Mass Casualty Plan

Policy: CATRAC-EM-Weather Effective: 6/2007- Draft Revised: Reviewed: 5/2007 Page 1 of 8

HOSPITAL MASS CASUALTY SURGE PROTOCOL- WEATHER EVENT

POLICY:

(Hospital Name) will attempt to meet the emergent and variable levels of need for casualties in the event of a Weather related major disaster.

I. PURPOSE:

As a healthcare provider and community leader, (Hospital Name) and their staff shall assume a primary role and responsibility for providing emergent and acute care services (safely and within the scope of their service) to the community during times of medical crisis. (Hospital Name) shall work directly with the (County Emergency Medical Services) Department Operations Center (EMS DOC) to plan and coordinate medical disaster response, operations and recovery activities, during times of medical crisis.

(Hospital Name) has adopted the Hospital Incident Command System (HICS) standard as a mitigation strategy. HICS serves as the hospitals’ operations response structure during in a medical disaster event and is designed to provide clearly defined job duties and responsibilities. In addition, the Hospital Mass Casualty Surge Protocol, and related disaster response policies and procedures shall provide detailed facility specific guidance in managing all aspects of medical disaster response. A well-coordinated response to a disaster saves lives and minimizes pain and suffering.

II. SCOPE:

The scope of the Hospital Mass Casualty Surge Protocol is to guide the hospital in responding effectively to any event that presents the potential for a large number of persons seeking emergent and/or acute medical assistance, at the location of the hospital, or the defined hospital zone, following a mass casualty event. The Hospital Mass Casualty Surge Protocol consists of a number of procedures designed to respond to those situations most likely to disrupt the normal operations of the hospital. Each response is designed to assure availability of resources for the continuation and appropriate placement of patient care during a medical disaster. The plan also addresses the medical needs of victims of a hospital or community based incident. The program is also designed to assure compliance with applicable codes and regulations. The program is applied to all hospital staff.

III. FUNDAMENTALS:

A. Disasters will occur. Effective assessment and planning reduces the impact of the disaster on the quality of patient care.

B.Disasters can be best managed by developing a redundant set of resources and standards such as HICS and other facility disaster response policies and procedures, to mitigate the anticipated impact.

C. The (County EMS/ EOC) coordinates with local, county, state, federal, civil authorities, and EMS system providers to conduct situation status assessment and allocate resources throughout the (County) Operational Area. The incident or event will be managed to provide the greatest medical good for the greatest number. Policy: CATRAC-EM-Weather Effective: 6/2007- Draft Revised: Reviewed: 5/2007 Page 2 of 8

D. Periodic drills, both community and internal, are essential for maintaining staff awareness of disaster procedures, patient surge capacity influx, and for evaluating the effectiveness of plan.

E. Scheduled drills and actual implementations of the Hospital Mass Casualty Surge Protocol provide opportunities to observe staff performance and to identify opportunities for improvement.

IV. OBJECTIVES:

A.Each implementation and drill, or exercise are documented and critiqued. Findings are used to identify opportunities to improve the protocol, staff training, or the resources available to staff during emergency situations. Each implementation and drill or exercise shall be followed by development of an After Action Report (AAR). The AAR will be distributed to the Hospital Environment of Care Committee and the (County EMS/ EOC).

B.Staff required to respond are trained. Training includes use of personal protective equipment, decontamination, other specialized equipment required to be used or operated, and mass casualty surge plans/standard operating procedures.

C. (Hospital Name) will conduct an annual evaluation of the objectives, scope, performance, and effectiveness of the protocol and report the results to the Hospital Environment of Care Committee and (County EMS/ EOC). The EMS Department will aggregate the results and provide a report to the MMRS Medical-Health Subcommittee.

PROCEDURE: A.Activation of the protocol will be initiated by (County EMS/ EOC) through a Med-Alert notice. The protocol has four levels of activation based on the severity of the event and data collected by (County EMS/ EOC) staff. The levels are named as follows: SURGE ONE, SURGE TWO, SURGE THREE, and SURGE FOUR.

SURGE ONE – Notification to area hospitals by (County EMS/ EOC). Hospitals activate command centers and internal disaster plans per their hospital policies and procedure. Upon activation of command centers, all communications and requests will be between (County EMS/ EOC) Operations Center (EMS DOC) and the Hospital Command Centers.

