties Mass casualty incident (MCI) Greatest amount of deaths, injuries and property damage; least common; multiple hospitals involved major earthquakes, volcanic eruptions, structural failures, fires in densely populated areas, certain hazardous materials events, CBRNE events MCI activation is dependent on resource capabilities and capacities 23 Earthquakes Hurricanes Tornadoes Floods Tsunami Fire US: 5,000 deaths annually and billions of dollars of property loss/damage National Severe Storms Laboratory (NSSL) photo of tornado in Alfalfa, OK 24 8

9 Multi-vehicle collisions Chemical, biological, radiological, nuclear, explosive incidents (CBRNE) considered a deliberate attack that may produce large numbers of casualties significant psychological component Hazardous materials HAZMAT incident is considered unintentional 25 CBRNE: 2013 Boston Marathon explosions HazMat: 2013 West, Texas explosion Criminals Crazies Crusaders Revenge Renown Reaction Combinations of Natural, man-made and technological events Catastrophic Simultaneous or cascading ( snowball ) Massive population displacement 9

10 D = Detection I = Incident command S = Safety and security A = Assess hazards S = Support T = Triage and treatment E = Evacuation R = Recovery 28 Anticipated or unexpected Geographic area affected Event magnitude Population density and types Resources Capabilities Capacities Field situation reports Life/Safety Issues Incident Stabilization Efforts Property Damage Environmental effects Capability Available resources Trained Equipped Capacity Tactical duration Depth of knowledge Equipment limitations 10

11 Management of Individual Healthcare Assets (Tier 1) Management of a Healthcare Coalition (Tier 2) Jurisdiction Incident Management (Tier 3) Management of State Response (Tier 4) Interstate Regional Management Coordination (Tier 5) Federal Support to State, Tribal, and Jurisdiction Management (Tier 6) Portable ACS: Western Shelter Gatekeeper II System 11

12 BAH Level 1 Surge Plan Alternate Care Site Map Emergency Severity Index START 12

13 Emergency Department Charge Nurse Emergency Department Physician (Technical Advisor) Hospitalist (Technical Advisor) Safety Officer Liaison Officer External Triage Nurse Internal Triage Nurse Trauma Nurse ER Unit Secretary Decontamination Unit Leader ER Technician Scribes Transporters Emergency Department Administration Hospital Security Admitting 13

14 EOP Document Annex (supporting documents) Communications Job Action Sheets HICS Forms Evacuation Plan HVA Priorities Surge Plan Appendix (Data) HVA AAR Inventory Resource Directory Kaiser Permanente HVA Template Job Description Basic Guidelines Position Mission/Objective Incident Command Accountability Immediate/Intermediate/Long-Term Planning Documents and Tools 14

15 Licensed Healthcare Practitioners The HICS provides the hospital with a chain of command, a flexible organizational chart, prioritized checklists, and a common languageto better facilitate communication and coordination with other facilities and agencies outside of the hospital 44 15

16 Oregon coverage of Volunteer Healthcare ESAR-VHP (SERV-OR) Medical Reserve Corps FEMA Independent Study Program (ISP) *IS-100.HCB: Introduction to the Incident Command System (ICS 100) for Healthcare/ Hospitals *IS-700.A: National Incident Management System (NIMS) An Introduction *IS-200.HCA: Applying ICS to Healthcare Organizations 16

17 *Online *Independent Study *Free *College Credits Dynamic Interactive State-wide Perfect for mass casualty movement Healthcare Alerts Disaster Alerts Multi-layered notification 17

18 Ethical Framework for Health Care in Times of Crisis Rumor Control Public Information Requests for Aid Off-Site image storage 18

19 Intra-State Inter-State Local Federal Tribal Infrastructure Fusion Liaison Officers 100% FEMA Funded (FREE!) Fuel/ Airfare/ Housing/ Food Simulated Healthcare Center Full-time actors Real CBRNE/HazMat Environ CEUs Too many courses to list Hospital Emergency Response Training for Mass Casualty Incidents Incident Command: Capabilities, Planning and Response Actions for All Hazards Healthcare Leadership for Mass Casualty Incidents Instructor Training Certification 19

20 Highly Infectious Disease Management 2-Day SME Practitioner Instructors Use grant funding $300 Rachel Stappler A.J. Piovesan There are Emergencies, Disasters and Critical Incidents Licensed Healthcare Practitioners should have Job Action Sheets (JAS) within the hospital s Emergency Operations Plan (EOP) The Hospital Incident Command System (HICS) is the facility s structural organization during a disaster START is a preferred rapid assessment tool during Mass Casualty Incidents (MCI) PAs can perform MSE, if in by-laws 60 20

21 QUESTIONS? Todd Adelman THANK YOU FOR EVERYTHING YOU DO! Different from standard triage models Utilitarian approach Greatest good for the greatest number injured Traumatic injuries are common after disaster Exacerbations of pre-existing medical conditions 63 21

22 Simple Triage And Rapid Treatment Simple Triage And Rapid Treatment In the early 1980 s the START method was developed in California by Hoag hospital and Newport Beach Fire and Marine. It provided rescuers with an easy, simple step-by-step approach to assessing and treating a large number of patients with varying degrees of injuries. Simple Triage And Rapid Treatment The Initial assessment and treatment of each patient is accomplished within 30 seconds. Initial treatment is limited to correcting immediate life-threatening conditions (i.e. opening an airway and controlling severe bleeding) 22

