INITIATING THE EMERGENCY OPERATIONS PLAN
Notification of a disaster situation to a facility varies with each sit-uation. Generally, the notification to the facility comes from out-side sources unless the initial incident occurred at the facility. The disaster activation plan should clearly state how the EOP is to be initiated. If communication is functioning, field incident com-mand will give notice of the approximate number of arriving pa-tients, although the number of self-referring patients will not be known.
Patient tracking is a critical component of casualty management. Disaster tags, which are numbered and include triage priority, name, address, age, location and description of injuries, and treat-ments or medications given, are used to communicate patient in-formation. The tag should be securely placed on the patient and remain with the patient at all times. The tag number and the pa-tient’s name are recorded in a disaster log. The log is used by the command center to track patients, assign beds, and provide families with information.
Triage is the sorting of casualties to determine priority of health care needs and the proper site for treatment. In nondisaster situ-ations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. For exam-ple, a young man who has a chest injury and is in full cardiac ar-rest would receive advanced cardiopulmonary resuscitation, including medications, chest tubes, intravenous fluids, blood, possibly even emergency surgery in an effort to restore life. In a disaster, however, when health care providers are faced with a large number of casualties, the fundamental principle guiding re-source allocation is to do the greatest good for the greatest num-ber of people. Decisions are based on the likelihood of survival and consumption of available resources. Therefore, this same pa-tient, and others with conditions associated with a high mortality rate, would be assigned a low triage priority in a disaster situation, even if the person is conscious. Although this may sound uncaring, from an ethical standpoint the expenditure of limited resources on individuals with a low chance of survival, and denial of those resources to others with serious but treatable conditions, cannot be justified.
The triage officer rapidly assesses those injured at the disaster scene. Victims are immediately tagged and transported or given life-saving interventions. One person performs the initial triage while other emergency services personnel perform life-saving mea-sures (eg, intubation) and transport patients. Although emergency medical services personnel carry out initial field triage, secondary and continuous triage at all subsequent levels of care is essential.
Staff should control all entrances to the acute care facility so that incoming patients are directed to the triage area first. The triage area may be outside the entry or just at the door of the ED. This allows all patients, including those arriving by medical trans-port and those who walk in, to be triaged. Some patients already seen in the field will be reclassified in the triage area, based on their current presentation.
Triage categories separate patients according to severity of injury and use a color-coded tagging system so that the triage category is immediately obvious. There are several triage systems in use across the country, and every nurse should be aware of the system used by his or her facility and community. The North Atlantic Treaty Organization (NATO) triage system is one that is widely used and is presented here. It consists of four colors—red, yellow, green, and black. Each color signifies a different level of priority. Table 72-1 describes each category and gives examples of how dif-ferent injuries would be classified.
Each facility must determine its supply lists based on its own needs assessment. The Red Cross has developed a basic survival/ shelter resource kit. The EOP committee should determine the top 10 critical medications used during normal day-to-day operations and then anticipate which other medications may be required in a disaster or an MCI. For example, the hospital might plan to have available a stockpile of cyanide kits or antibiotics used in treating biological agents. Information should be avail-able about local resources for stocking or restocking any of the basic and special supplies, how those supplies are requested, and the time required to receive those supplies.
Communication is a key component of disaster management. Communication within the vast team of disaster responders is paramount; however, effective, informative communication with the media and worried family members is also crucial.
Although the media have an obligation to report the news and can play a significant positive role in communication, the number of reporters, newscasters, and their support teams can be over-whelming, possibly compromising operations and patient confi-dentiality. A clearly defined process for managing the media, which includes a designated spokesperson, a site for the dissemination of information (away from patient care areas), and a regular sched-ule for providing updates should be part of the disaster plan.
Such a plan helps to prevent the release of contradictory or in-accurate information. Initial statements should focus on current efforts and what is being done to better understand the scope and impact of the situation. Information about casualties should not be released. Security staff should not allow media personnel access to patient care areas.
Friends and family members converging on the scene must be cared for by the facility. They may be feeling intense anxiety, shock, or grief and should be provided with information and up-dates about their loved ones as soon as possible and regularly thereafter. They should not be in the triage or treatment areas, but in a designated area staffed by available social service workers, counselors, therapists, or clergy. Access to this area should be con-trolled to prevent families from being disturbed. See Chart 72-2 for a discussion of cultural variables to consider when coping with disaster-related injuries and death.