 Activate Code Yellow  Activate Hospital Command Center  Determine if facility lockdown or restricted access is necessary  Activate Internal Alert  Determine the potential casualty number and medical condition types  Communicate Situation Status and Resource Needs to the EMS DOC  Consider activation of limited staff call-back  Cancel Elective, Routine or Non-Essential Surgery Accelerate Discharge Policy: CATRAC-EM-Weather Effective: 6/2007- Draft Revised: Reviewed: 5/2007 Page 3 of 8

SURGE TWO – At Surge Two, the mass casualty event is escalating and requires further mobilization of resources. Hospitals prepare to accept a surge of mass casualties. Surge Two is designed to address the facilities’ internal disaster response, operations and recovery procedures.

 Activate Code Black  Communicate Situation Status and Resource Needs to the EMS DOC  Establish logistics necessary to sustain operations  Fully Activate Staff Call-Back  Staff Vacant Internal Bed Capacity  Mobilize Additional Beds within Facility  Activate Public Information Officer (PIO) Media Briefing Area  Activate Family Information Area

SURGE THREE – At Surge Three, the mass casualty event has escalated further and requires mobilization of resources outside the facility to manage the patient numbers. (County EMS/ EOC) will activate mass casualty hospital zones per EMS policy and the extent of the incident or event. Hospital resources are mobilized outside for mass casualty operations.

 Establish External Security Perimeter Control  Communicate Situation Status and Resource Needs to the EMS DOC  Mobilize External Triage  Mobilize External Registration  Mobilize External Treatment  Mobilize External Holding (post treatment monitoring)  Mobilize External Discharge Mobilize External Morgue as Appropriate

SURGE FOUR – The (County EMS/ EOC) in coordination with hospitals will expand external operations to include full mobilization of the Mass Casualty Hospital Zoning System and Casualty Staging Areas. The (County EMS/ EOC) will deliver needed resources to hospitals and the external casualty staging locations. Hospitals and (County EMS/ EOC) will plan for transport of patients out of the affected area. Hospitals and (County EMS/ EOC) will plan for the recovery phase of the event.

 Communicate Situation Status and Resource Needs to the EMS DOC  Form Hospital Zone Strike Team(s) with assigned pre-hospital resources for response to priority incidents within the hospital zone as requested by the EMS DOC.  Receive Resources from the EMS DOC  Assist with Establishment of Assigned Casualty Staging Areas with Pre-hospital Resources  Establish communications between Hospital Command Center and each assigned Casualty Staging Area  Assign Resources to Hospital and Assigned Casualty Staging Areas based upon Priority Needs  Each Hospital Command Center communicates with the EMS DOC regarding Hospital Command Center and Casualty Staging Area situation status and resource needs.  Refer Greens to Assigned Casualty Staging Area Policy: CATRAC-EM-Weather Effective: 6/2007- Draft Revised: Reviewed: 5/2007 Page 4 of 8

 Receive Reds and Yellows from Assigned Casualty Staging Areas  Plan for all Necessary Patient Transport Inside or Out of the County

The general indications for Surge Four activation by the EMS Department would be systemic or area emergency department overload scores ranging at 101 or higher for situations that maybe longer term (days or weeks). This would not prevent the Department from activating Surge Four at lower emergency department overload scores for situations that are expected to further escalate at the Department discretion.

A. Activation of any surge levels: 1. When information is received and substantiated that (Hospital Name) may become involved in receiving casualties, the ER staff member will inform the senior Administrator on site (CEO or VP) or, if not available, the Resource Nurse. The senior administration staff person will assume the position of Emergency Incident Commander (EIC) and will make the decision regarding Code Status and notify the PBX Operator. 2. The Hospital will then be placed on Code Yellow, and the PBX Operator will make the announcement, “ATTENTION PLEASE - CODE YELLOW NOW EXISTS”. This message will be announce three times. 3. In the event that the ER is notified that victims are being sent to the hospital, the ER staff member, or Resource Nurse, must then notify the EIC of the change in status, along with a census report. 4. The Hospital will then be placed on Code Black, and the PBX Operator will make the announcement, “ATTENTION PLEASE – CODE BLACK NOW EXISTS”. This message will be announced three times. 5. The EIC will make a decision regarding the calling back of staff and physicians to assist with the disaster and ER may be requested to assist in this recall. 6. The EIC will assign a physician to serve as the Medical Triage Officer (usually the ER physician on duty). This physician will be the leader of the triage team. 7. In the case of Code Yellow or Code Black, all ER personnel will be required to remain on duty until an “ALL CLEAR” is announced, or they are dismissed by the Resource Nurse or a member of the Emergency Command Center. 8. During the Code Yellow, additional carts from PCU will be delivered to the ER. 9. Should the disaster yield a possible hazardous material event, the Emergency Department will keep a Decontamination Kit in the department at all times. 10. During the Code Black, Security and/or designated personnel will secure the building. 11. Non-acute ER patients should have a disposition completed in a timely manner with the appropriate discharge/transfer from the department. 12. All requests from media are to be referred to the EIC. No media personnel shall be given access to the ER treatment areas. The designated media location is in the west end of the Main Lobby. 13. The ER staff will be responsible for monitoring the COR radio for reports of incoming traffic relative to actual numbers of casualties and their status. Updates to be given to the Emergency Command Center. 14. Additional stretchers may be obtained from the Day Patient area by notifying the Cath Lab Team Leader or Resource Nurse and requesting the number of stretchers needed. 15. Every effort shall be made to transfer patients in need of admission to the appropriate facility or to respective in-patient areas. 16. The Registration Clerk is to pull the disaster packets located in the ER Triage area. Each packet will include: a) ER Nursing Record and Physician Record Policy: CATRAC-EM-Weather Effective: 6/2007- Draft Revised: Reviewed: 5/2007 Page 5 of 8

