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Emergency Preparedness, Mass Casualty, and Disaster Nursing

Emergency Preparedness, Mass Casualty, and Disaster Nursing Signature Healthcare Brockton Hospital School of Nursing:

Signature Healthcare Brockton Hospital School of Nursing:

NU202/NU4202B

Judith Gaudiano, RN, MSN

Teaching/Learning

Outcomes

Teaching/Learning Outcomes Discuss the role of the nurse/student nurse in disaster preparedness and response. Describe

Discuss the role of the nurse/student nurse in disaster preparedness and response. Describe interactions among local, state & federal emergency response systems. Evaluate personal protection procedures necessary during a mass casualty event. List triage protocol of patients including category, priority, color and examples

How Did We Get Here?????

How Did We Get Here????? Prior to September 11, 2001 Hurricane Katrina August 29, 2005 Natural

Prior to September 11, 2001 Hurricane Katrina August 29, 2005 Natural Disasters: Earthquake in Haiti, Fires/Mudslides in California… Terrorism

What About Disaster Nursing?

What About Disaster Nursing? Nurses comprise the largest group of health care professionals. The public trusts

Nurses comprise the largest group of health care professionals. The public trusts nurses: poll on honesty and ethics Nurses want to know what is expected of them and how they can be best utilized

Emergency vs. Disaster

Emergency vs. Disaster Emergency: Encompasses an unforeseen combination of circumstances calling for immediate action for

Emergency: Encompasses an unforeseen combination of circumstances calling for immediate action for a range of victims from one to many.

Example: Motor vehicle crash calls for emergency assistance for a small number of individuals whose injuries are minor to very severe or fatal

Accommodated within the emergency management system already in place

Disaster….

Disaster…. “An occurrence, either natural or man- made, that causes human suffering and creates human needs

“An occurrence, either natural or man- made, that causes human suffering and creates human needs that victims cannot alleviate without assistance.” ARC, 1975 Complex emergencies that significantly overwhelm available hospitals, emergency medical services, facilities and resources.

Two types of disasters….

Two types of disasters…. Multiple casualty incidents: more than 2 but fewer than 100 persons injured.

Multiple casualty incidents: more than 2 but fewer than 100 persons injured. School bus accident with 60 children on board. Mass casualty incident: 100 or more casualties are involved. Entire community affected by the release of a hazardous material such as a chemical as a result of a train derailment.

Types of Disasters

A. Natural Disasters

Types of Disasters A. Natural Disasters Hurricane Tornado Storm Flood Earthquake Tidal Wave(Tsunami)

Hurricane Tornado Storm Flood Earthquake Tidal Wave(Tsunami) Landslide

Mudslide Snowstorm Avalanche Drought Famine Epidemics Volcanic Eruption Wildfires

Possible Injuries/illnesses

Possible Injuries/illnesses Earthquakes: crush injuries, lacerations, internal injuries, fractures Hurricanes &

Earthquakes: crush injuries, lacerations, internal injuries, fractures Hurricanes & Floods:

drownings, burns, lacerations, GI illness, vector transmitted illnesses

Tornadoes: severe soft tissue injuries, contusions, complex lacerations, multiple fractures. Snowstorms:

dehydration, hypothermia, frost bite Chronic illnesses:

diabetes, asthma, etc.

Types of Disasters cont…. B. Man-Made

Types of Disasters cont…. B. Man-Made Unintentional Fires Transportation accidents Food or water contamination

Unintentional Fires Transportation accidents Food or water contamination Chemical spills Release of Hazardous Materials

Intentional Group Violence (Riots) Terrorism:

iBombings

iChemical/Biological

Agents

iNuclear Attacks

Man Made Intentional Disasters

Man Made Intentional Disasters Terrorism: “Calculated use of violence or the threat of violence to: a)

Terrorism: “Calculated use of violence or the threat of violence to:

a) Induce fear

b) Coerce or to intimidate governments or societies in the pursuit of goals that are generally political, religious or ideological

c) Obtain leverage, influence and power through publicity generated by their violence.” (Hoffman, 2008)

Methods of terrorism…

Methods of terrorism… 1) Conventional: bombs, guns, car bombs 2) Nonconventional: chemical, biologic, nuclear agents

1) Conventional: bombs, guns, car bombs

2) Nonconventional: chemical, biologic, nuclear agents

Physical Injuries After Blast Events:

truck bombs, missiles…

Injuries After Blast Events: truck bombs, missiles… Blast Lung : hemothorax, pulmonary contusion Auditory :

Blast Lung: hemothorax, pulmonary contusion

Auditory: tympanic membrane rupture

Head Injuries: concussion, stroke, spinal cord injury

Abdominal: perforated bowel, ruptured liver/spleen

Extremities: traumatic amputation, crush injuries, compartment syndrome, burns

Biological Terrorism Agents

Biological Terrorism Agents Biological agents may be delivered or spread in a number of ways. Due

Biological agents may be delivered or spread in a number of ways. Due to modern travel, spread of infection may occur in areas thousands of miles apart. Health care providers need to be aware of potential signs of biological weapon dissemination. Signs and symptoms are similar to those of common disease process. Isolation practices depend upon the infecting agent. Always use Standard Precautions Some agents require Transmission-Based Precautions. Terminal disinfection and disposal of wastes is dependent upon the infecting agent.