The role of the nurse during a disaster varies. The nurse may be asked to perform outside his or her area of expertise and may take on responsibilities normally held by physicians or advanced prac-tice nurses. For example, a critical care nurse may intubate a pa-tient or even insert chest tubes. Wound débridement or suturing may be performed by staff registered nurses. A nurse may serve as the triage officer.
Although the exact role of a nurse in disaster management depends on the specific needs of the facility at the time, it should be clear which nurse or physician is in charge of a given patient care area and which procedures each individual nurse may or may not perform. Assistance can be obtained through the incident command center, and nonmedical personnel can provide services where possible. For example, family members can provide nonskilled interventions for their loved ones. Nurses should remember that nursing care in a disaster focuses on essential care from a perspective of what is best for all patients.
New settings and atypical roles for nurses arise during a disaster: the nurse may provide shelter care in a temporary housing area, or bereavement support and assistance with identification of de-ceased loved ones. Individuals may require crisis intervention, or the nurse may participate in counseling other staff members and in critical incident stress management (CISM). At-risk popula-tions may also require special considerations during a disaster (Chart 72-3).
Disasters represent a disparity between the resources of the health care agency and the needs of the victims. This generates ethical dilemmas for the nurses and other providers of care. Issues in-clude conflicts related to
· Rationing care
· Futile therapy
· Assisted suicide
Nurses may find it difficult to not provide medical care to the dying, or to withhold information to avoid spreading fear and panic. Clinical scenarios that are unimaginable in normal cir-cumstances, confront the nurse in extreme instances. Other eth-ical dilemmas may arise out of health care providers’ instinct for self-protection and protection of their families. For example, what should a pregnant nurse do when incoming disaster victims have been exposed to radiation, yet too few nurses are available?
Nurses can plan for the ethical dilemmas they will face during disasters by establishing a framework for evaluating ethical ques-tions before they arise and by identifying and exploring possible responses to difficult clinical situations. They can consider how the fundamental ethical principles of utilitarianism, beneficence, and justice will influence their decisions and care in disaster response.
Although most people pull together and function during a dis-aster, both individuals and communities suffer immediate and sometimes long-term psychological trauma. Common responses to disaster include
· Somatization (fatigue, general malaise, headaches, gastro-intestinal disturbances, skin rashes)
· Posttraumatic stress disorder
· Substance abuse
· Interpersonal conflicts
· Impaired performance
Factors that influence an individual’s response to disaster in-clude the degree and nature of the exposure to the disaster, loss of friends and loved ones, existing coping strategies, available re-sources and support, and the personal meaning attached to the event. Other factors, such as loss of home and valued possessions, extended exposure to danger, and exposure to toxic contamina-tion, also influence response and increase the risk of adjustment problems. Those exposed to the dead and injured, eyewitnesses and those endangered by the event, the elderly, children, emergency first-responders, and medical personnel caring for victims are considered to be at higher risk for emotional sequelae.
Nurses can assist disaster victims by providing active listening and emotional support, giving information, and referring pa-tients to a therapist or social worker. Health care workers must refer individuals to mental health care services, because experi-ence has shown that few disaster victims seek these services and early intervention minimizes psychological consequences. Nurses can also discourage victims from subjecting themselves to re-peated exposure to the event through media replays and news ar-ticles, and encourage them to return to normal activities and social roles when appropriate.
CISM is an approach to preventing and treating the emotional trauma that can affect emergency responders as a consequence of their jobs and that can also occur to anyone involved in a disaster or MCI. Critical incident stress management is handled by CISM teams that are available to the OEM. There are 350 such teams in the United States. All branches of emergency services have CISM teams, as do the military and many industries (eg, airline industry).
Components of a management plan include education before an incident about critical incident stress and coping strategies; field support (ensuring that staff get adequate rest, food and fluids, and rotating work loads) during an incident; and defus-ings, debriefings, demobilization, and follow-up care after the incident.
Defusing is a process by which the individual receives education about recognition of stress reactions and management strategies for handling stress. Debriefing is a more complicated interven-tion; it involves a 2- to 3- hour process during which participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing (eg, flashbacks, difficulty sleeping, intrusive thoughts), and other psychological ramifica-tions. In follow-up, members of the CISM team contact the par-ticipants of a debriefing and schedule a follow-up meeting if necessary. People with ongoing stress reactions are referred to mental health specialists.
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