b) ID bracelet with previously assigned identifying numbers (manually written 1..2..3..etc.) c) Disaster tags, or triage, found in the ED or some will be keep in the ‘De-con’ shed outside the ED.

B. Communications 1. Notification of the appropriate code status will be initiated by the EIC. 2. All significant issues/changes of status are communicated to the EIC in the Emergency Command Center. (2nd Floor Classroom) 3. Messengers will be utilized from the Personnel Pool as needed. 4. Cellular phones may be utilized where applicable.

C. Emergency Incident Command Center 1. The Emergency Incident Command Center will be located in the 2nd Floor Classroom. An alternate area will be named in the event the 2nd Floor Classroom is unusable. D. Additional Personnel 1. Additional staffing needs, i.e., physicians, nurses or ancillary support and volunteers may be reached by contacting the Personnel Pool (located in the Cafeteria). 2. Relatives of the suspected casualties will be ushered to the family waiting area designated to be the second floor waiting area. 3. As casualty lists are released, they are to be sent to the Emergency Command Center immediately via a messenger.

E. Casualty/Surge Care/Decontamination 1. Triage will be established in the ER parking lot or Ambulance Bay area (depending on space required and level of PPE is needed), with members of the Triage Team. 2. Minimum of 4 trained personnel will don appropriate PPE for decontamination; If less than 10 exterior shower will be used. Greater than 10, mass casualty shelters and portable shower will be erected & utilized depending of the number of patients in fluxing in need of decontamination prior to entering the Emergency Department. No one is to be donned in the suits for more than 20 minutes due to heat fatigue, thus two persons semi suited, ready to don the full suit by placing the PAPR’s on, must be in waiting to relieve the first set of staff, and so on. 3. Triage Team members include: a) Medical Triage Officer - The designated medical triage officer is the on-duty ER physician. b) Triage Nurse – an ER RN or Resource Nurse. c) Transporters - The necessary number of transporters can be obtained from the Personnel Pool. d) Registration Clerk - Two (2) clerks shall be available. e) Patient Care Partner f) Additional staff to be considered; Respiratory Therapist, Lab tech.

F. Triage Team Function 1. Initial examination, reception, Decontamination (if needed), classification and identification of all casualties. 2. Assignment to treatment areas. 3. Transfer of the dead to the holding room.

G. Triage Nurse Responsibilities 1. Assist Registration Clerks with compiling of information and tagging incoming casualties. 2. Assist in assuring that all casualties are tagged correctly. Policy: CATRAC-EM-Weather Effective: 6/2007- Draft Revised: Reviewed: 5/2007 Page 6 of 8

H. Examining Procedure 1. An initial examination of each patient will be made by the physician member of the Triage Team. 2. The physician’s findings and his/her instructions for disposition of the patient to a treatment area will be dictated to the ER RN or Resource Nurse or a Registration Clerk to record on the Hospital Emergency Medical Tag and Disaster Tag. 3. Attach the cardboard portion of the tag to the patient’s wrist. A pre-assigned unit number will be assigned to each patient and a casualty list will be maintained and periodically forwarded to the ER Registration area. 4. Disaster tags should have priority indications as follows: a) BLACK - NO PRIORITY Patient is either dead on arrival or is so critically injured that his/her prognosis is grave. The deceased victims shall be transferred to the holding room, and the critically injured with grave prognosis shall be transferred to an area of the ER if available or to a vacant PCU room. b) RED - HIGH PRIORITY Those patients who require emergent care with an associated high probability for survival. c) YELLOW - INTERMEDIATE PRIORITY Those patients who require treatment, but can await treatment. d) GREEN - LOW PRIORITY Minor injuries, i.e., walking wounded.