Biologic agents of terrorism…

Biologic agents of terrorism… Anthrax-acute bacterial infection spore producing organism. Exposure: prophylaxsis with

Anthrax-acute bacterial infection spore producing organism.

Exposure: prophylaxsis with oral Ciprofloxacin for 60 days Confirmed case: anti-infectives IV

Smallpox-(Varioloa)-DNA Virus

Supportive care and antibiotics Vaccine within 4 days for those exposed.

Chemical Weapons: Overview

Chemical Weapons: Overview Chemical substances that quickly cause injury and/or death and cause panic and social

Chemical substances that quickly cause injury and/or death and cause panic and social disruption Agents

Nerve agents Blood agents Vesicants Pulmonary agents

Agents vary in volatility, persistence, toxicity, and period of latency Limitation of exposure is essential with evacuation and decontamination as soon possible and as close to the scene of the incident as possible

Nerve Agents: Most toxic agents in existence

Nerve Agents: Most toxic agents in existence Sarin, soman organophosphates Inhibits cholinesterase causing cholinergic

Sarin, soman organophosphates Inhibits cholinesterase causing cholinergic symptoms progressing to loss of consciousness, seizures, copious secretions, apnea, and death Treatment: supportive care, atropine, benzodiazepine and pralidoxime (activates cholinesterase) Decontaminate with copious amounts of soap and water or saline for at least 20 minutes Blot, do not wipe off Plastic equipment will absorb sarin gas & increase exposure time

Vesicants: Chemicals cause blistering & burning

Vesicants: Chemicals cause blistering & burning Lewisite, sulfur mustard, nitrogen mustard, phosgene Cause

Lewisite, sulfur mustard, nitrogen mustard, phosgene Cause blistering and burning Respiratory effects can be serious and cause death Decontamination with soap and water, do not scrub or use hypochlorite solutions Eye exposure requires copious irrigation

Treatment for lewisite exposure: dimercaprol IV for systemic toxicity or topically for burns.

Radiation Exposure

Radiation Exposure Radiation exposure may occur due to nuclear weapon, nuclear reactor incidents, or exposure to

Radiation exposure may occur due to nuclear weapon, nuclear reactor incidents, or exposure to radioactive samples e.g uranium, plutonium

Exposure to radiation is affected by time distance and shielding

Radiation Decontamination

Radiation Decontamination Triage outside the hospital Cover floor and use strict isolation precautions to prevent the

Triage outside the hospital Cover floor and use strict isolation precautions to prevent the tracking of contaminants Air ducts and vent are sealed Waste is double bagged and labeled radiation waste Staff protection Water resistant gowns, two pairs of gloves, caps, goggles, masks, and booties

Dosimetry

devices (more than 800 rad of

total body high mortality)

Radiation Decontamination

Radiation Decontamination Patients are surveyed for radiation and directed to the decontamination area Decontaminate

Patients are surveyed for radiation and directed to the decontamination area Decontaminate each patient outside the ED with a shower Water, tarps, towels, soap, gowns, all patient belongings, etc. must be collected and contained Patients are resurveyed and reshowered as necessary Showering should be performed to not contaminate clean areas with runoff from the showering Biologic samples—nasal and throat swabs, blood Internal contamination requires additional treatment— catharsis, gastric lavage with chelating agents (agents that combine with radioactive substances and then excreted)

How prepared is the American health care system for a mass casualty event?

the American health care system for a mass casualty event? American Hospital Association reports: 7/10 hospitals

American Hospital Association reports:

7/10 hospitals have a bioterrorism response plan 3/4 integrate chemical terrorism into plan 5/10 have nuclear terrorism in the plan BH has a disaster plan, bioterrorism plan and a radiation exposure plan.

So what happens when a disaster occurs???

So what happens when a disaster occurs??? First response at local level: Emergency Medical System of

First response at local level: Emergency Medical System of police, firemen,

Public Health Agencies activate their disaster plans City/State activation of Emergency Operations Center (EOC) National Response Plan activated by the Federal Emergency Management Agency (FEMA)

hospitals

Response to Disaster….

Federal activation of the “National Disaster Medical System” Centers for Disease Control & Prevention activated for a bioterrorism-related incident American Red Cross activation Voluntary organization Chartered by the U.S. Congress in 1905 Authority to act as the primary voluntary national disaster relief agency for the American people.