23 Simple Triage And Rapid Treatment The Triage Tag A Tag is placed on each patient once they have been assessed. The tag displays the patient s current status and advises those providing treatment with one of the four possible treatment priorities: Minor Delayed Immediate Deceased There are a variety styles and sizes of Triage Tags The Triage Tag Simple Triage And Rapid Treatment Each tab is distinctly color-coded allowing fast patient priority identification from a distance DECEASED IMMEDIATE DELAYED MINOR BLACK = Expectant, Deceased, Palliative RED = Emergent, Immediate YELLOW = Urgent, Delayed GREEN = Non-urgent, Minor Simple Triage And Rapid Treatment 69 DMS All Risk Triage Tags 23

24 The Triage Tag Simple Triage And Triage Tags are designed with tear-off tabs. Unused tabs are removed and the last remaining tab designates the patient s priority. Rapid Treatment Last remaining tab indicated patient priority In this case IMMEDIATE Unused tabs torn off Used with permission of the Newport Beach Fire Department ( 71 Copyright 2007 ENA Upon your arrival, first make sure the scene is safe. Begin by directing the walking wounded away from the immediate scene to a pre-determined evaluation and treatment area. Tag them as MINOR (GREEN) 24

25 Field Sorting Motion to all victims and state: If you want help right now, follow me All those who are able to walk are Green RPM Systems Assessment Respirations Perfusion Mental Status 30-2-Can Do Threshold between Red and Yellow 30 respirations per minute 2 second capillary refill Can follow commands 25

26 Start where you stand - begin the triage process with the patient closest to you. Solicit the help of bystanders and/or uninjured victims. They can be utilized to control bleeding, help maintain an open airway or hold c-spine traction. Do not spend too much time on any one patient. Move quickly from one patient to the next. Assess each patient s RPMs Respirations Perfusion Mental Status RPM ASSESS RESPIRATIONS If the patient is not breathing then Open the Airway If the patient is still not breathing then tag them as DECEASED (BLACK) Move on to the next patient... R RPM ASSESS RESPIRATIONS If breathing is present then Assess the Rate If the rate is greater than >30/minute then tag them as IMMEDIATE (RED) Move on to the next patient If the rate is less than <30, then assess PERFUSION 26

27 RPM ASSESS PERFUSION P If a radial pulse is absent (or) the capillary refill is greater than > 2 seconds then tag them as IMMEDIATE (RED) Move on to the next patient If a radial pulse is present (or) the capillary refill is less than < 2 seconds then assess MENTAL STATUS M RPM ASSESS MENTAL STATUS If the patient cannot follow simple commands (or) has an altered mental status (or) is unconscious, then tag them as IMMEDIATE (RED) Move on to the next patient If patient is able to follow simple commands then tag them as DELAYED (YELLOW) Move on to the next patient 27

28 Nobody s Wrong Extremely rapid during Mass Casualty Incidents Early decisions in pre-hospital setting are for rapid transport Hospital First-Receivers can be non-medical, but START-trained Some patients will improve, while others decompensate As patients proceed toward facility, there is increased practitioner critical thinking Multi-vehicle collision Five patients arrive simultaneously Unrestrained adult patients Restrained pediatric patients One trauma bay available 83 A: 38-yr-old obese female, dyspneic, upper thigh deformity B: 40-yr-old male, minimally responsive, shallow respirations, bleeding from mouth C: Elderly female, unresponsive, large scalp wound, large amount of blood noted D: 14-yr-old female, screaming, lower back pain E: 8-yr-old male, crying, bloody gauze to forehead 84 28

29 B: RED 40-yr-old male, minimally responsive, shallow respirations, bleeding from mouth C: RED Elderly female, unresponsive, large scalp wound, large amount of blood noted A: YELLOW 38-yr-old obese female, dyspneic, upper thigh deformity E: YELLOW 8-yr-old male, crying, bloody gauze to forehead D: GREEN 14-yr-old female, screaming, lower back pain 85 Explosion at local factory On scene report of 25 patients Decontamination completed on scene Five patients have just arrived 86 A: 44-yr-old male, CPR in progress B: 38-yr-old male, left hand injury, moaning C: 40-yr-old male, screaming, burns to torso and upper extremities D: 26-yr-old female, crying, penetrating trauma through calf E: 28-yr-old male, abrasions to face and upper extremities, bleeding from ears 87 29

30 C: RED 40-yr-old male, screaming, burns to torso & upper extremities E: YELLOW 28-yr-old male, abrasions to face and upper extremities, bleeding from ears B: YELLOW 38-yr-old male, left hand injury, moaning D: YELLOW 26-yr-old female, crying, penetrating trauma through calf A: BLACK 44-yr-old male, CPR in progress 88 Journal Disaster Medicine and Public Health Preparedness Courses Basic Disaster Life Support (BDLS) Advanced Disaster Life Support (ADLS) Clinician Outreach Communication Activity (COCA) Continuing Education Credit for COCA Conference Calls 30