I. Sorting Procedure 1. Minor injuries (green tag) will be sent to Day Patient for treatment and discharged in all cases where possible. 2. All discharged patients are to wait in the east end of the Lobby for pick up. 3. High priority patients (red tag) will be directed to the ER for stabilizing treatment and transferred to critical care area or appropriate facility. 4. Intermediate priority patients (yellow tag) requiring x-ray or surgery that is not of an urgent nature will be transferred to the PCU, one of the PCU pods may be designated a staging area if beds are not available to admit causalities into. 5. Patients with mortal injuries with low probability for survival (black tag) will be transferred to an area of the ER or to a designated area on one of the PCU pods. 6. All patients that are declared dead on arrival will be sent to the Body Holding Room. This category of victim will be tagged with the black portion of the disaster tag and the letter “D” written on the tag.

J. Registration of Casualties 1. Pertinent information only should be requested of casualties during a disaster situation. The Registration Clerks will be stationed at the triage area and will check all casualties for identification tags that were placed prior to arrival and tag those individuals who did not have tags placed in the field. Use a sharpie (permanent marking type pen) pens and tape to make each cot, if a mass casualty situation is present and active, 2. The Registration Clerks will be responsible for receipt and storage of personal effects and valuables. 3. At the time of actual treatment, a treatment record shall be completed with as much information as possible, to include at a minimum a list of the treatment(s) performed. a) Oversee departmental operations and assist with trouble-shooting where appropriate. 1. Communication Policy: CATRAC-EM-Weather Effective: 6/2007- Draft Revised: Reviewed: 5/2007 Page 7 of 8

a) Act as liaison between the Emergency Department and the Command Post. b) Request additional clinical and/or ancillary support.

K. EMERGENCY DEPARTMENT Senior RN 1. Departmental Preparation a) Assignment of personnel to triage and whom to assign to decontamination responsibilities outside the ED department. b) Oversee departmental preparation. c) Notify EIC of expected number and types of casualties as soon as this information is available. d) Assign staff member to answer incoming calls and monitor EMS radio for updated reports. e) The only entrance to the department will be through the triage receiving area. f) Maintain accurate count of expected casualties. 2. Organization a) Oversee the triage area and assign additional personnel as needed. 3. Communications a) Provide periodic status reports to the EIC. b) Facilitates interdepartmental communications.

L. Alternate Care areas. 1. Alternate care area will be set up on the initiation of a Code Black. a) Day Patient - This area will accept minor injuries (green tag). Personnel for this area will be assigned by the Emergency Incident Command Center. Basic first aid measures will be performed with rapid treatment and discharge. Supplies for this area will be on a cart or kit, located at the registration area. b) ER - This area will receive red-tagged patients that require emergent care with high probability of survival. c) Lobby – The east end of the lobby is for discharged patents that are waiting transportation. The west end of the Lobby is for media relations/public information. d) 2nd Floor Waiting Area is an area for family members of causalities to await news of their family member. e) The meditation room (off ante room) is for bereavement. f) PCU – An area of PCU may be designated to receive the Code Black patients, another area may be designated a staging area for patients waiting bed placement.

M. Emergency Supplies 1. Supply needs are to be communicated to the Emergency Incident Command Center who will coordinate with the Materials Management and any staff with access to the mass casualty/surge trailer in order to obtain any medical supplies, beds or other items that will be required to meet the needs of the patients. 2. The Operations Chief (usually the VP of Clinical Services) shall work with the Lead Medical Technologist to assure that the hospital maintains an adequate supply of blood to meet the needs of the patients. The Lead Medical Technologist (AKA – Lab Team Leader) will work with the Red Cross to arrange the delivery of the proper blood products. 3. Should there be an interruption in the supply of water, the Emergency Command Center will arrange with a local bottled water company to provide the hospital with drinking water. Policy: CATRAC-EM-Weather Effective: 6/2007- Draft Revised: Reviewed: 5/2007 Page 8 of 8

N. Transfer to Other Hospitals 1. In the event that patient load exceeds the hospital’s capacity, it may become necessary to divert or transfer casualties to other local institutions. These accommodations may be in cooperation with the (County EMS/ EOC), National Disaster Medical System or the Department of Civil Defense to coordinate other available facilities and transportation between the institutions. 2. Refer to the Transfer Policy and Procedure prior to transferring any patient to another facility.

P. Evacuation 1. In the event that the building or facility can no longer safely support patient care, employees or staff, the evacuation plan will be initiated.