Congress in 1905 Authority to act as the primary voluntary national disaster relief agency for the

Emergency Operations Plan (EOP)

Emergency Operations Plan (EOP) Health care facilities are required by the Joint Commission to create a

Health care facilities are required by the Joint Commission to create a plan for emergency preparedness and to practice this plan twice a year. Essential components of the plan:

An

activation response

An

internal/external communication plan

A plan for coordinated patient care Security plans Identification of external resources A plan for people management and traffic flow

Triage French word “to sort”

Triage French word “to sort” The sorting of patients to determine priority health care needs and

The sorting of patients to determine priority health care needs and the proper site of treatment. In non-disaster situations healthcare workers assign highest priority and allocate most resources to the most critically ill. (Ruptured aortic aneurysm) In disaster situations with large numbers of casualties decisions are based on the likelihood of survival and the consumption of resources: patient with high mortality rate receives low triage category. Triage categories

North Atlantic Treaty Organization Triage System

North Atlantic Treaty Organization Triage System Priority 1 RED (Immediate): Injuries life threatening but survivable with

Priority 1 RED (Immediate): Injuries life threatening but survivable with treatment Priority 2 YELLOW (Delayed): Require some medical attention but care can be delayed for hours Priority 3 Green (Minimal/Ambulatory):

Minor injuries, Treatment can wait for hours to days Priority 4 Black (Expectant): Catastrophic injuries, not expected to survive. Comfort measure provided

Personal Protective Equipment (PPE)

Personal Protective Equipment (PPE) Purpose: To shield the health care provider from chemical, physical, biological, and

Purpose: To shield the health care provider from chemical, physical, biological, and radiological hazards that may exist when caring for contaminated patients. Categories of protective equipment:

Level A: self-contained breathing apparatus (SCBA) and vapor-tight chemical resistant suit, gloves and boots Level B: high level of respiratory protection (SCBA) but lesser skin and eye protection; chemical resistant suit Level C: air-purified respirator, coverall with splash hood, chemical resistant gloves and boots Level D: typical work uniform

Psychological Responses of Disaster Victims

Psychological Responses of Disaster Victims Anger Shame Survivors’ Guilt Acute Stress Disorder

Anger Shame Survivors’ Guilt Acute Stress Disorder Post-Traumatic Stress Disorder Bereavement

Managing Short- and Long-Term Psychological Effects After a Disaster

Short- and Long-Term Psychological Effects After a Disaster Provide active listening and emotional support Provide

Provide active listening and emotional support Provide information as appropriate Refer to therapist or other resources Discourage repeated exposure to media regarding the event Encourage return to normal activities and social roles Critical incident stress management (CISM) Programs that include education, field support, defusing, debriefing, demobilization and follow-up components Persons with ongoing stress reactions should be referred to mental health specialists

Psychological

Interventions

Psychological Interventions ∗ Anxiety Management Deep breathing, relaxation training, positive self-talk, journals,

Anxiety Management

Deep breathing, relaxation training, positive self-talk, journals, logs, art, music, thought stopping, meditation, visualization, assertiveness training

Psychological

Interventions…….

Psychological Interventions……. Crisis Intervention---Most common intervention reported by nurses… active

Crisis Intervention---Most common intervention reported by nurses… active listening… allowing victims/survivors/caregivers to “tell their stories”

“Emotional needs of the people were often a higher priority than medical

needs.”

with Katrina survivors

Stated by a nurse working

Disaster Preparedness in Nursing School Curriculum

Disaster Preparedness in Nursing School Curriculum Nursing care of patients: head injuries chest injuries shock

Nursing care of patients:

head injuries chest injuries shock first aid

ABC’s of

care

CPR Disaster

Triage

Personal Protective Equipment +communication skills Accurate & timely documentation Crisis Intervention skills Expression of own feelings: panic, fear overwhelmed, sadness

ARC Program to prepare student nurses as volunteers…

ARC Program to prepare student nurses as volunteers… “Nursing students can be valuable to the recovery

“Nursing students can be valuable to the recovery of a stricken community” Examples of activities:

blood, organ, tissue collection first aid, CPR, HIV/AIDS education administration of vaccines, antidotes, antibiotics, IV’s Patient assessment (Physical & Psychological)

Core Competencies for Nurses in Disaster Preparedness…

Core Competencies for Nurses in Disaster Preparedness… Identify and Locate the agency’s emergency response plan

Identify and Locate the agency’s emergency response plan Describe emergency response roles and demonstrate them in regularly scheduled drills Demonstrate the use of equipment including Person Protective Equipment

Nurse Competencies continued…

Nurse Competencies continued… Demonstrate correct use of emergency communication equipment Describe communication

Demonstrate correct use of emergency communication equipment Describe communication roles in emergency response Identify you own level of/limitations in knowledge, skills and authority Participate in continuing education to maintain up-to-date knowledge

Volunteer in Massachusetts…….

Volunteer in Massachusetts……. MA System for Advance Registration of Volunteer Health Professionals (MSAR)

MA System for Advance Registration of Volunteer Health Professionals (MSAR) Activated during a large-scale disaster Supported by the MA Department of Public Health and the MA Medical Society, and the MA Board of Registration in Nursing Quick identification and deployment of skilled, pre-credentialed nurses.